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THE  DISEASES  OF  INFANCY 
AND  CHILDHOOD 


Digitized  by  the  Internet  Archive 

in  2010  With  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofinfanc1916holt 


THE 

DISEASES  OF  INFANCY 
AND  CHILDHOOD 

FOR    THE    USE    OF   STUDENTS 
AND    PRACTITIONERS    OF    MEDICINE 

BY 

L  EMMETT  HOLT,  M.D.,  Sc.D.,  LLD. 

PROFESSOR  OF   DISEASES  OF  CHILDREN  IN  THE   COLLEGE  OF  PHYSICIANS    AND  SURGEONS 

(COLUMBIA    UNIVERSITY),    NEW    YORK;    ATTENDING   PHYSICIAN    TO    THE    BABIES' 

AND    FOUNDLING   HOSPITALS,    NEW   YORK;    CORRESPONDING   MEMBER    OF 

THE  GESELLSCHAFT  FUR  INNERE  MEDIZIN  UND  KINDERHEILKUNDE, 

VIENNA,    AND   HONORARY   MEMBER   OF   THE    GESELLSCHAFT 

FUR   KINDERHEILKUNDE,    GERMANY 

AND 

JOHN   HOWLAND,  A.M.,  M.  D. 

PROFESSOR   OF   PEDIATRICS   IN   THE   JOHNS   HOPKINS   UNIVERSITY,    BALTIMORE; 

DIRECTOR    OF    THE    HARRIET   LANE    HOME;    PEDIATRICIAN-IN-CHIEF    TO     . 

THE   JOHNS  HOPKINS   HOSPITAL;  CORRESPONDING  MEMBER  OF 

THE   GESELLSCHAFT  FUR  INNERE   MEDIZIN   UND 

KINDERHEILKUNDE,    VIENNA 


SEVENTH  EDITION,  FULLY  REVISED 

WITH  TWO  HUNDRED  AND  FIFTEEN  ILLUSTRATIONS 


NEW  YORK  AND  LONDON 

D.    APPLETON    AND    COMPANY 

1916 


Copyright,  1897,  1902,  1905,  1907,  1909,  1911,  1916, 
By  D.  APPLETON  AND  COMPANY 


Printed  in  the  United  States  of  America 


PREFACE   TO   THE   SIXTH   EDITION, 


In  the  preparation  of  this  edition  tlie  author  has  associated  with 
him  Dr.  John  Howland.  his  former  assistant,  who  will  hereafter  be 
connected  with  the  work  as  joint  author. 

Progress  along  man}'  lines  in  paediatrics  has  been  rapid  during  the 
last  two  years.  To  make  room  for  new  knowledge  without  unduly 
enlarging  the  size  of  the  volume  has  made  it  necessary  to  cut  out  about 
seventy- five  pages  of  old  material.  It  is  believed  that  this  has  been 
accomplished  without  imjoairing  the  value  of  the  chapters  which  have 
been  abridged.  The  decision  of  the  publishers  to  make  entirely  new 
plates  has  made  this  comparatively  easy. 

There  is  scarcely  a  page  in  the  book  which  has  not  been  subject  to 
some  revision.  Many  articles  have  been  entirel}'  rewritten  and  several 
new  ones  appear  for  the  first  time  in  this  edition.  The  greater  part  of 
the  new  material  will  be  found  in  the  chapters  upon  Xutrition  and 
Infant  Feeding,  Infant  Mortality,  Intestinal  Intoxication,  Pyloric  Ste- 
nosis, Appendicitis,  Acute  Peritonitis,  Endocarditis  and  Pericarditis, 
Cerebro-spinal  and  Other  Forms  of  Acute  Meningitis,  Acute  Poliomye- 
litis, Hereditary  Syphilis  and  Tuberculosis. 

A  number  of  the  old  illustrations  have  been  omitted  as  no  longer 
necessary:  others  have  been  replaced  by  better  ones.  In  all,  thirty-six 
new  illustrations  have  been  introduced,  including  twelve  radiographs. 
All  illustrations  are  from  original  sources  unless  otherwise  stated. 

The  authors  desire  to  acknowledge  their  indebtedness  to  Dr.  F.  H. 
Bartlett  for  much  assistance  rendered  in  every  way  in  the  work  of 
revision;  to  Dr.  H.  H.  Mason  for  correction  of  the  proof  sheets,  and 
to  Dr.  X.  C.  Holt  for  the  preparation  of  the  index. 

14  West  Fifty-fifth  Street, 
New  York. 


PREFACE  TO  THE  SEVENTH  EDITION 


In  this  Seventh  Edition  the  authors  have  endeavored  to  hring  the 
book  abreast  of  the  science  of  the  day.  In  the  five  years  which  have 
elapsed  since  the  last  revision  there  have  been  great  advances  in  our 
knowledge  of  many  of  the  subjects  which  are  considered  in  a  general 
textbook  upon  Pediatrics.  The  endeavor  has  been  made  to  introduce 
this  new  knowledge  without  greatly  changing  the  general  arrangement 
of  the  book.  To  do  this  without  increasing  the  size  of  the  volume  has 
made  it  necessary  to  cut  out  nearly  one  hundred  pages  of  old  material, 
and  to  condense  other  portions  of  the  book.  It  is  believed  that  this 
has  been  done  without  impairing  the  value  of  the  chapters  which  have 
been  abridged.  The  decision  of  the  publishers  to  make  entirely  new 
plates  has  made  this  comparatively  easy. 

There  is  scarcely  a  page  in  the  book  but  has  been  subjected  to  re- 
vision. Sixteen  new  articles  appear  for  the  first  time  in  this  edition. 
The  more  important  ones  are  Acidosis,  Neuropathic  and  Exudative 
Diathesis,  Cardiac  Arrhythmia,  Acute  Lymphatic  Leukemia,  Banti's 
Disease,  Osteogenesis  Imperfecta,  Still's  Disease,  Syphilis  of  the  Ner- 
vous System,  Pellagra,  Epidemic  Catarrh,  Duodenal  Ulcer,  and  Idiosyn- 
crasies to  Food  Stulfs. 

More  than  twenty  chapters  have  been  almost  entirely  rewritten,  the 
most  important  being  those  upon  Birtlj  Paralyses,  Milk  and  Infant 
Feeding,  Digestion  in  Infancy,  Chronic  Intestinal  Indigestion,  Hirsch- 
sprung's Disease,  Asthma,  Accidental  Heart  Murmurs,  Hydronephrosis, 
Gonococcus  Vaginitis,  Tetany,  Convulsions,  Epilepsy,  Hydrocephalus, 
Poliomyelitis,  Diseases  of  Ductless  Glands,  Diabetes,  Hodgkin's  Disease, 
and  Tuberculous  Adenitis. 

Many  old  illustrations  have  been  omitted  and  fifteen  new  ones  in- 
troduced, all  of  them  from  original  sources.  Especial  attention  has 
been  devoted  by  the  authors  to  the  newer  methods  of  diagnosis  and 
treatment. 

The  authors  desire  to  acknowledge  the  assistance  of  Dr.  N.  Curtice 
Holt  in  the  correction  of  the  proof  sheets  and  the  preparation  of  the 
index. 

L.  Emmett  Holt, 
John  Howland. 


CONTENTS 


PA^T  I 

CHAPTER  '      PAGR 

I. — Hygiene  and  General  Care  of  Infants  and  Young  Children  .  1 
Care  of  the  newly-born  child ;  bathing ;  clothing ;  care  of  the  eyes ; 
care  of  the  mouth  and  teeth;  care  of  the  skin;  care  of  the  genital 
organs;  vaccination;  training  to  proper  control  of  rectum  and 
bladder;  general  hygiene  of  the  nervous  system;  sleep;  exercise; 
airing;  the  nursery;  the  nurse;  the  amount  of  air  space  required 
by  infants;  the  care  of  premature  and  delicate  infants;  incubators; 
the  feeding  of  the  premature  infant. 

II. — Growth  and  Development  of  the  Body        .        .        .        .        .        .15 

Weight;  height;  growth  of  extremities  as  compared  with  the 
trunk ;  the  head ;  the  chest ;  the  abdomen ;  muscular  development ; 
development  of  special  senses;  speech;  dentition. 

III. — Peculiarities   of  Disease  in   Children 30 

Etiology;  symptomatology  and  diagnosis;  pathology;  prognosis 
and  infant  mortality;  prophylaxis;  therapeutics. 


PAKT  II 

Section  I. — Diseases  qf  the  Newly  Born 

I. — Asphyxia .69 

II. — Congenital  Atelectasis     ..........      74 

III. — Icterus 77 

IV. — The  Acute  Infections  of  the  Newly  Born 82 

The    acute    pyogenic    diseases;     ophthalmia;    tetanus;     epidemic 
hemoglobinuria;  fatty  degeneration  of  the  newly  born;  pemphigus. 

V. — Hemorrhages 96 

Traumatic   or  accidental   hemorrhages;   spontaneous  hemorrhages. 

VI. — Birth  Paralyses 106 

Cerebral  paralysis ;  facial  paralysis ;  brachial  paralj'sis. 

ix 


X  CONTENTS 

CHAPTER  PAGE 

VII. — Tumors    of   the  Umbilicus,    Mastitis,   etc. 114 

Umbilical  hernia ;   mastitis ;   intestinal   obstruction ;    diaphragmatic 
hernia;  congenital  stridor;  sclerema;  inanition  fever. 


Section  II. — Nutrition 

I. — Introductory 127 

The  food  constituents  and  the  purposes  they  subserve  in  nutrition. 

II. — The  Infant's  Dietary 134 

Woman's  milk;  cow's  milk;  top  milk — skimmed  milk;  milk  sterili- 
zation ;  commercial  pasteurization  of  milk ;  pasteurization  vs. 
sterilization;  methods  of  heating  milk;  frozen  milk;  peptonized 
milk;  condensed  milk;  dried  milk;  buttermilk  and  other  forms 
of  fermented  milk;  protein  milk;  junket,  curds  and  whey;  beef 
preparations;  cereals;  infant  foods. 

III. — Infant  Feeding 165 

Choice  of  methods;  breast  feeding;  maternal  nursing;  wet-nursing; 
weaning;  mixed  feeding;  artificial  feeding;  formulas  for  whole 
milk ;  schedule  for  healthy  infants  during  the  first  year ;  feeding  in 
difficult  cases. 

IV. — Feeding  after  the  First  Year 209 

Healthy  infants  during  the  second  year ;  feeding  from  the  third  to 
the  sixth  year;  feeding  during  acute  illness;  idiosyncrasies  to  food- 
stuffs; acidosis. 

V. — The  Derangements  of  Nutrition 218 

Inanition;  marasmus;  malnutrition. 

VI. — Diseases  Due  to  Faulty  Nutrition 231 

Scorbutus;  rickets. 

VII.— Diatheses 260 

The  exudative  diathesis;  the  nem'opathic  diathesis. 

Section  III. — Diseases  op  the  Digestive  System 

I. — Diseases  of  the  Lips,  Tongue,  and  Mouth  .  .  .  .  .  -  267 
Malformations ;  diseases  of  the  lips ;  diseases  of  the  tongue ;  dental 
caries;  alveolar  abscess;  difficult  dentition;  catarrhal  stomatitis; 
herpetic  stomatitis;  ulcerative  stomatitis;  thrush;  gonorrheal  sto- 
matitis; syphilitic  stomatitis;  diphtheritic  stomatitis;  gangrenous 
stomatitis. 

II. — Diseases  of  the  Pharynx 288 

Acute  pharyngitis;  uvulitis;  elongated  uvulva ;  retropharyngeal 
abscess;  adenoid  vegetations  of  the  vault  of  the  pharynx. 


CONTENTS  xi 

CHAPTER  PAGE 

III. — Diseases  of  the  Tonsils 300 

Membranous    tonsillitis;  ulceromembranous    tonsillitis;    follicular 

tonsillitis;  phlegmonous  tonsillitis;  chronic  hypertrophy  of  the 
tonsils. 

IV. — Diseases  of  the  Esophagus      . 311 

Malformations;  acute  esophagitis;  retro-esophageal  abscess. 

V. — Diseases  of  the  Stomach       ^        .        . 315 

Digestion  in  infancy;  malformations, and  malpositions  of  the  stom- 
acliphypert^-ophic  stenosis  of  the  pylorus;  vomiting;  cyclic  vomit- 
ing; acute  gastritis;  chronic  gastric  indigestion;  dilatation  of  the 
stomach;  ulcer  of  the  stomach;  duodenal  ulcers;  tumors  of  the 
stomach;  hemorrhage  from  the  stomach;  the  swallowing  of  foreign 
bodies. 

VI. — Diseases  of  the  Intestines 348 

Malformations  and  malpositions;  diarrhea;  acute  intestinal  indi- 
gestion and  diarrhea. 

VII. — Diseases  of  the  Intestines   {continued) 373 

Acute  ileocolitis — dysentery;  amebic  colitis;  amyloid  degeneration 
of  the  intestines;  tuberculosis  of-  the  intestines  and  mesenteric 
lymph  nodes. 

VIII. — Diseases  of  the  Intestines  {continued) 395 

Chronic  intestinal  indigestion;  intestinal  colic;  chronic  constipa- 
tion; hypertrophy  and  dilatation  of  the  colon;  intussusception. 

IX. — Diseases  of  the  Intestines  {continued) 418 

Appendicitis;  intestinal  worms. 

X. — Diseases  of  the  Rectum '  .        •    430 

Prolapsus  ani;  fissure  of  the  anus;  proctitis;  ischiorectal  abscess; 
rectal  polypus;  hemorrhoids;  incontinence  of  feces. 

XI. — Diseases  of  the  Liver 436 

^Catarrhal  jaundice;  new  growths;  acute  yellow  atrophy;  congestion 
of  the  liver;  abscess  of  the  liver^suppurative  hepatitis;  cirrhosis; 
amyloid  degeneration;  fatty  liver;  hydatids;  biliary  calculi. 

XII. — Diseases  of  the  Peritoneum ■        .        .    444 

Acute  peritonitis;  chronic  (non-tuberculous)  peritonitis;  tubercu- 
lous peritonitis;  ascites;  subphrenic  abscess. 


Section  IV. — Diseases  on  the  Respiratory  System 

I. — Nasal  Cavities •    457 

Acute   rhinopharyngitis ;    chronic   nasal    catarrh ;    chronic    rhinitis ; 
epistaxis. 


xii  CONTENTS 

CHAPTER  PAGE 

II. — Diseases  of  the  Larynx 465 

Catarrhal  spasm  of  the  larynx;  acute  catarrhal  laryngitis;  sub- 
mucous laryngitis — edema  of  the  glottis;  chronic  laryngitis;  new 
growths;  foreign  bodies  in  the  larynx  and  bronchi. 

III. — Diseases  of  the  Lungs 476 

The  peculiarities  of  the  lungs  in  infancy  and  early  childhood ;  acute 
catarrhal  bronchitis;  fibrinous  bronchitis;  chronic  bronchitis; 
asthma. 

IV. — Diseases  of  the  Lungs   {continued) 492 

Pneumonia;  acute  bronchopneumonia. 

V. — Diseases  of  the  Lungs   (continued) 526 

Lobar  pneumonia;  pleuropneumonia;  hypostatic  pneumonia; 
chronic  bronchopneumonia — chronic  interstitial  pneumonia — bron- 
chiectasis; abscess  of  the  lung;  gangrene  of  the  lung;  acquired 
atelectasis — pulmonary  collapse ;  emphysema. 

VI.— Pleurisy 557  ' 

Dry  pleurisy;  pleurisy  with  serous  effusion;  empyema. 


Section  V, — Diseases  of  the  Circulatory  System 

I. — Peculiarities  of  the  Heart  and  Circulation  in  Early  Life      .        .    575 

II. — Congenital  Anomalies  of  the  Heart 579 

III. — Pericarditis 588 

Acute  pericarditis;  chronic  pericarditis  with  adhesions. 

IV. — Endocarditis  and  Valvular  Disease  of  the  Heart         ....    594 
Malignant   endocarditis;    myocarditis;   accidental   murmurs;   func- 
tional   disturbances   of  the  heart;    diseases   of  the   blood  vessels. 

Section  VI. — Diseases  of  the  Urogenital  System 

I. — The  Urine  in  Infancy  and  Childhood 615 

Lordotic,  orthostatic  or  cyclic  albuminuria;  hematuria;  hemoglobi- 
nuria; pyuria;  anuria;  diabetes  insipidus.  ^ 

II. — Diseases  of  the  Kidneys 623 

Malformations  and  malpositions;  uric-acid  infarctions;  chronic 
congestion  of  the  kidney;  acute  degeneration  of  the  kidneys;  acute 
diffuse  nephritis;  chronic  nephritis;  tuberculosis  of  the  kidney; 
tumors  of  the  kidney;  pyelitis — pyelocystitis ;  renal  calculi;  perine- 
phritis, 


CONTENTS  xiii 

CHAPTER  PAGE 

III. — Diseases  of  the  Genital  Organs  .        .        ...        .        .        .    650 

Malformations;  diseases  of  the  male  genitals;  diseases  of  the 
female  genitals;  gangrenous  vulvitis. 

IV. — Enuresis 662 

Vesical  calculus. 

Section  VII. — Diseases  of  the  Nervous  System 
I. — Introductory 669 

II. — General  and  Functional  Nervoxts  Diseases 671 

Convulsions ;  tetany ;  epilepsy ;  chorea ;  other  spasmodic  affections ; 
hysteria;  headaches;  disorders  of  speech;  disorders  of  sleep;  in- 
jurious habits  of  infancy  and  childhood. 

III. — Diseases  op  the  Brain  and  Meninges  .        .        .        .        .        .        .    719 

Malformations;  pachymeningitis;  acute  meningitis;  cerebrospinal 
meningitis ;  acute  meningitis  due  to  other  causes ;  tuberculous  men- 
ingitis; chronic  basilar  meningitis  in  infants;  thrombosis  of  the 
sinuses  of  the  dura  mater;  cerebral  abscess;  cerebral  tumor;  hy- 
drocephalus ;  chronic  internal  hydrocephalus ;  infantile  cerebral 
paralysis;  amaurotic  family  idiocy;  mental  deficiency;  Mongolian 
idiocy;  deaf-mutism. 

IV.- — Diseases  of  the  Spinal  Cord 796 

Malformations;  spinal  meningitis;  myelitis;  compression-myelitis; 
acute  poliomyelitis;  tumors  of  the  spinal  cord;  hereditary  ataxia, 
diseases  associated  with  progressive  wasting;  congenital  myatonia. 

V. — Diseases  of  the  Peripheral  Nerves 828 

Multiple  neuritis;  diphtheritic  paralysis;  facial  paralysis. 

Section  VIII. — Diseases  of  the  Blood,  Xymph  Nodes,  Ductless  Glands, 

Bones  and  Joints 

I. — Diseases  op  the  Blood      .        . 839 

Secondary    anemia;    chlorosis;    pseudolcukemic    anemia;    pernicious 
anemia ;  leukemia ;  hemophilia ;  purpura. 

II. — Diseases  op  the  Lymph  Nodes 860 

Simple  acute  adenitis;  simple  chronic  adenitis;  syphilitic  adenitis; 
tuberculous  adenitis;  Hodgkin's  disease. 

III. — Diseases  of  the  Ductless  Glands 876 

The  spleen;  enlargement  of  the  spleen;  diseases  of  the  thyroid; 
sporatic  cretinism ;  hypothyroidism ;  Graves'  disease ;  hyperthy- 
roidism; diseases  of  other  ductless  glands;  diseases  of  the  thymus; 
status  Ivmohaticus. 


xiv  COXTEXTS 

CHAPTER  PAGE 

I^'. — Diseases  op  the  Bones  and  Joints 896 

Osteogenesis  imperfecta;  chondrodystrophy;  acute  arthritis  of  in- 
fants; chronic  arthritis;  tuberculous  diseases  of  the  bones  and 
i  oints. 

V. — Diseases  of  the  Skin 920 

Congenital  ichthj'osis ;  miliaria ;  seborrhea ;  eczema  ;  f urunculosis ; 
gangrenous  dermatitis;  impetigo  contagiosa;  urticaria;  scabies; 
tinea   tonsurans — ringworm   of  the   scalp. 


"\'I. — Diseases  of  the  Ear 

Acute  otitis. 

Section  IX. — The  Specific  iNFECTiors  Diseases 
I. — Scarlet   Fever     . 
II.— ^Measles 

III. — RlBELLA 

IV. — Varicella      . 
V. — Vaccinia — Vaccination 
VI. — Pertussis 

VII.— ^luMPS 


VIII. — Diphtheria 
IX. — Typhoid   Fever   . 

X. — TrBERCI'LOSIS 

XL- — Syphilis 

XII. — IXFLIENZ  \     . 

XIIL— ^Ialaria 

Section  X. — Other  General  Diseases 

I. — Rheimatism 

II. — Di.\bktes  I\Iellitus 

III. — Pellagra       .        .        .        .    ' 


938 


952 

975 

991 

994 

997 

1003 

1015 

1020 

1059 

1067 

1103 

1130 

1139 

1149 
1155 
1158 


Index 1163 


LIST  OF  ILLUSTRATIONS 


PLATES 

PLATE  FACING 

PAGE 

I.    Chart  showing  by  months  the  mortality  of  New  York  City  for  the 

different  ages  for  three  consecutive  years 44 

II.     A,  Costochondrai  junction  in  early  rickets;  B,  Normal  costochondral 

junction 244 

III.  Typical   rickets .248 

IV.  Deformity  of  the  chest  in  severe  rickets 252 

V.    Extensive  superficial  ulceration  of  the  colon 376 

VI.  Deep  follicular  ulcers  of  the  colon 378 

VII.  Membranous  inflammation  of  the  ileum 386 

VIII.  Acute  bronchopneumonia 498 

IX.  Acute  pleuropneumonia 546 

X.  Chronic  bronchopneumonia 548 

XI.  Acute  pneumococcus  meningitis,  complicating  pleuropneumonia  .        .  744 

XII.  A,   Blood   of   an   eight-months'   fetus;    B,   Simple   anemia;    C,  von 

Jaksch's  anemia;  D,  Acute  lymphatic  leukemia      ....  840 

XIII.  Tuberculosis  of  the  tracheobronchial  Ijmiph  nodes       ....  1078 


ILLUSTEATIOXS   IX   THE   TEXT 

FIGURE 

1.  Weight  curve  for  the  first  twenty  days 

2.  Weight  curve  for  the  first  year  . 

3.  Skull,  showing  premature  ossification  . 

4.  Deaths,  New  York  City,  per  1,000  of  population 

5.  Deaths  by  months.  New  York  City  . 
8.  Chief  causes  of  death  first  year  . 

7.  Colon  of  a  child  six  months  old  . 

8.  Pemphigus    neonatorum         .... 

9.  Triple    cephalhematoma         .... 

10.  Meningeal  hemorrhage  of  the  newly  born  . 

11.  Erb's   paralysis 

12.  Umbilical  fistula  and  tumors  .... 

13.  Diaphragmatic  hernia 

14.  Temperature  chart  in  inanition  fever  . 

15.  Apparatus  for  examination  of  human  milk  . 

XV 


PAGE 

16 

17 

23 

44 

45 

47 

65 

95 

98 

107 

112 

115 

119 

124 

139 


xvi  LIST  OF  ILLUSTRATIONS 

FIGURE                                     .  pAf  E 

16.  A,  Babcock  tubes;  B,  Lewi's  modification  for  human  milk      .        .        .  140 

17.  Chart  showing  effect  of  pregnancy  on  weight  of  nursing  infant  .        .        .  178 

18.  Case  of  marasmus ■      .        .  223 

19.  Case  of  scurvy 235 

20.  Costochondral  junction  in  marked  rickets 247 

21.  Rachitic  skull,  inside  view 249 

22.  Rachitic  head 250 

23.  Rachitic  skull,  external  view .        .        .  250 

24.  Rachitic  thorax  in  outline 251 

25.  Rachitic  spine 252 

26.  Multiple  fractures  in  rickets 253 

27.  Epithelial  desquamation  of  the  tongue 270 

28.  Thrush 282 

29.  Adenoid  vegetations 295 

30.  Temperature  chart,  streptococcus  angina  following  measles     .        .        .  303 

31.  Gastric  peristalsis  in  pyloric  stenosis 323 

32.  Malformations  of  the  rectum       .        . 349 

33.  Chart  showing  mortality  from  diarrheal  diseases  in  New  York      .        .  352 

34.  Chart  showing  deaths  under  one  year  per  1,000  of  population  under 

one  year,  New  York  City,  summer  months 353 

35.  Temperature  chart  of  acute  intestinal  intoxication  with  fatal  relapse      .  362 

36.  Acute  catarrhal  ileocolitis,  severe  form 376 

37.  Follicular  ulceration  of  the  colon,  early  stage 378 

38.  Follicular  ulceration  of  the  colon,  later  stage 379 

39.  Membranous    colitis .  380 

40.  Temperature  chart  in  ileocolitis 383 

41.  Temperature  chart  in  membranous  colitis         ......  385 

42.  Temperature  chart  in  membranous  colitis 386 

43.  Chronic  intestinal  indigestion       .        , 396 

44.  Ileocecal  intussusception 411 

45.  Mechanism  of  intussusception .        .  413 

46.  An  air  vesicle  in  bronchopneumonia  .    ■ 493 

47.  An  air  vesicle  in  lobar  pneumonia 494 

48.  Bronchopneumonia  with  thickened  bronchus 499 

49.  Bronchopneumonia  with  emphysema 501 

50.  Bronchopneumonia,  diffuse  purulent  infiltration        .        .        .        .        .  502 

51.  Persistent   bronchopneumonia 504 

52.  Temperature  chart  in  mild  uncomplicated  bronchopneumonia  .        .        .  509 

53.  Temperature  chart,  prolonged  bronchopneumonia 510 

54.  Temperature  chart,  relapsing  bronchopneumonia       .        .        .        •        •  510 

55.  Temperature  chart,  rapidly  fatal  bronchopneumonia  ...*..  511 

56-59.  Physical  signs  in  bronchopneumonia 513 

60.  Temperature  chart,  persistent  bronchopneumonia 515 


LIST  OF  ILLUSTRATIONS  x\'ii 

FIGURE  PAGE 

6L  Temperature  chart,  bronchopneumonia  following  pertussis     .        .        .  516 

62.  Temperature  chart,  bronchopneumonia  complicating  influenza       .        .  518 

63.  Bronchopneumonia — X-ray 520 

64.  Temperature  chart,  typical  lobar  pneumonia 531 

65.  Temperature  chart,  remittent  type,  lobar  pneumonia 532 

66.  Temperature  chart,  lobar  pneumonia,  subnormal  temperature  after  crisis  532 

67.  Temperature  chart,  abortive  pneumonia 533 

68-70.  Physical  signs,  lobar  pneumonia 536 

71.  Lobar  pneumonia — X-ray 537 

72.  General  subcutaneous  emphysema 557 

73.  Section  of  lung,  showing  distribution  of  fluid  in  chest      ....  564 

74.  Empyema — X-ray .  565 

75.  Empyema — X-ray 565 

76.  Temperature  chart,  empyema  following  pneumonia 566 

77.  Temperature  chart,  empyema  following  pneumonia  .        .        .        .        .  566 

78.  Deformity  after  old  empyema 572 

79.  Apparatus  for  inducing  pulmonary  expansion  after  empyema  .        .        .  573 

80.  Congenital  cardiac  disease 581 

81.  Clubbing  of  fingers  in  congenital  cardiac  disease 584 

82-83.  Pericarditis  with  effusion — X-ray 591 

84.  Congenital  malformations  of  the  kidneys  and  ureters       ....  626 

85.  Sarcoma  of  the  kidney 641 

86.  Tetany 679 

87.  Meningocele     . 720 

88.  Encephalocele           .        . 720 

89.  Hydrencephalocele           .        .    " 720 

90.  Meningocele 720 

91.  Frontal  meningocele 721 

92.  Nasofrontal  meningocele 721 

93.  Incidence  of  cerebrospinal  meningitis 727 

94.  Posture  in  cerebrospinal  meningitis .        ,  731 

95.  Temperature  chart,  cerebrospinal  meningitis,  recovery   ....  735 

96.  Temperature  chart,  cerebrospinal  meningitis,  treated  by  serum      .        .  739 

97.  Temperature    chart,    cerebrospinal    meningitis,    with   late    injection    of 

serum 740 

98.  Seasonal  occurrence  of  tuberculous  meningitis 749 

99.  Tracing  of  respiration  in  tuberculous  meningitis 751 

100.  Temperature  chart  in  tuberculous  meningitis 752 

101.  Chronic  basilar   meningitis 755 

102.  Chronic  basilar   meningitis   .        .        . 756 

103.  Brain  in  external  hydrocephalus 770 

104.  Brain  in  internal  hydrocephalus 771 

105.  Section  of  a  normal  brain 772 

3  ^ 


xviii  LIST  OF  ILLUSTRATIOXS 

FIGURE  PAGE 

106.  Vertical  transverse  section  of  a  brain  in  congenital  hydrocephalus  .         .  774 

107.  Oxycephaly  with  exophthalmus 777 

108.  Scaphocephaly 778 

109.  Brain  showing  atrophj' 779 

110.  Convulsions  in  spastic  paraplegia :  781 

111.  Spastic  paraplegia 782 

112.  Recent  meningeal  hemorrhage 784 

113.  Infantile  hemiplegia  showing  contractures "  786 

114.  Brain  in  idiocy 791 

115-117.  Various  types  of  mental  defect 792 

118-120.  Mongolian  idiocy 794 

121.  Spina  bifida,  meningocele  (partially  diagrammatic) 797 

122.  Spina  bifida,  meningocele 798 

123.  Spina  bifida,  meningomj^elocele   (partially  diagrammatic)       .        .        .  798 

124.  Spina  bifida,  sacral 800 

125.  Infantile  spinal  paralysis  of  lower  extremity- 815 

126.  Infantile  spinal  paralysis  of  shoulder  . 816 

127.  Muscular  pseudohypertrophy 825 

128.  Alcoholic   neuritis •        .  830 

129.  Diphtheritic  paralysis 831 

130.  Facial  paralysis 836 

131.  Acute  suppurative  adenitis,  cervical •  863 

132.  Acute  suppurative  adenitis,  inguinal 864 

133.  Cicatrices  following  tuberculous  adenitis 871 

134-135.  Cretins,  showing  effect  of  thyroid  treatment 883 

136-137.  Cretins,  showing  effect  of  thyroid  treatment 885 

138.  Infantile  myxedema 887 

139.  Enlarged  thymus     .         .         . 892 

140.  Osteogenesis  imperfecta — X-ray 896 

141.  Chondrodj'strophy,  radiograph  of  skull 898 

142.  Chondrodystrophy,  long  bones 898 

143.  Chondrodystrophy,  infantile  figure       .     - 899 

144.  Chondrodystrophy,  trident  hand 899 

145.  Chondrodystrophy,   adult  figure 899 

146.  Section  of  the  spine  in  Pott's  disease 908 

147.  Hip-joint    disease 913 

148.  Tuberculous  dactylitis 919 

149.  Congenital   ichthyosis 921 

150.  Temperature  chart,  acute  otitis,  following  influenza 940 

151.  Temperature  chart,  acute  otiti.^,  early  paracentesis 941 

152.  Temperature  charts  in  scarlet  fever,  mild  cases 958 

153.  Temperature  chart  in  scarlet  fever,  typical  curve 959 

154.  Temperature  chart  in  severe  imcomplicated  scarlet  fever  ....  960 


LIST  OF  TLLI'STPvATTOXS  xix 

FIGURE  PAGE 

155.  Temperature  chart  in  fatal  septic  scarlet  fever 961 

156.  Temperature  chart  in  scarlet  fever  with  late  otitis 965 

157.  Temperature  chart  in  scarlet  fever  with  late  nephritis       ....  966 
158-159.  Temperature  charts  in  measles,  typical  curve 981 

160.  Temperature  chart  in  measles,  occasional  course 982 

161.  Temperature  chart  in  measles,  prolonged  course 982 

162-163.  Temperature  charts  in  measles  complicated  by  pneumonia        .        .    983 

164.  Table  showing  protective  power  of  vaccination 998 

165-169.  Vaccination  vesicles 1000 

170.  Generalized    vaccinia      .        .       , 1001 

171.  Temperature  chart  in  typhoid  fever,  short  course 1062 

172.  Temperature  chart  in  typhoid  fever,  with  relapse 1062 

173.  Tuberculous  bronchopneumonia,  diffuse  consolidation       ....  1076 

174.  Cavity  from  tuberculous  bronchopneumonia 1076 

175.  Pulmonary  tuberculosis,  extensive  caseation 1077 

176.  Miliary  tuberculosis  of  the  lungs 1085 

177.  Temperature  chart  of  tuberculosis  following  measles        ....  1088 

178.  Temperature   chart   of  tuberculous  bronchopneumonia,   general  tuber- 

culosis     1089 

179.  Temperature  chart  of  tuberculous  bronchopneumonia  with  softening     .  1090 

180.  Tuberculous  bronchial  glands 1098 

181.  Early  eruption  of  hereditary  syphilis,  legs 1111 

182.  Early  eruption  of  hereditary  syphilis,  face 1112 

183.  Syphilitic  scaling  of  the  sole 1112 

184.  A  later  form  of  eruption  in  hereditary  syphilis 1113 

185.  Hereditary  syphilis 1115 

186.  Syphilitic  periostitis  of  the  fibula,  radiograph 1115 

187-188.  Syphilitic  dactylitis  .        .        .        .        . 1116 

189-190.  Syphilitic  dactylitis,  radiograph .  1117 

191.  Syphilitic  notched  teeth 1117 

192.  Syphilitic  teeth,  deformed 1118 

193.  Syphilitic  osteoperiostitis  of  the  tibia 1119 

194.  Syphilitic  osteoperiostitis  of  the  tibia,  radiograph 1120 

195.  Temperature  chart  of  severe  influenza  in  an  infant 1132 

196.  Temperature  chart  of  acute  bronchopneumonia  complicating  influenza  .  1133 

197.  Temperature  chart,  influenza,  bronchitis,  otitis 1134 

198.  Temperature  chart,  double  tertian  intermittent  fever        .        .        .        .1141 

199.  Temperature  chart,  tertian  intermittent  fever 1142 

200.  Temperature  chart  in  malaria,  irregular  type 1143 

201.  Pellagra 1160 


THE   DISEASES   OF   INFANCY  AND 
CHILDHOOD 

PART   I 


CHAPTEE  I 

HYGIENE  AND   GENERAL  CARE  OF  INFANTS  AND   YOUNG 

CHILDREN 

The  physical  development  of  the  child  is  essentially  the  product  of 
the  three  factors— inheritance,  surroundings,  and  food.  The  first  of  these 
it  is  beyond  the  physician's  power  to  alter ;  the  second  is  largely  and  the 
third  almost  entirely  within  his  control,  at  least  in  the  more  intelligent 
classes  of  society.  These  two  subjects,  infant  hygiene  and  infant  feeding, 
are  the  most  important  departments  of  pediatrics. 

The  Care  of  the  Newly-Bom  Child. — After  the  ligature  of  the  cord  the 
child  should  be  wrapped  in  a  thick  blanket  and  placed  in  a  warm  room. 
In  hospital  practice  the  eyes  should  be  cleansed  with  absorbent  cotton  and 
water  which  has  been  boiled,  and  then  two  or  three  drops  of  a  two  per 
cent  solution  of  nitrate  of  silver,  after  Crede's  method,  instilled  into  each 
eye  by  means  of  a  glass  rod  or  eye-dropper.  In  private  practice  a  ten  per 
cent  solution  of  argyrol  may  be  substituted,  unless  the  mother  has  had  a 
purulent  vaginal  discharge,  in  which  case  the  silver  solution  should 
always  be  used.  The  bath  should  now  be  given  in  a  warm  room ;  the  body 
being  first  oiled  thoroughly  in  order  to  remove  the  vernix  caseosa  and 
then  washed  in  water  at  a  temperature  of  100°  F.  The  mouth  should  be 
cleansed  with  sterile  water  and  a  soft  cloth,  and  no  violence  employed. 
The  cord  may  be  covered  with  sterilized  talcum  or  bismuth  powder,  and 
wrapped  in  sterile  gauze  or  surgeon's  lint.  The  abdomen  should  now  be 
enveloped  in  a  flannel  band,  eight  or  ten  inches  wide,  and  pinned  rather 
snugly.  Before  dressing  is  completed,  the  child  should  be  submitted  to  a 
thorough  examination  for  injuries  received  during  delivery,  congenital 
deformities,  also  as  to  the  condition  of  the  respiration,  circulation,  etc. 

1 


2  HYGIENE  AND  GENERAL  CARE 

After  dressing,  the  child  should  be  placed  in  his  crib  and  covered  with 
blankets,  and  if  the  feet  are  cold,  or  the  fingers  and  lips  a  little  blue,  he 
should  be  surrounded  by  hot-water  bottles  covered  with  flannel,  and 
placed  near,  but  not  in  contact  with,  the  body.  The  crib  should  be  placed 
in  a  quiet,  darkened  room.  The  young  infant  should  not  occupy  the 
same  bed  as  the  mother,  unless  he  greatly  needs  the  warmth  of  her  hodj, 
other  means  of  artificial  heat  not  being  at  hand. 

The  cord  should  be  kept  dry  and  disturbed  as  little  as  possible  until 
it  falls  off.  Under  ordinary  circumstances  the  cord  separates  from  the 
fourth  to  the  seventh  day,  the  average  being  the  fifth  day.  The  stump 
should  then  be  covered  with  the  sterilized  talcum  or  bismuth  powder, 
and  a  pad  of  sterile  gauze  about  one-fourth  of  an  inch  thick  and  two 
inches  square  applied  and  secured  in  position  by  means  of  the  abdominal 
band.  The  purpose  of  this  is  to  prevent  umbilical  hernia.  The  pad 
should  be  continued  for  the  first  month.  The  use  of  stronger  antiseptic 
dressings  than  those  recommended  is  somewhat  objectionable,  since  it 
preserves  the  cord  too  long  and  delays  separation.  The  full  bath  should 
not  be  given  until  the  cord  has  separated. 

The  physician  should  always  see  to  it  that  the  infant  cries  enough  to 
keep  the  lungs  properly  expanded. 

The  question  of  food  for  the  newly-born  infant  is  considered  in  the 
chapter  upon  infant  feeding. 

Bathing. — For  the  first  few  months  the  bath  should  be  given  at  98° 
F.  The  room  should  be  warm,  preferably  there  should  be  an  open  fire. 
The  bath  should  be  short  and  the  body  dried  quickl}^  without  too  vigorous 
rubbing.  The  addition  of  salt  to  the  bath  is  an  advantage  where  the  skin 
is  unusually  delicate  or  excoriations  are  present.  One  large  handful 
should  be  used  to  a  gallon  of  water.  By  the  sixth  month  the  temperature 
of  the  bath  for  healthy  infants  may  be  lowered  to  95°  F.,  and  by  the  end 
of  the  first  year  to  90°  F.  Older  children  who  are  healthy  should  be 
sponged  or  douched  for  a  moment  at  the  close  of  the  tepid  bath  with 
water  at  65°  or  70°  F.  During  childhood  the  warm  bath  is  preferably 
given  at  night.  In  the  morning  a  cold  sponge  bath  is  desirable.  This 
should  be  given  in  a  warm  room  and  while  the  child  stands  in  a  tub 
partly  filled  with  warm  water.  This  cold  sponge  should  last  but  half  a 
minute,  and  be  followed  by  a  brisk  rubbing  of  the  entire  body. 

In  some  young  infants  and  even  older  children  there  is  no  proper 
reaction  after  the  bath,  even  when  given  at  the  temperatures  mentioned ; 
children  being  pale,  slightly  blue  about  the  lips  and  under  the  eyes.  All 
tub  bathing,  and  especially  all  cold  bathing,  should  then  be  stopped,  since 
a  continuance  can  only  be  a  drain  upon  the  child's  vitality. 

Clothing. — The  clothing  of  infants  should  be  light,  warm,  non-irri- 
tating to  the  skin,  and  loose  enough  to  allow  free  motion  of  the  extrem- 


THE  CARE  OF  THE  XEWLY-BORX  CHILD  3 

ities ;  nor  should  bauds  be  pinned  so  tightly  about  the  trunk  as  to  embar- 
rass the  movements  either  of  the  chest  or  of  the  abdomen.  The  chest 
should  be  covered  with  a  woollen  shirt,  high  in  the  neck  and  with  long 
sleeves.  All  petticoats  should  be  supported  from  the  shoulders  and  not 
from  waistbands.  Canton  flannel  and  stockinet  are  both  superior  as 
absorbents  to  the  more  commonly  used  linen  diapers.  Stockinet  has  the 
advantage  of  being  very  soft  and  pliable.  Care  should  be  taken  that  in 
infants  the  feet  be  kept  warm.  If  the  circulation  is  very  poor,  a  bag  of 
hot  water  should  always  be  in  the  crib.  Chilling  of  the  surface  is  some- 
times responsible  for  attacks  of  colic. 

The  abdominal  band  is  usually  worn  during  infancy.  It  cannot  be 
considered  in  any  sense  a  necessity  after  the  first  few  months,  except 
in  cases  of  very  thin  infants  whose  supply  of  fat  in  the  abdominal  walls 
is  an  insufficient  protection  to  the  viscera.  For  the  first  few  weeks  a  band 
of  plain  flannel  is  to  be  preferred;  later,  a  knitted  band  with  shoulder- 
straps.  The  fashion  of  low  neck  and  short  sleeves  for  infants  and  very 
young  children  has  fortunately  passed  away — let  us  hope,  not  to  return. 

During  the  summer  the  outer  clothing  should  be  light  and  the  under 
clothing  of  the  thinnest  flannel  or  gauze.  The  changes  in  the  tempera- 
ture of  morning  and  evening  may  be  me-t  by  extra  wraps.  The  custom  of 
allowing  young  children  to  go  with  legs  bare  has  many  enthusiastic  advo- 
cates; while  it  may  not  be  objectionable  during  the  heat  of  summer,  its 
advantages  at  any  season  are  very  questionahle  in  a  changeable  climate 
like  that  of  ISTew  York  or  the  Atlantic  coast.  Many  delicate  children  are 
certainly  injured  by  such  ill-advised  attempts  at  hardening. 

The  night  clothing  of  infants  should  be  similar  to  that  worn  during 
the  day,  but  should  be  loose,  the  material  being  of  the  lightest  flannel. 
The  night  clothing  for  older  children  should  consist  of  a  thin  woollen 
shirt  and  a  union  suit  with  waist  and  trousers,  and  in  some  cases  with 
feet,  if  there  is  a  tendency  to  get  outside  the  coverings.  The  common 
mistake  is  to  overload  all  children,  but  especially  infants,  with  covering 
at  night.  This  is  an  explanation  of  much  of  the  restless  sleep  which  is 
seen,  particularly  in  delicate  children. 

Care  of  the  Eyes. — During  the  first  few  days  at  the  daily  1)ath  the 
eyes  shoidd  be  cleansed  with  a  saturated  solution  of  boric  acid.  They 
should  be  carefully  protected  from  too  strong  light  during  early  infancy. 
It  is  desirable  that  a  child  should  always  sleep  in  a  darkened  room. 

Care  of  the  Mouth  and  Teeth. — The  mouth  of  the  newl}^-born  infant 
should  be  gently  cleansed  at  each  morning  bath  with  boiled  water  and 
a  soft  cloth.  On  the  first  appearance  of  thrush  the  mouth  should  be 
washed  after  every  feeding  with  a  solution  of  bicarbonate  of  soda  or  boric 
acid  (ten  grains  to  the  ounce).  It  should  be  applied  with  a  swab  made 
by  twisting  a  Int  of  cotton  upon  a  wooden  toothpick,  and  not  by  the 


4  HYGIENE  AND  GENERAL  CARE 

nurse's  finger.  Harm  is  often  done  by  the  use  of  too  much  zeal  in 
cleansing  the  mouth  of  a  young  infant. 

The  primary  teeth  as  well  as  those  of  the  permanent  set  should  receive 
daily  attention.  Too  often  they  are  neglected  altogether.  Dirty  teeth 
are  likely  sooner  or  later  to  become  carious;  and  carious  teeth,  besides 
being  a  cause  of  bad  breath  and  pain,  are  a  constant  menace  to  the  health 
of  the  child,  since  they  are  frequently  the  cause  of  severe  infections.  Such 
teeth  should  either  be  filled  or  removed. 

Care  of  the  Skin. — The  skin  of  a  young  infant  is  exceedingly  delicate, 
and  excoriations,  intertrigo,  and  eczema  are  of  very  common  occurrence. 
These  conditions  are  much  easier  of  prevention  than  of  cure.  The  first 
essential  in  the  care  of  the  skin  is  cleanliness,  and  this  must  be  secured 
without  the  use  of  strong  soaps  or  too  much  rubbing.  Napkins  must  be 
removed  as  soon  as  soiled  or  wet.  Some  bland  absorbent  powder,  like 
starch,  talcum,  or  the  stearate  of  zinc,  should  be  used  in  all  the  folds  of 
the  skin,  in  the  neck,  in  the  axillae,  groins,  and  about  the  genitals,  and 
in  the  folds  of  the  thighs,  particularly  in  very  fat  infants.  If  plain  water 
■produces  an  undue  amount  of  irritation,  the  salt  or  bran  bath  should  be 
employed. 

Care  of  the  Genital  Organs. — The  female  genitals  need  but  little 
attention  in  young  children,  except  as  to  cleanliness.  This  is  more  often 
neglected  in  older  children  than  in  infants. 

In  males  the  prepuce  should  receive  attention  during  the  first  few 
weeks  of  life.  If  the  foreskin  is  long  and  the  preputial  orifice  small, 
circumcision  should  be  done.  If  it  is  not  long,  but  is  only  adherent, 
these  adhesions  should  be  broken  up,  the  parts  thoroughly  cleansed  and 
the  foreskin  retracted  dally  until  there  is  no  disposition  to  a  recurrence 
of  the  adhesions.  These  operations  will  be  discussed  more  at  length  in 
a  subsequent  chapter.  The  only  thing  to  be  emphasized  in  the  present 
connection  is  that  the  prepuce  should  receive  proper  attention  in  early 
infancy,  since  this  can  now  be  done  with  less  pain  and  discomfort  to  the 
child,  and  at  the  same  time  better  results  are  obtained.  If  this  matter 
is  neglected  during  infancy,  it  is  apt  to  be  overlooked  until  harm  has 
been  produced  by  local  or  reflex  irritation  which  phimosis  or  adherent 
prepuce  may  have  excited. 

Vaccination. — This,  although  considered  elsewhere,  should  be  men- 
tioned in  this  connection  as  among  the  things  requiring  the  physician's 
attention  during  the  first  months  of  life. 

Training  to  Proper  Control  of  Rectum  and  Bladder. — It  is  surprising 
to  see  what  can  be  accomplished  by  intelligent  efforts  at  training  in  these 
particulars.  An  infant  can  often  be  trained  at  three  months  to  have  its 
movements  from  the  bowels  when  placed  upon  a  small  chamber.  This 
not  only  saves  a  great  amount  of  washing  of  napkins,  but  there  is  soon 


HYGIENE  OF  THE  NERVOUS  SYSTEM  5 

formed  a  habit  of  having  tlie  bowels  move  at  a  regular  time  or  times  each 
day.  The  infant  must  be  put  upon  the  chamber  soon  after  his  feeding. 
The  importance  of  training  young  children  to  regular  habits  regarding 
evacuations  from  the  bowels  can  hardly  be  overestimated.  It  should  be 
impressed  upon  every  mother  and  nurse  by  the  physician,  and  especially 
the  necessity  of  beginning  training  during  infancy.  Much  of  course  will 
depend  upon  the  food  and  the  digestion ;  but  habit  is  a  very  large  factor 
in  the  case. 

The  training  of  the  bladder  is  not  quite  so  important,  but  the  proper 
education  of  this  organ  adds  much  to  the  comfort  of  the  child  and  the  ease 
with  which  he  is  cared  for.  Before  the  end  of  the  first  year  many  intelli- 
gent children  can  be  trained  to  indicate  a  desire  to  empty  the  bladder. 
Many  mothers  and  nurses  succeed  in  training  children  so  well  that  by 
the  tenth  or  eleventh  month  napkins  are  dispensed  with  during  the  day. 
On  the  other  hand,  it  is  very  common  to  see  children  of  two  and  even  two 
and  a  half  years  still  wearing  napkins  because  of  the  lack  of  proper  train- 
ing. Before  he  has  reached  the  age  of  three  years  a  healthy  child  will 
usually  go  from  10  p.m.  until  morning  without  emptying  the  bladder. 
The  annoyance  and  discomfort  from  the  neglect  of  early  training  in  this 
particular  are  very  great.  Night  feeding  is  responsible  for  much  of  the 
difficulty  experienced  in  training  children  to  hold  the  water  during  the 
night. 

Greneral  Hygiene  of  the  Nervous  System. — Great  injury  is  done  to 
the  nervous  system  of  children  by  the  influences  with  which  they  are 
surrounded  during  infancy,  especially  during  the  first  year.  The  brain 
grows  more  during  the  first  two  years  than  in  all  the  rest  of  life.  Normal 
healthy  development  of  the  nervous  centers  demands  quiet,  rest,  peaceful 
surroundings,  and  freedom  from,  everything  which  causes  excitement  or 
undue  stimulation. 

The  steadily  increasing  frequency  of  functional  nervous  diseases 
among  young  children  is  one  of  the  most  powerful  arguments  for  greater 
attention  by  physicians  to  the  subject  of  hygiene  of  the  nervous  system 
during  infancy.  Most  parents  err  through  ignorance.  Playing  with 
young  children,  stimulating  to  laughter  and  exciting  them  by  sights, 
sounds,  or  movements  until  they  shriek  with  apparent  delight,  may  be  a 
source  of  amusement  to  fond  parents  and  admiring  spectators,  but  it  is 
almost  invariably  an  injury  to  the  child.  This  is  especially  harmful  when 
done  in  the  evening.  It  is  the  plain  duty  of  the  physician  to  enlighten 
parents  upon  this  point,  and  insist  that  the  infant  shall  be  kept  quiet, 
and  that  all  such  playing  and  romping  as  has  been  referred  to  shall, 
during  the  first  year  at  least,  be  absolutely  prohibited. 

Sleep. — The  sleep  of  the  newly-born  infant  is  profound  for  the  first 
two  or  three  days  and  under  normal  conditions  almost  continuous.     In 


6  HYGIENE  AND  GENERAL  CARE 

the  case  of  prolonged  or  tedious  labor,  or  where  from  any  cause  undue 
compression  has  been  exerted  upon  the  head,  it  may  approach  the  con- 
dition of  semi-coma  for  twenty-four  or  forty-eight  hours.  This  may  be 
so  deep  as  to  excite  apprehensions  of  serious  brain  lesions.  If,  however, 
there  are  associated  with  it  no  convulsions  and  no  rigidity,  this  early 
stupor  usually  passes  away  on  the  second  or  third  day. 

The  sleep  of  early  infancy  is  quiet  and  peaceful,  but  not  very  deep 
after  the  first  month.  After  the  third  year  the  heavy  sleep  of  childhood 
is  commonly  seen.  A  healthy  infant  during  the  first  few  weeks  sleeps 
from  twenty  to  twenty-two  hours  out  of  the  twenty-four,  waking  only 
from  hunger,  discomfort,  or  pain.  During  the  first  six  months  a  healthy 
infant  will  usually  sleep  from  sixteen  to  eighteen  hours  a  day,  the  waking 
periods  being  only  from  half  an  hour  to  two  hours  long.  At  the  age  of 
one  year  most  infants  sleep  from  fourteen  to  fifteen  hours,  viz.,  from 
eleven  to  twelve  hours  at  night,  and  two  or  three  hours  during  the  day, 
usually  in  two  naps.  AYhen  two  years  old  usually  thirteen  to  fourteen 
hours'  sleep  are  taken;  eleven  or  twelve  hours  at  night  and  one  or  two 
hours  during  the  day,  generally  in  a  single  nap.  At  the  age  of  four  years 
children  require  from  eleven  to  twelve  hours'  sleep.  It  is  always  desir- 
able, and  in  most  cases  with  regularity  it  is  possible,  to  keep  up  the  daily 
nap  until  children  are  five  years  old.  From  six  to  ten  years  the  amount 
of  sleep  required  is  ten  or  eleven  hours,  and  from  ten  to  sixteen  years 
nine  hours  should  be  the  minimum. 

Training  in  proper  habits  of  sleep  should  be  begun  at  birth.  From 
the  outset  an  infant  should  be  accustomed  to  being  put  into  his  crib  while 
awake  and  to  go  to  sleep  of  his  own  accord.  Eocking  and  all  other  habits 
of  this  sort  are  useless  and  may  even  be  harmful.  An  infant  should  not , 
be  allowed  to  sleep  on  the  breast  of  the  nurse,  nor  with  the  nipple  of  the 
bottle  in  his  mouth.  Other  devices  for  putting  infants  to  sleep,  such  as 
allowing  the  child  to  suck  a  rubber  nipple  or  anything  else,  are  positively 
injurious.  If  such  means  of  inducing  sleep  are  resorted  to  the  infant 
soon  acquires  the  habit  of  not  sleeping  without  them.  We  have  known  of 
one  instance  where  the  habit  of  rocking  during  sleep  was  continued  until 
the  child  was  two  years  old;  the  moment  the  rocking  was  stopped  the 
infant  would  wake,  and  in  consequence  this  practice  was  continued  by 
the  devoted  but  misguided  parents.  A  quiet,  darkened  room,  a  warm 
and  comfortable  bed,  an  appetite  satisfied,  and  dry  napkins  are  all  that 
are  needed  to  induce  sleep  in  a  healthy  child. 

The  periods  of  sleep  in  young  infants  are  usually  from  two  to  three 
hours  long,  with  the  exception  of  once  or  twice  in  the  twenty-four  hours, 
when  a  long  sleep  of  five  or  six  hours  occurs.  The  purpose  of  training 
is  to  have  the  child  take  this  long  sleep  at  night.  The  habit  of  regular 
sleep  is  best  established  by  wakening  the  infant  regularly  every  three  or 


EXERCISE  7 

four  hours  during  the  day  for  feeding,  and  allowing  him  to  sleep  as  long 
as  possible  during  the  night.  This  training  goes  hand-in-hand  with 
regular  habits  of  feeding.  Such  habits  are  easily  formed  if  the  plan  be 
systematically  followed  from  the  outset. 

By  the  fourth  month  all  feeding  between  10  p.m.  and  6  a.m.  should  be 
discontinued.  If  this  is  done  most  infants  can  be  trained  by  this  time 
to  sleep  all  night.  If  the  room  is  lighted,  and  the  child  taken  from  the 
crib  or  rocked  or  fed  as  soon  as  he  wakens  at  night,  there  is  no  such  thing 
as  the  formation  of  good  habits  of  sleep.  Eegularity  in  sleep  and  feeding 
not  only  makes  the  care  of  young  infants  very  much  easier,  but  is  of  a 
good  deal  of  importance  for  the  health  of  the  cliild. 

The  causes  of  disturbed  or  irregular  sleep  in  young  infants  are  mainly 
two — hunger  and  indigestion.  In  nursing  infants  it  is  usually  the  for- 
mer ;  in  those  artificially  fed  usually  the  latter.  Sleeplessness  from  hun- 
ger is  often  seen  in  children  who  are  nursed  thirty  or  forty  minutes  and 
then  fall  asleep,  but  wake  in  fifteen  or  twenty  minutes  crying  and  fretful. 
After  being  quieted  they  may  fall  asleep  again  for  half  an  hour,  but 
wake  at  short  intervals.  The  peaceful  sleep  of  two  or  three  hours  which 
should  follow  a. proper  feeding  is  never  seen.  With  this  restlessness  from 
indigestion  other  signs  are  usually  present,  stationary  weight,  etc.  The 
disturbed  sleep  due  to  overfeeding  shows  itself  by  much  the  same  symp- 
toms, except  that  the  first  sleep  after  the  meal  is  usually  longer. 

Exercise. — This  is  no  less  important  in  infancy  than  in  later  child- 
hood. An  infant  gets  his  exercise  in  the  lusty  cry  which  follows  the  cool 
sponge  of  the  bath,  in  kicking  his  legs  about,  waving  his  arms,  etc.  By 
these  means  pulmonary  expansion  and  muscular  development  are  in- 
creased and  the  general  nutrition  promoted.  An  infant's  clothing  should 
be  such  as  not  to  interfere  with  his  exercise.  Confinement  of  the  legs 
should  not  be  permitted.  In  hospital  practice  we  have  often  had  a  chance 
to  observe  the  bad  results  which  follow  when  very  young  infants  are 
allowed  to  lie  in  the  cribs  nearly  all  the  time.  Little  by  little  the  vital 
processes  flag,  the  cry  becomes  feeble,  the. weight  is  first  stationary,  then 
there  is  a  steady  loss.  The  appetite  fails  so  that  food  is  at  first  taken 
without  relish,  then  at  times  altogether  refused;  later,  vomiting  ensues 
and  other  symptoms  of  indigestion.  This,  in  many  cases,  is  the  beginning 
of  a  steady  downward  course  which  goes  on  until  a  condition  of  hopeless 
marasmus  is  reached.  Such  infants  must  be  taken  up  every  few  hours 
and  carried  about  the  wards ;  the  position  should  be  frequently  changed, 
and  general  friction  of  the  entire  body  employed  at  least  twice  a  day. 
Every  means  must  be  made  use  of  to  stimulate  the  vital  activity.  The 
value  of  systematic  attention  to  these  matters  cannot  be  overestimated  in 
hospitals  for  infants.  Infants  who  are  old  enough  to  creep  or  stand 
usually  take  sufficient  exercise  unless  they  are  restrained.     At  this  age 


8  HYGIENE  AND  GENERAL  CARE 

they  should  be  allowed  to  do  what  tlie_y  are  eager  to  do.  Every  facility 
should  be  afforded  for  using  their  muscles.  Exercise  may  be  encouraged 
by  placing  upon  the  floor  in  a  warm  room  a  mattress  or  a  thick  "com- 
fortable/' and  allowing  the  infant  to  roll  and  tumble  upon  it  at  will.  A 
large  bed  may  answer  the  same  purpose. 

In  older  children  every  form  of  out-of-door  exercise  should  be  encour- 
aged— ball,  tennis,  and  all  running  games,  horseback  riding,  the  bicycle, 
tricycle,  swimming,  coasting,  and  skating.  Up  to  the  eleventh  year  no 
difference  need  be  made  in  the  exercise  of  the  two  sexes.  Companionship 
is  a  necessity.  Children  brought  up  alone  are  at  a  great  disadvantage  in 
this  respect,  and  are  not  likely  to  get  as  much  exercise  as  they  require. 
The  amount  of  exercise  allowed  delicate  children  should  be  regulated 
with  some  degree  of  care.  It  may  be  carried  to  the  point  of  moderate 
muscular  fatigue,  but  never  to  muscular  exhaustion.  The  latter  is  par- 
ticularly likely  to  be  the  case  in  competitive  games. 

Exercise  should  have  reference  to  the  symmetrical  development  of  the 
whole  body.  In  prescribing  it  the  specific  needs  of  the  individual  child 
should  be  considered.  By  carefully  regulated  exercises  very  much  may 
be  done  to  check  such  deformities  as  round  shoulders  and  slight  lateral 
curvature  of  the  spine,  and  also  to  develop  narrow  chests  and  feeble 
thoracic  muscles.  For  purposes  like  these,  gymnastics  are  exceedingly 
valuable  to  supplement  out-of-door  exercise,  but  they  can  never  take  their 
place. 

There  are  two  important  points  with  reference  to  exercise  indoors. 
First,  the  playroom  should  be  cool — about  60°  F.  Secondly,  during  all 
active  exercise  the  clothing  should  be  loose  and  light,  so  as  to  allow  the 
freest  possible  motion  of  the  body. 

Airing. — In  summer  there  can  be  no  possible  objection  to  a  young 
infant  being  allowed  out  of  doors  at  the  end  of  the  first  week.  He  should 
be  kept  in  the  open  air  as  much  as  possible  during  the  day.  In  the  fall 
and  spring  this  should  not  be  permitted  until  the  child  is  at  least  a  month 
old,  and  then  only  when  the  out-of-door  temperature  is  above  G0°  F. 
During  his  outing  the  head  should  be  protected  from  the  wind  and  the 
eyes  from  the  sun.  The  duration  of  the  outing  at  first  should  be  only 
fifteen  or  twenty  minutes,  the  time  being  gradually  lengthened  to  two  or 
three  hours.  The  child  shoulu  be  gradually  accustomed  to  changes  of 
temperature  in  the  room  by  opening  wide  the  windows  for  a  few  minutes 
each  day  even  before  he  is  taken  out  of  doors,  the  child  being  dressed 
meanwhile  as  for  an  outing.  In  the  case  of  children  born  late  in  the  fall 
or  in  the  winter  this  means  of  giving  fresh  air  may  be  advantageously 
begun  at  one  month  and  followed  throughout  the  first  winter.  It  is  only 
necessary  in  all  such  cases  that  the  changes  ])e  made  very  gradually  both 
as  to  the  length  of  the  airing  and  as  to  the  temperature.     The  great 


NURSERY  9 

advantage  of  this  plan  over  that  more  commonly  followed  of  keeping 
young  infants  closely  housed  for  the  first  six  months  in  case  they  are 
born  in  the  fall  or  early  winter,  we  can  positively  affirm  from  quite  a 
wide  observation  of  both  methods.  It  is  a  matter  of  very  serious  impor- 
tance that  every  infant  be  furnished  an  abundance  of  pure  fresh  air  in 
winter  as  well  as  in  summer.  When  the  plan  above  outlined  is  carefully 
and  judiciously  followed,  the  tendency  to  catarrhal  affections  instead  of 
being  increased  is  thereby  greatly  lessened. 

When  four  or  five  months  old,  there  is  no  reason  why  a  healthy  child 
should  not  go  out  of  doors  on  pleasant  days  if  the  temperature  is  not 
below  20°  F.  While  there  is  a  prejudice  on  the  part  of  many  mothers 
and  some  physicians  against  a  child's  sleeping  out  of  doors  in  cold 
weather,  it  is  a  practice  which  we  have  always  urged  upon  mothers,  and 
have  never  seen  followed  by  any  but  the  most  beneficial  results.  The 
days  of  all  others  when  infants  and  very  young  children  should  not  be 
out  of  doors  are  when  there  are  high  winds,  especially  those  from  the 
northeast,  an  atmosphere  of  melting  snow,  and  during  severe  storms. 
Delicate  infants  must  of  course  be  more  carefully  guarded  during  the 
cold  season.  With  most  of  these  the  plan  of  house-airing  is  all  that 
should  be  attempted. 

Nursery. — This  should  be  the  sunniest  and  best-ventilated  room  in 
the  house.  It  is  the  physician's  duty  to  see  that  proper  attention  is  paid 
to  the  hygiene  of  the  room  in  which  the  child  spends  at  least  four-fifths 
of  his  time  during  the  first  year,  and  two-thirds  of  his  time  during  the 
first  two  or  three  years  of  life.  Sunlight  is  absolutely  indispensable. 
Sunny  rooms  always  contain  less  organic  matter  and  less  humidity,  and 
hence  a  rooni  upon  the  north  side  of  the  house  should  always  be  avoided ; 
preferably  one  in  the  second  story  should  be  chosen.  Nothing  which  can 
in  any  way  contaminate  the  air  of  the  room  should  be  allowed.  There 
should  be  no  washing  and  drying  of  clothes  or  of  napkins.  ISTo  food 
should  be  allowed  to  stand  about  the  room.  Gas  should  not  be  allowed 
to  burn  at  night;  a  small  wax  night-light  furnishes  all  that  is  needed 
in  the  nursery.  If  possible  the  heat  should  be  from  an  open  fire;  the 
next  best  thing  is  the  Franklin  heater.  Nothing  in  the  room  is  worse 
than  steam  heat  from  a  radiator  unless  it  be  a  gas  stove,  which  under  no 
circumstances  should  be  allowed,  except  possibly  for  a  few  minutes  each 
morning  during  the  bath. 

The  temperature  of  the  room  during  the  day  should  not  be  over  70° 
F.  It  is  important  that  every  nursery  should  have  a  thermometer,  and 
that  this  and  not  the  sensations  of  the  nurse  should  be  the  guide.  It  is 
almost  invariably  true  that  the  nursery  is  overheated.  Often  no  other 
explanation  can  be  found  for  chronic  indigestion  and  falling  weight 
excepting  a  nursery  whose  habitual  temperature  ranges  from  75°  to  80° 


10  HYGIENE  AND  GENERAL  CARE 

F.  At  night  for  the  first  few  weeks  the  temperature  should  not  be  allowed 
to  fall  below  65°  F.  After  two  months  the  night  temperature  may  fall  to 
60°  or  even  50°  F. 

Free  ventilation  without  draughts  is  an  absolute  necessity.  This  is 
best  accomplished  by  ventilators  in  the  windows,  of  which  there  are  many 
excellent  devices  sold  in  the  shops.  While  the  child  is  absent  from  the 
room  the  windows  should  be  widely  opened  and  free  airing  of  the  nursery 
accomplished.  The  room  should  always  be  thoroughly  aired  at  night 
before  the  child  is  put  to  bed.  After  the  first  year  the  window  may  be 
open,  unless  the  outside  temperature  is  as  low  as  80°  F.  If  the  window 
is  open  the  door  of  the  nursery  should  be  closed,  that  currents  of  air  may 
be  avoided.    The  ventilation  by  means  of  an  open  fire  is  the  most  efficient. 

The  furniture  of  the  nursery  should  be  as  simple  as  possible,  heavy 
hangings  should  be  positively  forbidden,  and  upholstered  furniture  used 
only  to  a  small  extent.  Floors  covered  by  large  rugs  are  much  more 
cleanly  than  carpets,  and  hence  are  to  be  preferred. 

The  child,  whenever  it  is  possible,  should  have  a  separate  bed;  and 
so  should  the  newly-born  infant,  in  order  to  prevent  the  danger  of  over- 
lying by  the  mother,  which  is  seen  as  an  occasional  cause  of  death,  and 
also  to  avoid  the  danger  of  too  frequent  night  nursing,  which  is  injurious 
alike  to  mother  and  child.  Separate  beds  for  older  children  will  prevent 
the  spread  of  many  forms  of  infection.  The  crib  for  infants  should 
be  one  which  does  not  rock,  in  order  that  this  unnecessary  and  vicious 
practice  may  not  be  carried  on.  The  mattress  should  be  of  hair  and 
quite  firm.  The  pillow  should  be  small ;  in  the  summer,  hair  pillows  are 
an  advantage  but  not  a  necessity.  The  position  of  the  child  during  sleep 
should  be  changed  from  time  to  time  from  one  side  to  the  other  and  then 
to  the  back.  Attention  to  all  these  details  should  not  be  beneath  the 
physician's  notice,  since  the  violation  of  these  plain  rules  of  hygiene  is 
at  the  bottom  of  many  of  the  milder  disorders  and  even  of  some  of  the 
more  serious  diseases  seen  in  infancy. 

The  Nurse, — The  nurse  of  a  young  child  should  be  healthy,  young 
or  in  middle  life,  free  from  tuberculous  or  syphilitic  taint,  from  catarrhal 
affections  of  the  nose  and  throat,  and  not  of  a  nervous  or  excitable  tem- 
perament. She  should  be  neat  in  habit,  of  quiet  disposition,  and,  most 
of  all,  she  should  be  a  person  of  intelligence. 

The  Amount  of  Air  Space  Required  by  Infants. — The  nursery  should 
always  be  as  large  a  room  as  possible.  One  of  the  reasons  why  young 
infants  do  so  badly  in  institutions  is  because  of  overcrowding.  In  a 
well-ventilated  ward  there  should  be  allowed  to  each  infant  at  least  1,000 
cubic  feet.  Children  over  two  years  old  are  not  so  sensitive  to  their 
surroundings,  and  may  thrive  in  wards  where  only  700  or  800  cubic  feet 
are  allowed  to  each  child. 


PREMATURE  AND  DELICATE  INFANTS  11 


THE  CARE  OF  PREMATURE  AND  DELICATE  INFANTS 

Infants  born  before  term,  and  some  exceedingly  delicate  ones  who 
are  born  at  full  term,  require  very  special  and  particular  care.  The 
vitality  is  so  feeble  in  these  children  that  if  they  are  handled  in  the 
ordinary  way  they  survive  at  most  but  a  few  weeks.  The  symptom  which 
indicates  that  such  special  care  is  necessary  is  most  of  all  the  weight  of 
the  child.  Either  congenital  feebleness  or  prematurity  may  be  assumed 
in  most  of  the  children  weighing  less  than  five  pounds ;  also  if  the  length 
of  the  body  is  less  than  nineteen  inches.  In  these  children  all  the  organs 
are  likely  to  be  imperfectly  developed  and  they  are  not  ready  for  their 
work.    Especially  is  this  true  of  the  lungs  and  of  the  organs  of  digestion. 

The  clinical  picture  presented  by  these  cases  is  quite  characteristic. 
The  body  is  limp;  the  skin  very  soft  and  delicate  and  almost  transparent; 
the  cry,  a  low  feeble  whine  not  unlike  the  mew  of  a  kitten ;  the  respiratory 
movements,  extremely  irregular,  sometimes  scarcely  perceptible  for  several 
seconds ;  the  movements  of  the  extremities  infrequent  and  never  vigorous. 
The  general  appearance  is  one  of  torpor.  The  muscles  of  the  mouth  and 
cheek  and  tongue  may  lack  the  requisite  force  for  sucking,  so  that  this  is 
practically  impossible,  and  even  deglutition  is  slow,  difficult,  and  pro- 
longed. It  is  difficult  to  maintain  the  normal  body  temperature ;  unless 
closely  watched  this  may  fall  far  below  the  normal,  and  may  rise  quite 
as  much  above  it  with  the  use  of  too  much  artificial  heat.  We  once  saw 
a  fluctuation  of  13°  E.  occur  in  a  few  hours  from  such  causes.  All  the 
symptoms  mentioned  vary  much  according  to  the  degree  of  prematurity. 

In  the  management  of  these  cases  there  are  three  problems  to  be 
solved :  the  first  to  maintain  the  animal  heat,  the  second  to  nourish  the 
infant,  the  third  to  prevent  infection.  Difficult  as  it  always  is  to  rear  a 
premature  infant,  these  difficulties  are  much  increased  in  cases  where 
proper  means  are  not  adopted  immediately  after  birth.  The  loss  which 
these  children  sustain  during  the  first  few  days  is  in  very  many  cases  so 
great  that  subsequent  measures,  however  well  carried  out,  are  futile.  The 
heat-producing  power  is  so  feeble  that  the  body  temperature  quickly  falls 
below  normal  unless  artificial  heat  is  constantly  used.  The  effect  of  cold 
upon  these  delicate  infants  is  very  serious,  and  not  only  growth  but  even 
life  depends  upon  maintaining  the  body  temperature  steadily  and  uni- 
formly. Their  extreme  susceptibility  is  something  which  it  is  difficult 
for  one  to  appreciate  who  has  not  had  experience  in  these  cases. 

One  of  the  simplest  means  of  maintaining  the  temperature  is  to  oil 
the  skin  and  then  roll  the  entire  body,  including  extremities,  in  absorbent 
cotton  or  lamb's  wool ;  even  the  neck  and  cranium  may  be  covered,  leaving 
only  the  face  exposed.     The  usual  diaper  may  be  replaced  by  a  pad  of 


12  HYGIENE  AND  GENERAL  CARE 

gauze  and  absorbent  cotton.  The  body  is  then  wrapped  in  blankets, 
placed  in  a  clothes-basket  or  bassinet  with  protected  sides,  and  surrounded 
by  bottles  or  bags  containing  hot  water.  A  blanket  or  sheet  should  par- 
tially cover  the  top  of  the  basket,  forming  a  sort  of  hood  to  protect  the 
eyes  from  light  and  the  face  and  head  from  draughts.  In  using  hot- 
water  bags,  some  caution  must  be  exercised  or  too  much  heat  may  be 
secured.  We  have  seen  the  temperature  of  an  infant  raised  six  or  seven 
degrees  from  this  cause.  The  temperature  of  the  child  should  at  first  be 
taken  every  few  hours  to  make  sure  that  a  proper  amount  of  external 
heat  is  supplied. 

A  more  efficient  means  of  furnishing  artificial  heat  is  by  the  electric 
pad.  These  small  heaters  may  be  attached  like  a  drop-light  to  any 
electric  fixture.  A  convenient  size  is  ten  by  fifteen  inches.  The  pad, 
which  can  be  obtained  of  any  electric  supply  company,  is  placed  beneath 
two  or  three  thicknesses  of  blanket,  upon  which  the  infant  lies  in  its 
basket.  Since  the  pads  occasionally  get  out  of  order  they  must  be  used 
with  some  caution,  as  they  have  been  known  to  burn  the  bedclothes  and 
even  the  baby. 

With  such  means  as  those  described  it  is  possible  to  maintain  the  body 
temperature  at  normal  even  in  a  room  kept  at  the  ordinary  temperature. 
It  is  preferable  to  have  a  warmer  room;  80°  or  even  85°  F.  is  desirable 
for  feeble  infants.  Adequate  ventilation,  however,  is  indispensable. 
With  intelligent  care  excellent  results  can,  however,  often  be  obtained 
with  no  other  means  for  maintaining  heat  than  the  padded  basket  and 
hot- water  bottles;  but  the  other  accessories  make  the  problem  an  easier 
one. 

Premature  infants  should  be  fed  without  being  removed  from  the 
basket,  until  they  are  strong  enough  to  take  the  breast.  The  position 
should  be  frequently  changed  and  some  freedom  of  movement  of  the 
limbs  permitted,  but  the  infants  should  be  handled  as  little  as  possible. 
The  body  should  be  oiled  and  fresh  cotton  applied  every  other  day.  The 
rectal  temperature  at  first  should  be  taken  several  times  a  day  in  order 
to  be  sure  that  sufficient  artificial  heat  is  being  supplied,  but  not  too 
much.  The  latter  condition  is  one  that  often  obtains.  So  long  as  the 
rectal  temperature  varies  only  between  98°  and  10(T°  F.  one  should  be 
satisfied. 

Incubators. — Personally,  we  have  not  found  the  usual  small  incubator 
a  very  satisfactory  means  of  caring  for  the  premature  infant.  The  diffi- 
culties in  successful  operation  are  many  and  the  dangers  consequent  upon 
the  mode  of  ventilation  are  considerable.  Except  by  persons  experienced, 
their  use  is  not  to  be  advised.  In  hospitals  with  specially  trained  nurses 
they  may  give  excellent  results,  but  in  the  average  home  the  simpler 
measures  above  described  are  much  safer  and  quite  efficient. 


PREMATUKE  AND  DELICATE  INFANTS  13 

Every  institution  receiving  and  caring  for  premature  infants  should 
have  a  specially  equipped  room  for  that  purpose.  It  should  be  of  suffi- 
cient size  to  accommodate  several  patients.  We  have  had  such  a  room 
constructed  in  the  Babies'  Hospital  which  seems  to  fulfill  all  the  require- 
ments. The  room  has  a  floor  space  of  thirteen  by  sixteen  feet  with  ceiling 
eleven  feet  high.  This  is  arranged  for  five  infants,  which  gives  each 
child  450  cubic  feet  of  air.  The  cribs  are  separated  by  glass  plates,  which 
project  three  feet  from  the  side  wall  and  are  four  feet  in  height,  form- 
ing an  alcove  for  each  infant.  The  purpose  of  this  is  to  diminish  the 
chances  of  bed-to-bed  infection.  The  room  has  double  partition  walls 
and  double  windows.  The  temperature  is  controlled  by  a  thermostat 
regulator  and  is  maintained  at  about  90°  F.  The  room  is  provided  with 
a  special  ventilating  apparatus  by  means  of  which  the  entire  air  of  the 
room  can  be  changed  in  a  few  minutes.  This  is  done  several  times  a  clay. 
Such  a  room  possesses  all  the  advantages  of  the  small  incubator  without 
any  of  its  drawbacks.  The  infants  are  clothed  in  a  single  loose  garment 
of  absorbent  cotton  and  cheese-cloth  and  lightly  covered.  In  this  room 
the  normal  body  temperature  is  easily  maintained.  For  wet-nursing, 
bathing,  and  changing  of  napkins,  the  children  are  removed  to  an  ante- 
room which  is  kept  at  a  temperature  of,  about  75°  F.  When  the  bottle 
is  given  they  are  fed  in  their  cribs.  After  reaching  the  weight  of  about 
five  pounds  they  are  removed  to  the  anteroom  for  a  few  days,  after  which 
they  are  placed  in  the  ward  or  sent  home. 

Feeding. — The  feeding  of  the  premature  infant  is  not  less  important 
than  the  maintenance  of  heat  and  proper  ventilation.  Infants  at  eight 
months  and  those  weighing  five  pounds  or  thereabouts  can  usually  be 
made  to  take  the  breast  after  the  first  few  days.  Few  below  this  age  or 
weight  will  do  so.  Some  will  suck  from  a  bottle,  but  the  majority  must 
be  fed  by  other  means.  A  medicine  dropper  may  be  used,  or  the  Breck 
feeder ;  the  smallest  and  feeblest,  however,  must  be  fed  by  gavage,  using  a 
funnel  and  small' rubber  catheter.  The  food  should  be  slowly  given;  if 
rapidly,  some  is  liable  to  be  regurgitated,  and  this  may  produce  attacks 
of  asphyxia  or  even  an  aspiration  pneumonia.  The  quantity  of  food  and 
frequency  of  feeding  will  depend  upon  the  size  and  age  of  the  child.  A 
seven  months'  baby  weighing  three  and  a  half  pounds  should  have,  for  the 
first  twenty-four  hours,  only  water,  one  to  three  teaspoonfuls  every  hour. 
Then  regular  food  every  three  hours  beginning  with  half  an  ounce,  in- 
creased to  one  ounce  in  a  few  days  and  gradually  to  one  and  a  half  or  two 
ounces  at  the  end  of  about  three  weeks. 

Artificial  feeding  is  seldom  very  successful  with  premature  infants. 
With  some  of  the  larger  and  more  vigorous,  cow's  milk  modified  accord- 
ing to  the  directions  given  in  the  chapters  on  Infant  Feeding  gives  good 
results.    We  once  succeeded  with  a  child  of  three  pounds  two  ounces.    For 


14 


HYGIENE  AND  GENERAL  CARE 


most  of  them  micler  four  and  a  half  pounds,  breast-milk  is  essential.  If 
the  child  is  born  near  term,  the  mother  may  be  able  to  nurse  it.  Occa- 
sionally this  may  be  done  at  eight  months,  but  seldom  earlier,  so  that  the 
milk  of  some  other  woman  must  usually  be  depended  upon. 

As  the  premature  baby  requires  only  from  six  to  eight  ounces  of 
breast-milk  a  day  for  the  first  few  weeks,  this  may  be  secured  from  some 
other  nursing  woman ;  a  friend  might  be  willing  to  furnish  it  or  it  could 
be  purchased  from  any  healthy  woman  who  has  an  abundant  supply.  It 
is  sufficient  if  it  is  drawn  fresh  twice  a  day,  the  utmost  precautions,  of 
course,  being  taken  to  secure  cleanliness.  At  first  equal  parts  of  breast- 
milk  and  a  four-  or  five-per-cent  solution  of  milk  sugar  may  be  given; 
th^  degree  of  dilution  being  gradually  lessened  until  pure  milk  is  taken. 
Eight  feedings  a  day  are  usually  necessary,  the  amount  at  one  feeding 
may  be  from  two  drams  to  one  ounce  depending  upon  the  size,  age,  and 
digestive  powers  of  the  infant.  It  is  not  important  that  the  baby  of  the 
woman  furnishing  the  milk  should  be  of  the  same  age  as  the  foster  infant. 
The  milk  of  any  woman  whose  baby  is  between  one  and  eight  months  old 
will  answer.  We  have  successfully  fed  premature  infants  with  breast- 
milk  from  women  whose  children  were  older  than  this.  Another  plan  is  to 
secure  a  wet-nurse  and  permit  her  to  bring  her  own  baby  into  the  house. 
She  expresses  for  the  premature  infant  the  required  amount  of  milk 
three  or  four  times  a  day,  and  the  rest  of  the  time  nurses  her  own  child. 
In  this  way  her  fiow  of  milk  is  maintained;  if  the  breasts  are  pumped 
exclusively  the  supply  rapidly  diminishes.  The  secretion  of  the  milk  in 
the  mother  may  be  promoted  by  her  suckling  the  wet-nurse's  baby  or 
some  other  vigorous  infant.  The  above  are  temporary  expedients  and  in 
most  instances  need  not  be  continued  more  than  two  or  three  weeks,  at 
the  end  of  which  time  the  mother  may  be  able  to  nurse  her  own  child. 

The  results  with  premature  babies  will  depend  very  much  upon  how 
soon  after  birth  they  receive  proper  care.  Immediately  after  birth  meas- 
ures should  be  taken  to  secure  the  best  care  and  provide  adequately  for 


Voorhees  saved 

Tarnier  saved 

Tarnier  saved 

Voorhees 

excluding  cases 

Age. 

without  incu- 

with inaubators. 

saved  with 

dying  a  few 

bators. 

incubators. 

hours  after  birth. 

Bom  at  6    months 

0.0% 

16.0% 

"      "61      "       

29.5% 

36.6% 

22.0% 

66.6% 

"      "7        "       

39.0% 

49.8% 

41.0% 

71.0% 

"     "7*      "       

54.0% 

77.0% 

75.0% 

89.0% 

"     "8        "       

78.0% 

88.8% 

70.0% 

91.0% 

'■     "81      "       

88.0% 

96.0% 

maintaining  the  body  heat.  If  an  incubator  is  to  be  used  it  should  be 
in  readiness,  so  that  the  child  can  be  put  into  it  as  soon  as  he  is  breathing 
properly.     The  age  and  vigor  of  the  infant  are  of  the  greatest  impor- 


WEIGHT  15 

tance  in  estimating  the  chances  of  survival.  The  table  on  the  preceding 
page  gives  Tarnier's  statistics,  showing  the  percentage  of  premature  in- 
fants saved  during  a  period  of  five  years  vi^ithout  the  incubator,  and  dur- 
ing the  succeeding  five  years  with  the  incubator ;  also  the  percentage  saved 
at  the  Sloane  Hospital  for  Women  (New  York),  as  published  by  Voorhees. 
Eesults  will  improve  with  the  experience  of  the  physician  in  the  feed- 
ing and  care  of  these  very  sensitive  patients.  Much  is  yet  to  be  learned 
about  them. 


CHAPTEE   II 
GROWTH  AND  DEVELOPMENT  OF  THE  BODY 

Obsebvations  upon  growth  and  development  are  of  the  utmost  impor- 
tance during  infancy  and  childhood.  Only  by  this  means  are  very  many  ' 
diseases  detected  in  their  incipiency.  Early  recognition  carries  with  it 
in  most  cases  the  possibility  of  checking  such  pathological  processes  as, 
if  allowed  to  go  on,  may  affect  the  health  not  only  in  infancy  but  even 
throughout  life. 

By  familiarity  with  what  is  normal,  detection  of  the  abnormal  soon 
becomes  easy.  Investigation  in  regard  to  these  subjects  should  be  made 
a  part  of  the  physical  examination  of  every  child. 

WEIGHT 

The  weight  of  the  infant  is  the  best  means  we  have  to  measure  his 
nutrition.  It  is  as  valuable  a  guide  to  the  physician  in  infant  feeding  as 
is  the  temperature  in  a  case  of  continued  fever.  Although  the  weight  is 
not  to  be  taken  as  the  only  guide  to  the  child's  condition,  it  is  of  such 
importance  that  we  cannot  afford  to  dispense  with  it  during  the  first  two 
years.  It  is  of  great  advantage  to  keep  up  regular  observations  during 
childhood. 

Weekly  weighings  should  be  made  for  the  first  six  months,  bi-weekly 
for  the  rest  of  the  first  year,  and  monthly  during  the  second  year.  Del- 
icate children  should  be  weighed  even  more  frequently.  Balance  scales 
only  should  be  used.    The  spring  scales  are  not  reliable. 

Weight  at  Birth. — The  following  figures  are  taken  consecutively  in 
nearly  equal  proportion  from  the  records  of  the  N'ursery  and  Child's  Hos- 
pital, the  Sloane  Hospital,  and  the  Kew  York  Infant  Asylum,  and 
include  only  full-term  children : 

Average  weight  of  568  females 7. 16  lbs.  (3,260  grams). 

"  "  590  males 7.55    "    (3,400      "     ). 

"  "        1,158  infants 7.35    "    (3,330      "    ). 


16 


GROWTH  AND  DEVELOPMEXT 


Weig^ht  Curve  during  the  First  Few  Weeks. — The  accompanying 

chart  represents  the  variations  in  -weight  for  the  first  twenty  days.  These 
observations  were  made  upon  one  liundred  liealthy.  nursing  infants,  fifty 
males  and  fifty  females,  at  the  Xursery  and  Child's  Hospital.  The 
children  were  weighed  daily  during  the  period  of  observation.  The 
average  weight  at  birth  was  7.1  pounds.  The  curve  shows  a  very 
marked  loss  of  weight  on  the  first  day  and  a  slight  loss  on  the  second 
day,  the  lowest  point  being  touched  at  the  beginning  of  the  third  day; 
but  from  this  time  there  was  a  steady  gain.     The  average  initial  loss  in 


Name, Date  of  Birth, 189 

Gms. 

Lbs. 

1 

2 

3 

1 

5 

6 

7 

8 

9 

10 

11 

12 

13 

11 

15 

16 

17 

18 

19 

20 

1120 
iSlO 
1200 
1080 
3970 
3850 
3710 
3630 
3510 
3100 
3290 
3180 
3060 
2910 
2830 
2720 
2610 
2190 
2380 

9^ 

9 
8^ 
8X 

8 
7^ 
7K 

7K 
7 

6% 

^ 

' 

^,-r-' 

K--* 

^ 

\ 

.-"^■"^ 

\ 

^^ 

^ 

\ 

^ 

^ 

-^ 

6^2 

6K 
6 

5% 

5K 

N 

^^ 

r^ 

Fig.  1. — Weight  Cukve  of  the  Ftrst  Twenty  Days. 

these  cases  was  t^ji:  ounces,  being  in  each  sex  exactly  eleven  per  cent  of 
the  body  weight.  In  eight  hundred  and  thirty-five  cases,  including 
those  above  mentioned,  the  average  loss  was  nine  and  a  half  ounces. 
The  loss  of  the  first  days  is  chiefly  due  to  the  discharge  of  the  meconium 
and  urine,  but  is  in  part  from  the  excess  of  tissue  waste  over  the  nutri- 
ment derived  from  the  breasts.  After  the  third  day,  coincident  with 
an  abundant  secretion  of  milk,  there  is  a  steady,  daily  increase  in  weight. 
If  the  milk  is  very  scanty  or  is  wanting  altogether,  the  loss  in  weight 
continues. 

The  birth-weight  of  nursing  children  who  thrive  normally  is  regained 
on  the  average  on  the  tenth  day.  The  most  frequent  deviation  from  the 
normal  curve  consists  in  a  continued  loss  or  stationarv  weight  after  the 


WEIGHT 


17 


third  flay.  This  may  be  due  to  acute' illness,  such  as  bronchitis,  diar- 
rhea, pyemia,  or  hemorrhage,  but  in  the  majority  of  cases  there  is  a 
disturbance  of  nutrition  from  improper  or  insufficient  food. 

The  weight  curve  of  infants  who  are  artificially  fed,  even  though 
they  are  strong  and  vigorous  and  the  feeding  properly  done,  rarely  fol- 
lows for  the  first  month  the  same  line  as  that  of  nursing  infants.     We 


WEIGHT    CHART 

Name.                                                                DafP.  nf  RiTt.h                                              101 

(5 

i 

WEEK  OF  AGE 

1                                12                                  24                                  36                                 48 

IQ390 
10430 
9980 
9530 
9070 
8620 
8160 
7710 
7260 
G800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 

24 
23 
22 
21 
20 
19 
18 

n 

16 
15 
14 
13 
12 
II 
10 
9 
8 
7 
6 
5 

4 

1 

1 

^ 

r*i 

■* 

,^ 

N^ 

^ 

•^ 

^^ 

•-• 

J 

-- 

^ 

^ 

^ 

^ 

/ 

I 

/ 

/ 

/ 

/ 

A 

/ 

/ 

/ 

/ 

/ 

V 

/ 

. 

_ 

_ 

_J 

Fig.  2. — Weight  Chart. 


usually  see  an  initial  loss  which  is  about  the  same  as  in  nursing  infants, 
then  a  period  of  nearly  stationary  weight  lasting  from  one  to  two  weeks. 

Excessive  loss  in  weight  during  the  first  few  days,  from  any  cause 
whatsoever,  seriously  handicaps  an  infant  during  the  first  weeks  of  its 
life.  The  great  importance  of  this  has  not  been  sufficiently  appre- 
ciated. 

Weight  Curve  of  the  First  Year. — The  curve  of  the  accompanying 
chart  is  made  up  from  complete  weight  chaT'ts  of  about  two  hundred 
healthy  nursing  inf^grts  who  were  thriving  and  weighed  every  week,  and 
the  incomplete  charts  of  about  five  hundred  other  infants.  There  are 
represented  in  round  numbers  about  thirty  thousand  observations  on  chil- 
dren under  one  year.     The  period  of  most  rapid  increase  is  during  the 


i 


18  GROWTH  AND  DEVELOPMENT 

first  three  months.  It  is  slowest  from  the  sixth  to  the  ninth  month.  This 
curve  is  not  to  be  regarded  as  a  normal  line,  like  the  normal  line  of  the 
temperature  chart,  but  as  an  average  line.  An  infant  who  is  at  birth  a 
pound  above  the  average  may  keep  this  distance  above  the  line  for  the 
whole  year;  another,  weighing  one  pound  less  than  the  average,  may  be 
as  far  below  it.  Girls  throughout  the  year  are  on  the  average  half  a 
^  pound  lighter  than  boys.  No  single  child  exactly  follows  the  line  all 
'  the  way,  but  it  is  surprising  how  close  to  it  a  very  large  number  of  the 
cases  come. 

In  artificially-fed  infants  who  are  healthy  and  are  properly  fed,  the 
curve  does  not  differ  essentially  from  that  of  breast-fed  infants,  except 
in  the  slower  gain  of  the  first  month,  although  this  difference  is  usually 
made  up  before  the  sixth  month  is  reached. 
^        At  the  end  of  the  first  year  the  average  child  weighs  nearly  three 
/times  as  much  as  at  birth.     Perfect  health  during  the  first  year  is  seen 
only  in  children  who  are  gaining  steadily  in  weight.     A  child  may  not 
always  gain  rapidly,  but  he  should  gain  steadily,  and  if  he  does  not,  some- 
thing is  wrong.     All  the' conditions  surrounding  the  infant  should  be 
/  investigated,  but  especially  the  food.     One  should  not  be  satisfied  unless 
the  average  weekly  gain  during  the  first  six  months  is  at  least  four 
■  ounces.     In  the  second  six  months  it  may  be  slightly  less.     As  a  rule,  a 
child  who  gains  regularly  in  weight  is  thriving;  an  exception  must,  how- 
ever, be  made  in  the  case  of  some  infants  who  are  fed  chiefly  upon  carbo- 
hydrate foods. 

Weight  from  the  Second  to  the  Fifth  Year. — Comparatively  few  ob- 
servations have  been  published  upon  the  weight  during  this  period.  From 
nearly  two  thousand  personal  observations,  chiefly  from  private  practice, 
1  it  appears  that  the  normal  gain  of  a  healthy  child  is  about  six  pounds 
during  the  second  year,  about  five  during  the  third  year,  and  about  four 
^  pounds  during  the  fourth  year ;  the  actual  weights  are  given  in  the 
large  table  on  page  20.  During  this  period  the  gain  is  rarely  uniform 
after  the  first  year.  With  most  children  it  is  slowest  or  the  weight  is 
stationary  in  the  summer  months,  while  the  most  rapid  increase  is 
usually  seen  in  autumn.  Throughout  this  period .  girls  gain  in  about 
the  same  ratio  as  boys,  ,but  remain-  on  the  average  nearly  one  pound 
lighter.  During  almost  every  illness,  no  matter  of  what  character, 
the  gain  in  weight  ceases,  and  usually  there  is  a  loss,  the  rapidity  and 
extent  of  which  are  somewhat  proportionate  to  the  severity  of  the  attack ; 
but  it  is  ahvays  much  more  rapid  in  diseases  of  the  digestive  tract  than 
in  any  other  form  of  illness. 

Weight  of  Older  Children. — The  weights  given  in  the  table  of  children 
from  five  to  fourteen  years  are  from  Bowditch.  Observations  were  made 
upon  children  of  American  parentage  in  the  public  schools  of  Boston — 


HEIGHT 


19 


upon  4,327  boys  and  3,681  girls.^  It  is  to  be  remembered  that  these 
weights  include  the  ordinary  clothing,  while  those  below  five  years  are 
without  clothing.-  Our  own  observations  upon  children  in  private  prac- 
tice show  that  the  average  weight  for  the  fifth  and  sixth  years  is  one 
pound  greater  and  from  the  seventh  to  the  tenth  year  from  two  to 
three  pounds  greater  than  the  averages  of  the  public  school  children 
given  by  Bowditch. 

The  slowest  gain  is  from  the  fifth  to  the  eighth  year,  when  it  is  about 
four  pounds  a  year.  From  the  eighth  to  the  eleventh  year  it  rises  to 
about  six  pounds  a  year.  Up  to  the  eleventh  year  the  two  sexes  gain 
in  about  the  same  ratio.  From  the  eleventh  to  the  thirteenth  year  the 
girls  gain  much  more  rapidly,  passing  the  boys  for  the  first  time  and 
maintaining  this  lead  until  the  fifteenth  year,  when  again  the  boys 
pass  them. 

HEIGHT 

The  figures  showing  the  height  at  different  ages  are  given  in  the  table 
on  page  20.  The  measurements  of  infants  at  birth,  given  on  page  21,  are 
taken  in  about  equal  numbers  from  the  records  of  the  New  York  Infant 
Asylum  and  the  Sloane  Hospital  for  Women.  They  were  made  upon 
full-term  infants. 


^W.  T.  Porter  has  published  (1894)  observations  made  upon  14,744  children  of 
American  parentage  in  the  public  schools  of  St.  Louis.  His  figures  show  quite  a 
variation  from  those  of  Bowditch,  and  are  as  follows: 


Age. 

boys'  weight. 

girls' 

SVEIGHT. 

Kilos. 

Pounds. 

Kilos. 

Pounds. 

6  years 

19.66 
21.67 
23.91 
26.08 
28.49 
31.26 
33.45 
35.96 
40.34 
47.25 
52.10 

43.2 
47.7 
52.6 
57.4 
62.7 
68.8 
73.6 
79.1 
88.7 
103.9 
114.6 

18.76 
20.82 
22.71 
25.07 
27.43 
29.93 
33.17 
38.29 
43.12 
46.90 
50.06 

41.3 

7     "     

45.8 

8     "     

.50.0 

9      "     

55.1 

10      "     

60.3 

11      "     

65.8 

12     "     

73.0 

13      "     

84.2 

14     "     

94.9 

15     "     

103.2 

16      "     

110.1 

^  The  average  weight  of  the  ordinary  house  clothing  of  school  children,  accord- 
ing to  Bowditch,  is  at  five  years,  2.8  pounds  for  both  sexes;  at  seven  j'^ears,  3.5  for 
both  sexes;  at  ten  years,  5.7  pounds  for  boys  and  4.5  poimds  for  girls;  at  thirteen 
years,  7.4  pounds  for  boys  and  5.6  pounds  for  girls;  at  sixteen  years,  9.7  pounds 
for  boys  and  8.1  pounds  for  girls.    This  must  be  deducted  to  obtain  net  weights. 


20 


GEOWTH  AND  DEVELOPMENT 


Table  showing  Weight,  Height,  and  Circumference  of  the  Head  and  Chest  from  Birth  to 

the  Sixteenth  Year} 


Age. 


Birth  2 

6  months  2. . 
12  months  2. 
18  months  2. 

2  years  ^ .  .  . 

3  years  ^ .  .  . 

4  years  2 .  .  . 

5  years .... 

6  years 

7  years 

8  years .... 

9  years 

10  years. . . . 

11  years 

12  years .  .  . 

13  years . .  . 

14  years . .  . 

15  years . .  . 

16  years 


Sex. 


Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Gu-ls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Gu-ls. 

Boys. 

Girls. 


Weight. 


Pounds.       Kilos 


7.55 

7.16 

16.0 

15.5 

31.0 

20.5 

24.0 

23.5 

37.0 

26.0 

33.0 

31.0 

36.0 

35.0 

41.3 

39.8 

45.1 

43.8 

49.5 

48.0 

54.5 

52.9 

60.0 

57.5 

66.6 

64.1 

72.4 

70.3 

79.8 

81.4 

88.3 
91.3 

99.3 

100.3 

110.8 

108.4 

133.7 

113.0 


3.43 

3.26 

7.36 

7.03 

9.54 

9.31 

10.90 

10.68 

13.37 

11.81 

14.55 

14.0^ 

16.36 

15.90 

18.71 

18.06 

30.48 

19.87 

33.44 

21.78 

34.70 

24.01 

36.58 

26.10 

30.33 

29.07 

33.83 

31.87 

36.31 

36.90 

40.04 

41.36 

45.03 

45.50 

50.26 

49.17 

56.09 

51.24 


Height. 


Inches.         Cm 


20.6 

20.5 

354 

25.0 

39.0 

28.7 

30.0 

29.7 

33.5 

32.5 

35.0 

35.0 

38.0 

38.0 

41.7 

41.4 

44.1 

43.6 

46.3 

45.9 

48.3 
48.0 

50.1 

49.6 

53.3 

51.8 

54.0 

53.8 

55.8 

.57.1 

58.3 
58.7 

61.0 

60.3 

63.0 

61.4 

65.6 

61.7 


53.5 

52.2 

64.8 

63.6 

73.8 

73.2 

76.3 

75.6 

83.^ 
82.8 

89.1 

89.1 

96.7 

96.7 

106.0 

105.3 

113.0 

110.9 

117.4 

116.7 

133.3 

122.1 

137.3 

126.0 

133.6 

131.5 

137.3 

136.6 

141.7 

145.2 

147.7 

149.2 

155.1 

153.2 

159.9 

159.9 

166.5 

156.7 


Chest. 


Inches.        Cm 


13.4 

13.0 

16.5 

16.1 

18.0 

17.4 

18.5 

18.0 

19.0 

18.5 

30.1 

19.8 

30.7 

20.7 

31.5 

21.0 

33.3 

22.8 

33.7 

23.3 

34.4 

23.8 

35.1 

24.5 

35.8 
24.7 

36.4 


37.0 

26.8 

37.7 
28.0 

38.8 
29.2 

30.0 

30.3 

31.3 

30.8 


34.3 

33.2 

42.0 

41.0 

45.9 

44.4 

47.1 

45.9 

48.4 

47.0 

51.1 

50.5 

52.8 
52.2 

54.8 

53.5 

59.1 

58.3 

60.6 

59.5 

63.3 

60.8 

63.9 

62.5 

65.6 

63.0 

67.3 

65.8 

68.8 
68.3 

70.6 

71.3 

73.3 

74.1 

76.6 

76.8 

79.3 

78.8 


Head. 


Inches.       Cm, 


13.9 

13.5 

17.0 

16.6 

18.0 

17.6 

18.5 

18.0 

18.9 

18.6 

19.3 

19.0 

19.7 

19.5 

30.5 

20.2 


31.0 

20.7 


21.8 

21.5 


(Science,  April  12,  1895)  upon  4,319  children  over  six 
exceed  children  born  at  a  later  period  both  in  height 


1  The  observations  of  Boas 
years  old  show  that  first  born 
and  weight. 

2  These  weights  are  without  clothes;  after  five  years  clothes  are  mcluded. 


GROWTH  OF  EXTREMITIES  AS  COMPARED  WITH  TRUNK  21 

Average  length  of  231  male  infants  born  at  term. .  20.61  inches  (52.5  cm.)r 
"  "        "211  female    "         "      "    "  20.47     "       (52.2    "  ); 

"  "        "442  infants 20.54     "       (52.35"). 

The  most  rapid  gain  in  length  is  in  the  first  year.  During  this  period 
the  child  grows  on  an  average  a  little  over  eight  inches  (21  cm.).  This 
gain  is  usually,  but  not  always,  proportionate  to  the  increase  in  weight. 
During  the  second  year  the  average  increase  is  three  and  a  half  inches  (9 
cm.).  From  this  time  on  the  rate  of  increase  is  quite  uniform  in  both 
sexes  until  the  eleventh  year,  it  being  between  two  and  three  inches  a 
year. 

After  the  eleventh  year  in  girls  and  the  twelfth  in  boys  the  growth  is 
much  more  rapid.  In  height  the  girls  exceed  the  boys  at  the  twelfth 
and  thirteenth  years  for  the  only  time  in  their  growth. 

In  the  figures  given  in  the  preceding  table  those  of  five  years  and  over 
are  taken  from  Bowditch,  the  observations  being  made  upon  the  same 
children  as  those  whose  weights  were  taken.  The  observations  from  six 
months  to  four  years  inclusive  are  from  original  sources,  and  are  drawn 
from  about  eight  hundred  cases.  The  height  much  more  than  the  weight 
of  children  is  modified  by  hereditary  influences. 

Eachitic  children  during  infancy  and  early  childhood  are,  as  a  rule, 
shorter  than  others.  We  have  frequently  measured  such  children  during 
the  third  year  who  were  six  inches  below  the  average  for  that  age.  The 
effect  of  malnutrition  upon  the  length  of  the  body  is  much  less  than 
upon  the  weight. 

GROWTH  OF  THE  EXTREMITIES  AS  COMPARED  WITH  THE  TRUNK 

At  birth  the  trunk  is  relatively  long  and  the  extremities  short.  The 
middle  of  the  body  at  birth,  according  to  one  hundred  observations  on 
normal  infants  made  for  us  by  Wilbur  Ward  at  the  Sloane  Hospital,  is 
three-quarters  of  an  inch  (2  cm.)  below  the  center  of  the  umbilicus. 
Subsequently  the  growth  of  the  extremities  is  much  more  rapid  than  that 
of  the  trunk.  Thus  we  have  found  at  birth  the  length  of  the  lower  ex- 
tremities (measuring  from  the  anterior  superior  spine  of  the  ilium  to  the 
sole  of  the  foot)  to  be  forty-three  per  cent  of  the  length  of  the  body;  at 
five  years,  fifty-four  per  cent,  and  at  sixteen  years,  sixty  per  cent.  The 
above  figures  are  from  one  hundred  and  fifty  observations,  which,  al- 
though not  numerous  enough  for  exact  percentages,  are  still  sufficient  to 
give  a  very  good  idea  of  the  general  relation  of  the  length  of  the  extrem- 
ities to  that  of  the  body  as  a  whole.  These  facts  are  of  some  assistance 
in  the  diagnosis  of  diseases  attended  by  abnormalities  of  growth,  such 
as  rickets,  cretinism,  and  chondrodystrophy. 


22  GROWTH  AXD  DEVELOPMENT 

THE  HEAD 

Circumference. — The  average  circumference  of  the  head  at  birth  in 
four  himclred  and  forty-six  full-term  infants  observed  at  the  Sloane 
Hospital  and  Xew  York  Infant  Asylum  was  as  follows : 

Average  circumference  of  the  head,  231  males 13.90  inches  (35.5  cm.); 

215  females 13.52      "       (34.5  "    ); 

Total 446  infants 13.71      "       (35.0  "    ). 

The  occipitofrontal  measurement  was  the  one  taken. 

The  growth  of  the  head  is  most  rapid  during  the  first  year,  the  in- 
crease being  a;boiit  four  inches  (10  cm.).  It  is  about  half  an  inch  a 
month  during^  the  early  months,  and  a  fourth  of  an  inch  a  month  dur- 
ing the  later  months  of  the  first  year.  During  the  second  year  the 
increase  is  about  one  inch  (2.5  cm.).  From  the  second  to  the  fifth  year 
the  growth  is  slower,  being  only  about  one  and  a  half  inches  (4  cm.)  for 
the  three  years.  After  the  fifth  year  the  increase  in  the  circumference 
of  the  head  is  very  slow  (see  table) . 

Closure  of  the  Sutures. — The  main  sutures  of  the  cranium  are  not 
commonly  ossified  before  the  end  of  the  sixth  month,  and  very  frequently 
some  mobility  may  be  detected  at  the  end  of  the  ninth  month.  Distinct 
separation  of  the  cranial  bones  after  birth  is  abnormal.  It  is  most  fre- 
quently seen  in  premature  and  in  syphilitic  infants. 

Closure  of  the  Fontanels. — The  posterior  fontanel  is  usually  oblit- 
erated by  the  end  of  the  second  month.  The  anterior  fontanel  under 
normal  conditions  closes  on  an  average  at  about  the  eighteenth  month. 
The  usual  variations  are  between  the  fourteenth  and  twenty-second 
months.  At  the.  end  of  the  first  year  the  fontanel  is  generally  about 
one  inch  in  diameter.  An  open  fontanel  at  the  end  of  the  second  year 
may  be  considered  abnormal.  The  closure  of  the  fontanel  is  not  al- 
ways early  in  well-nourished  children,  nor  is  it  always  delayed  in  those 
suffering  from  malnutrition.  In  very  rare  cases  the  anterior  fontanel 
may  either  be  closed  at  birth  or  may  close  during  the  first  few  weeks  of 
life.  Closure  of  the  fontanel  by  the  middle  of  the  first  year  is  often  seen 
in  cases  of  arrested  cerebral  development.  This  indicates  a  serious  con- 
dition, usually  microcephalus.  Closure  of  the  fontanel  in  the  early 
months  of  the  second  year  may  be  due  to  the  slow  growth  of  the 
brain  in  a  child  suffering  from  general  malnutrition  but  otherwise 
normal. 

By  far  the  most  frequent  cause  of  delayed  closure  of  the  fontanel  is 
rickets,  in  which  condition  it  may  be  open  up  to  the  end  of  the  third 
year.    x\  large  fontanel  is  one  of  the  striking  featured  of  cretinism,  and 


THE  HEAD  23 

in  untreated  cases  is  often  seen  as  late  as  the  eighth  year  or  later.  In 
infancy  an  open  fontanel  with  a  rapid  growth  of  the  head  should  at 
once  suggest  hydrocephalus.  There  is  an  hereditary  condition  in  which 
the  fontanel  remains  open  even  to  adult  life.  Two  such  cases  in  father 
and  son  were  shown  us  by  Marie  in  Paris.  In  both  there  was  also  lack  of 
union  between  the  two  portions  of  the  clavicle. 

Shape  of  the  Head. — ^The  deformity  which  results  from  compression 


Fig.  3. — Premature  Ossification  op  the  Sagittal  Suture.     Death  at  six  weeks. 

during  labor  usually  disappears  by  the  end  of  the  first  month.  During 
the  first  year  the  head  often  becomes  flattened  at  the  occiput  in  conse- 
quence of  the  child's  lying  too  much  upon  tlue  back.  This  is  easily 
remedied  by  changing  his  position.  A  slight  obliquity  of  the  head  may 
result  from  a  habitual  position  during  nursing  or  sleep.  A  marked  de- 
gree of  obliquity  is  sometimes  congenital,  but  usually  disappears  by 
the  third  or  fourth  year. 

The  other  abnormalities  in  the  shape  of  the  head  are  chiefly  due  to 
rickets  and  hydrocephalus,  more  rarely  to  congenital  malformations  of 
the  brain.    They  will  be  considered  in  the  chapter  devoted  to  these  topics. 


24  GROWTH  AND  DEVELOPMENT 

Premature  ossification  of  the  sutures  of  the  cranium  occasionally 
gives  rise  to  striking  deformities  of  the  head.  Depending  upon  the 
sutures  involved  the  head  may  be  long  and  narrow  or  it  may  be  short  and 
high.  These  two  types  are  known  respectively  as  scaphocephaly  and  oxy- 
cephaly. They  are  referred  to  more  fully  in  the  chapter  upon  Internal 
Hydrocephalus.  Fig.  3  shows  a  skull  with  complete  obliteration  of  the 
sagittal  suture.  In  this  case  there  was  a  wide  separation  of  the  sutures 
at  the  junction  of  the  parietal  and  temporal  bones.  Premature  ossifica- 
tion of  the  OS  tribasilare  at  the  base  of  the  skull  is  largely  responsible  for 
the  prognathism  and  peculiar  formation  of  the  cranium  seen  in  chondro- 
dystrophy. 


THE  CHEST 

The  figures  showing  the  circumference  of  the  chest  at  the  different 
periods  of  childhood  have  already  been  given.  The  measurements  up  to 
and  including  five  years  are  from  personal  observations,  those  from  the 
sixth  to  the  sixteenth  are  taken  from  Porter^  and  are  drawn  from  obser- 
vations on  31,371  school  children.  The  measurement  of  the  chest  is  that 
taken  midway  between  full  inspiration  and  expiration,  and  at  the  level 
of  the  nipples. 

In  the  newly-born  child  the  antero-posterior  and  the  transverse  diam- 
eters of  the  chest  are  nearly  the  same.  As  age  advances,  the  transverse 
diameter  increases  very  much  more  rapidly,  so  that  the  outline  of  the 
chest  gradually  assumes  an  elliptical  shape,  which  it  maintains  during 
childhood. 

At  birth,  the  circumference  of  the  chest  is  about  one-half  inch  less 
than  that  of  the  head,  but  throughout  infancy  the  two  measurements  are 
nearly  the  same.  It  is  not  until  the  third  year  that  the  average  cir- 
cumference of  the  chest  exceeds  that  of  the  head.  The  chest  measure- 
ment in  infants  is  always  much  modified  by  the  amount  of  fat ;  but,  after 
making  due  allowance  for  this,  a  large  chest  always  indicates  a  robust 
child  and  a  small  chest  a  delicate  one.  If  at  any  age  the  circumference 
of  the  child's  chest  is  found  to  be  below  the  average,  means  should  be 
taken,  by  gymnastics  and  otherwise,  to  develop  it. 

In  infants  deformities  of  the  thorax  result  chiefly  from  rickets,  some- 
times from  empyema,  emphysema,  and  cardiac  disease ;  in  older  children, 
from  lateral  ciirvature  of  the  spine,  or  from  Pott's  disease.  A  peculiar 
deformity,  usually  congenital,  but  sometimes  rachitic,  is  the  funnel- 
shaped  chest,  the  Trichter  hrust  of  the  Germans.  It  consists  in  a  deep 
pitlike  central  depression  at  the  lower  end  of  the  sternum.  It  is  usually 
permanent. 


MUSCULAR  DEVELOPMENT  25 

THE  ABDOMEN  ,    ^" , 

Throughout  infancy  the  circumference  of  the  abdomen  isy'  as  a  rule, 
about  the  same  as  that  of  the  chest.  At  the  end  of  the  second  year 
the  measurements  of  the  head,  chest,  and  abdomen  are  very  ofteh-'identi- 
cal ;  after  this  time  the  chest  measurement  increases  much  more  rapidly 
than  the  other  two.  Marked  enlargement  of  the  abdomen  is  seen  in 
many  varieties  of  chronic  intestinal  disorders.  The  tympanites  that 
often  accompanies  rickets  is  a  frequent  cause  of  enlargement. 


MUSCULAR  DEVELOPMENT 

The  first  voluntary  movements  are  usually  in  the  fourth  month,  when 
the  infant  deliberately  attempts  to  grasp  some  object  placed  before  him. 
During  the  fourth  month,  as  a  rule,  the  head  can  be  held  erect  when  the 
trunk  is  supported.  In  many  infants  this  is  possible  in  the  early  part 
of  the  third  month.  At  seven  or  eight  months  a  healthy  child  is  usually 
able  to  sit  erect  and  support  the  trunk  for  several  minutes. 

In  the  ninth  or  tenth  month  are  usually  seen  the  first  attempts  to 
bear  the  weight  upon  the  feet.  At  eleven  or  twelve  months  a  child 
usually  stands  with  slight  assistance.  The  first  attempts  at  walking  are 
commonly  seen  in  the  twelfth  or  thirteenth  month.  The  average  age  at 
which  children  walk  freely  alone  has  been,  in  our  experience,  the  four- 
teenth or  fifteenth  month.  Quite  wide  variations  are  seen  in  healthy 
children.  Very  much  depends  upon  the  surroundings.  We  have  known 
infants  to  walk  at  ten  months  and  many  others  not  until  seventeen  or 
eighteen  months,  although  showing  no  evidences  of  disease,  and  although 
their  development  had  not  been  retarded  by  previous  illness.  A  very 
marked  difference  is  seen  in  different  families  with  respect  to  the  time 
of  walking. 

The  physician  is  often  consulted  because  of  backward  muscular  de- 
velopment, most  frequently  because  the  child  is  late  in  walking.  General 
malnutrition,  or  any  other  severe  or  prolonged  illness,  may  postpone  for 
several  months  this  or  any  of  the  other  functions  mentioned.  Wlien 
there  is  no  such  explanation  of  the  backwardness,  a  child  who  does  not 
hold  up  his  head,  sit  alone,  or  make  efforts  to  stand  or  walk  at  the  proper 
time,  should  be  submitted  to  a  careful  examination  for  mental  deficiency 
or  cerebral  or  spinal  paralysis,  but  especially  for  rickets,  which  is  the 
most  frequent  explanation  of  the  symptoms. 

Contrivances  for  teaching  infants  to  walk  are  unnecessar}^  and  their 
.effect  may  even  be  injurious.  An  infant  should  be  allowed  the  greatest 
possible  freedom  in  the  use  of-  his  limbs.     He  should  not  be  restrained 


26  GROWTH  AXD  DEVELOPMENT 

from  walking  when  inclined  to  do  so,  nor  continually  urged  to  walk  when 
no  voluntary  attempts  are  made.  Nothing  short  of  mechanical  restraint 
will  prevent  a  healthy  child  from  walking  or  standing  when  he  is  strong 
enouo-h  to  do  so. 


DEVELOPMENT  OF  THE  SPECIAL  SENSES 

Sight. — The  newly-born  infant  avoids  the  light.  The  pupils  contract 
in  a  light  room,  and  if  a  bright  light  is  brought  before  the  eyes  they 
close.  During  the  first  few  weeks  the  infant  indicates  by  every  sign  that 
excessive  light  is  unpleasant.  As  early  as  the  sixth  day  the  eyes  will 
sometimes  follow  a  light  in  the  room,  and  the  child  may  even  turn  the 
head  for  this  purpose.  The  muscles  of  the  eyes  of  the  newly-born  infant 
act  irregularly  and  not  in  harmony.  Coordinate  action  for  general  pur- 
poses is  not  established  until  about  the  end  of  the  third  month.  Even 
after  this  time  incoordinate  action  is  occasionally  seen.  The  eyelids 
also  move  irregularly,  and  are  often  partly  separated  during  sleep.  The 
cornea  is  but  slightly  sensitive  during  the  first  weeks.  In  Preyer's  child 
it  was  not  until  the  third  month  that  the  lids  closed  when  the  water  in 
the  bath  touched  the  lashes  or  the  cornea.  The  recognition  of  objects 
seen  is  usually  evident  in  the  sixth  month. 

It  is  important  that  the  room  in  which  the  newly-born  child  is  placed 
should  be  darkened,  and  that  for  the  first  few  weeks  the  eyes  should  be 
protected  against  strong  light. 

Hearing". — For  the  first  twenty-four  hours  after  birth  infants  are 
deaf.  This  deafness  sometimes  persists  for  several  days.  It  is  believed 
to  be  due  to  absence  of  air  from  the  middle  ear  and  to  swelling  of  the 
mucous  membrane  which  lines  the  tympanum.  With  the  movements  of 
respiration,  air  gradually  finds  its  way  into  the  middle  ear,  and  the  swell- 
ing subsides  during  the  first  few  days.  After  this  the  hearing  gradually 
improves,  and  during  the  early  months  of  life  it  is  very  acute.  The  child 
starts  at  the  slamming  of  a  door,  and  even  moderately  loud  noises  will 
waken  him  from  sleep.  By  the  end  of  the  second  .month  he  will  some- 
times turn  his  head  in  the  direction  from  which  the  sound  comes,  and 
by  the  end  of  the  third  month  this  will  usually  be  done.  Demme  found, 
in  observations  upon  one  hundred  and  fifty  infants,  that  voices  were 
recognized  on  an  average  at  three  and  a  half  months. 

Not  only  are  the  ears  unusually  sensitive  to  sound  in  infancy,  but 
the  impression  produced  upon  the  brain  is  often  marked— very  loud 
sounds  causing  great  fright. 

Touch. — Tactile  sensibility  is  present  at  birth,  but  is  not  highly  de- 
veloped except  in  the  lips  and  tongue,  where  it  is  very  acute  for  the  obvi- 


SPEECH  27 

ous  necessity  of  sucking.  After  the  third  month  it  is  fairly  acute  over 
the  surface  of  the  body  generally.  Two  especially  sensitive  areas, 
according  to  Preyer,  are  the  forehead  and  external  auditory  meatus. 

Sensibility  to  painful  impressions  is  present  in  early  infancy,  but 
very  dull  as  compared  with  later  childhood. 

Temperature  is  also  distinguished.  This  recognition  is  especially 
acute  in  the  tongue.  A  young  infant  is  often  seen  to  refuse  to  take  the 
bottle  because  the  milk  is  only  a  few  degrees  too  cold  or  too  warm. 

The  localization  of  sensory  impressions  comes  later,  probably  not 
much  before  the  middle  of  the  sixth  month,  and  is  very  imperfect 
throughout  the  first  year. 

Taste. — This  is  highly  developed,  even  from  birth.  According  to  the 
experiments  of  Kussmaul,  the  ability  to  distinguish  sweet,  sour  and  bit- 
ter, exists  in  the  newly-born  child — sweet  exciting  sucking  movements, 
and  bitter,  grimaces.  A  young  infant  detects  with  surprising  accuracy 
the  slightest  variation  in  the  taste  of  his  food,  and  the  smallest  difference 
is  often  enough  to  cause  him  to  refuse  the  bottle  altogether.  Sweet  sub- 
stances are  always  easily  administered,  and  in  combination  with  syrups 
even  very  bitter  substances-  can  be  given ;  but  to  aromatic  powders  and 
elixirs  he  usually  objects. 

Smell. — Observations  upon  the  sense  of  smell  in  newly-born  infants 
are  few  and  not  altogether  conclusive.  Kroner's  experiments  appear  to 
show  that  smell  is  present  in  the  newly  born.  It  has  been  noted  to  be 
especially  acute  in  infants  born  blind.  The  sense  of  smell  is  developed 
much  later  than  the  other  senses.  Detection  of  fine  differences  in  odors 
is  not  acquired  until  quite  late  in  childhood. 


SPEECH 

There  is  a  very  wide  variation  in  children  with  reference  to  the  time 
of  development  of  the  function  of  speech.  Girls,  as  a  rule,  talk  from 
two  to  four  months  earlier  than  boys.  Towards  the  end  of  the  first 
year  the  average  child  begins  with  the  words  "papa,"  "mamma."  By 
the  end  of  the  second  year  he  is  able  to  put  words  together  in  short 
sentences  of  two  or  three  words.  Progress  in  speech  from  this  time  is 
very  rapid,  each  month  showing  great  improvement.  Names  of  persons 
are  commonly  first  acquired,  then  the  names  of  objects.  Next  to  this 
the  verbs  are  learned,  and  then  adverbs  and  adjectives.  Conjunctions, 
prepositions,  and  articles  follow  in  order,  and  last  of  all  the  personal 
pronouns. 

If  a  child  of  two  years  makes  no  attempt  to  speak,  some  mental  defect 
may  usually  he  inferred  or  that  the  child  is  a  deaf  mute. 


28  GROWTH  AND  DEVELOPMENT 

DENTITION 

The  teeth  are  enclosed  at  birth  in  dental  sacs  which  are  situated  in 
the  gums.  Superficially  they  are  covered  by  the  submucous  connective 
tissue  and  the  mucous  membrane;  the  dental  sacs  rest  in  depressions  in 
the  alveolar  process  of  the  jaw.  The  tooth  grows  in  length  mainly  as  the 
result  of  the  calcification  of  its  roots,  and  being  thus  fixed  below,  it 
pushes  upward  towards  the  mucous  membrane.  This  growth  undoubtedly 
goes  on  steadily  from  birth  until  the  tooth  pierces  the  gum. 

The  deciduous  or  milk  teeth  are  twenty  in  number.  The  time  at 
which  they  appear  is  subject  to  considerable  variation  even  under  normal 
conditions.  The  following  is  the  order  and  the  average  time  of  appear- 
ance of  the  different  teeth : 

(1)  Two  lower  central  incisors 6  to   9  months. 

(2)  Four  upper  incisors 8  "  12 

(3)  Two  lower  lateral  incisors  and  four  anterior  molars  12  "  15      " 

(4)  Four  canines 18  "  24      " 

(5)  Four  posterior  molars 24  "  30      "  ^ 

At  1     year  a  child  should  have 6  teeth. 

At  1 1/2  years    "  "  "     12      " 

At  2        "  "  "  "  16      " 

At  21/2    "  "  "  " 20      " 

Quite  wide  variations  on  both  sides  of  the  average  are  common,  and 
are  not  always  easy  of  explanation.  In  many  cases  it  seems  to  be  a  family 
idiosyncrasy,  since  in  the  different  members  of  a  family  the  teeth  are 
apt  to  appear  at  about  the  same  time.  The  order  in  which  the  teeth 
appear  is  much  more  regular  than  the  time  of  their  appearance.  Slight 
variations  are  exceedingly  common,  but  marked  irregularities  in  the 
order  of  the  appearance  of  the  teeth  are  the  rule  in  idiotic  children  or 
those  suffering  from  slighter  mental  defects. 

The  teeth  may  pierce  the  gum  without  any  local  manifestations. 
Very  frequently,  however,  just  before  a  tooth  comes  through  there  is 
noticed  a  moderate  swelling  and  redness  of  the  mucous  membrane  of  the 
gum  overlying  it,  and  to  a  slight  degree  this  may  affect  the  general 
mucous  membrane  of  the  mouth.  This  condition  may  be  accompanied 
by  a  little  fretfulness  and  increased  salivation,  or  both  of  these  may  be 
entirely  wanting.  These  symptoms  usually  disappear  when  the  tooth 
has  pierced  the  gum.  The  symptoms  of  difficult  dentition  will  be  dis- 
cussed in  connection  with  Diseases  of  the  Mouth. 

Infants  may  be  born  with  teeth.  We  know  of  one  family  in  which 
this  occurred  in  three  members  of  three  successive  generations.  It  is, 
however,  rare.    It  is  almost  invariably  one  of  the  lower  central  incisors 


DENTITION  20 

that  is  present.  In  case  this  interferes  with  nursing,  or  if  it  is  ver}^ 
loosely  attached  to  the  gum,  it  should  be  extracted,  but  under  other 
circumstances  it  should  be  allowed  to  remain,  since,  if  it  is  removed, 
a  second  tooth  is  not  likely  to  appear  in  its  place  in  the  first  set.  It  is 
not  at  all  uncommon  for  the  first  teeth  to  appear  in  the  fourth  month. 
Such  teeth,  in  our  experience,  do  not  usually  differ  in  character  from 
those  appearing  later,  unless  they  are  in  children  who  are  syphilitic. 
Syphilitic  children  are  rather  prone  to  early  dentition,  and  under  such 
circumstances  rapid  and  early  decay  is  likely  to  take  place.  Nursing 
infants  are,  as  a  rule,  a  little  earlier  in  their  dentition  than  those  arti- 
ficially fed. 

Delayed  dentition  is  usually  due  to  rickets.  However,  in  many 
healthy  infants  no  teeth  appear  before  the  tenth  month;  and  we  have 
occasionally  seen  the  first  ones  at  thirteen  months  in  those  who  seemed 
perfectly  healthy  and  showed  no  other  evidence  of  rickets.  On  the  other 
hand,  it  is  by  no  means  invariable  that  dentition  is  late  in  rachitic  chil- 
dren. The  latest  dentition  is  seen  in  cases  of  cretinism.  In  such  chil- 
dren it  is  not  rare  for  the  first  teeth  to  appear  as  late  as  eighteen 
months  or  two  years.  As  a  rule,  dentition  and  ossification  of  the  bones  \ 
of  the  head  go  on  in  a  corresponding  manner ;  where  one  is  early  the 
other  is  likely  to  be  rapid,  and  conversely.  Great  irregularities  in  denti- 
tion are  common  in  children  with  defective  cerebral  development. 

Provided  an  infant  is  well  nourished  and  thrives  properly  for  the 
first  six  or  eight  months,  the  eruption  of  the  teeth  is  likely  to  go  on 
steadily  after  this  time,  even  though  the  child  may  later  have  chronic 
indigestion  or  suffer  from  extreme  malnutrition  from  any  cause  except 
rickets.  If,  however,  the  symptoms  of  malnutrition  date  from  birth, 
dentition  is  almost  invariably  delayed.  It  is  often  a  matter  of  very 
great  surprise  to  see  children  who  are  markedly  emaciated  as  a  result  of 
chronic  indigestion  or  ileocolitis  and  yet  go  on  cutting  their  teeth  reg- 
ularly. We  once  had  under  our  care  a  delicate  infant  of  sixteen  months, 
whose  body  length  was  twenty-eight  inches  and  whose  weight  was  less 
than  nineteen  pounds — almost  exactly  what  they  were  eight  months  previ- 
ously— and  yet  he  had  thirteen  teeth. 

Eruption  of  the  Permanent  Teeth. — The  first  to  appear  are  the  first 
molars,  which  usually  come  in  the  sixth  year,  and  hence  the  name  six 
year  old  molars,  which  is  applied  to  them.  These  appear  posterior  to  the 
second  molars  of  the  first  set. 

Tlie  incisors  and  canines  replace  the  corresponding  teeth  of  the  first 
set.  The  eight  bicuspids  take  the  place  of  the  eight  molars  of  the  first 
set.  The  molars  of  the  permanent  set  appear  back  of  the  bicuspids,  room 
l)eing  made  for  them  by  the  growth  of  the  jaw.  As  they  grow  and  pusli 
upward  the  permanent  teeth  cause  atrophy  of  the  roots  of  the  first  teeth, 


30  GROWTH  AND  DEVELOPMENT 

and  gradually  cut  off  their  blood  supjoly,  so  that  they  loosen  and  fall  out. 
The  following  table  from  Forchheimer  gives  the  average  time  of  the 
appearance  of  the  second  teeth : 

First  molars 6  years. 

Incisors 7  to   8      " 

Bicuspids    .■ 9  "  10      " 

Canines 12  "  14      " 

Second  molars 12  "  15      " 

Third  molars 17  "  25      " 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  in- 
fancy will  be  considered  in  the  chapter  on  Difficult  Dentition. 


CHAPTER    III 
PECULIARITIES  OF  DISEASE  IN  CHILDREN 

In  many  particulars  disease  in  children  differs  from  that  of  later  life. 
These  differences  relate  to  etiology,  pathology,  symptomatology,  diagno- 
sis, and  prognosis.  The  greatest  contrast  to  adult  life  is  presented  by 
infancy  and  early  childhood.  After  seven  years,  children  in  their  diseases 
resemble  adults  more  than  they  do  infants. 

ETIOLOGY 

1.  Inheritance  is  an  important  factor.  The  disease  most  frequently 
transmitted  directly  is  syphilis.  Occasionally  tuberculosis  and  other 
infectious  diseases  have  been  conveyed  directly  from. the  mother  to  the 
child.  In  cases  where  no  distinct  disease  is  transmitted,  children  may 
inherit  from  parents  constitutional  weaknesses  or  tendencies,  which  may 
manifest  themselves  in  infancy,  or  in  some  cases  not  until  later  child- 
hood. Under  this  head  we  may  place  the  influence  of  alcoholism,  lead 
poisoning,  rheumatism,  gout,  epilepsy,  and  insanity. 

3.  Malformations  must  be  considered,  particularly  in  the  first  two 
years  of  life.  The  most  important  of  these,  from  a  medical  standpoint, 
are  those  of  the  heart,  brain,  stomach  and  intestines,  and  kidney.  The 
various  malformations  of  the  mouth,  nose,  bladder,  rectum,  and  genital 
organs  belong  more  particularly  to  the  domain  of  surgery. 

3.  The  Diseases  or  Accidents  Connected  with  Birth. — Some  of  these 
are  distinctly  traumatic,  like  the  meningeal  hemorrhages.  A  very  large 
class  are  the  infectious  processes  in  the  newly  born.     Infection  usually 


SYMPTOMATOLOGY  AND  DIAGNOSIS  31 

takes  place  through  the  umbilical  wound,  more  rarely  through  the  skin 
or  mucous  membranes.  This  class  includes  pyemia,  with  its  varied 
lesions  in  the  brain,  lungs,  and  serous  membranes,  erysipelas,  ophthalmia, 
and  tetanus.  In  the  class  of  infectious  diseases  may  also  be  included 
many  of  the  varieties  of  pulmonary  and  intestinal  diseases  in  the  newly 
born,  and  probably  also  some  of  the  hemorrhagic  affections. 

4.  Conditions  Interfering  with  Proper  Growth  and  Development. — 
These  are  among  the  largest  etiological  factors  in  the  diseases  of  infancy. 
They  are  improper  food  or  feeding,  unhygienic  surroundings,  and  neglect. 
These  may  cause  specific  diseases,  like  rickets  or  scurvy,  or  may  lead  to  a 
condition  of  general  malniitrition  or  marasmus.  In  this  way  they  become 
most  important  predisposing  factors,  in  infancy,  to  the  acute  diseases  of 
the  gastro-enteric  tract,  and  later  in  childhood,  to  functional  nervous 
diseases. 

5.  Infection. — This  has  already  been  mentioned  as  an  important 
factor  in  diseases  of  the  newly  born.  The  number  of  diseases  in  later 
life  directly  traceable  to  this  is  very  large.  Under  this  head  should  be 
included  not  only  the  well-known  classes  of  infectious  and  contagious 
diseases,  but  also  a  very  large  number  of  varieties  of  infection  which 
as  yet  have  not  been  differentiated,  and  the  nature  of  which  is  but  im- 
perfectly understood. 


SYMPTOMATOLOGY  AND  DIAGNOSIS 

In  older  children  the  symptoms  of  disease  are  very  much  the  same  as 
in  adults,  and  similar  methods  of  examination  may  be  employed.  What 
is  really  peculiar  to  children  belongs  especially  to  the  first  three  years  of 
life,  before  speech  has  developed.  During  this  period  the  chief  and 
almost  the  sole  reliance  of  the  physician  must  be  upon  the  objective 
signs  of  the  disease.  It  is  not  so  much  that  diseases  in  early  life  are 
peculiar,  as  that  the  patients  themselves  are  peculiar. 

Two  fundamental  facts  are  always  to  be  kept  in  mind :  First,  that 
the  common  pathological  processes  are  comparatively  few,  being  chiefly 
of  the  gastro-enteric  tract,  the  lungs,  and  the  brain,  but  that  the  varia- 
tions in  clinical  types  are  almost  endless ;  the  second  is,  that  in  infants,  on 
account  of  the  susceptibility  of  the  nervous  system,  functional  de- 
rangements are  often  accompanied  by  very  grave  symptoms,  and  may 
even  prove  fatal  in  twelve  or  twenty-four  hours,  or  there  may  be  speedy 
and  complete  recovery  after  very  alarming  symptoms.  In  many  of 
these  cases  the  symptoms  are  so  indefinite  that  an  exact  diagnosis  is 
impossible  during  life,  and  even  the  autopsy  may  throw  but  little  light 
upon  them. 


32  PECULTArJTTES  OF  DISEASE  TX  CTTTLDREN 

At  the  bedside  it  is  of  great  assistance  to  the  pliysiciaii  if  he  can 
keep  in  mind  tlie  most  frequent  forms  of  acute  disease  tliat  are  likely  to 
be  met  with.  In  the  first  group,  including  those  which  are  very  com- 
mon, may  be  placed  acute  indigestion  and  ileocolitis,  bronchitis,  pneu- 
monia, pharyngitis,  tonsillitis,  and  otitis  media;  in  the  second  group, 
which  are  less  frequent,  are  placed  the  more  common  acute  infectious 
diseases;  in  the  third  group,  including  the  rarer  forms  of  acute  disease 
— meningitis,  tuberculosis,  rheumatism,  and  diseases  of  the  kidneys. 
In  all  circumstances,  the  season,  and  the  nature  of  the  prevailing  epi- 
demic, if  one  exists,  are  to  be  considered. 

In  the  examination  of  a  sick  infant  quite  a  different  method  is  to  be 

followed  from  that  pursued  with  adults.     Much  information  is  to  be 

■  gained  from  a  history  carefully  taken  from  an  intelligent  mother  or 

nurse,  and  much  more  from  a  close  observa|;ion  of  the  child,  whether 

asleep  or  awake,  quiet  or  crying. 

The  History. — In  view  of  the  fact  that  but  little  information  can 
be  had  from  the  patient,  none  at  all  in  most  cases,  it  is  important  to 
obtain  from  the  mother  or  nurse  as  full  and  complete  information  as 
230ssible.  A  good  history  carefully  obtained,  puts  the  physician  in  pos- 
session of  a  fund  of  information  about  the  patient  which  is  not  only  of 
the  greatest  value  in  arriving  at  a  diagnosis  in  the  illness  for  which  he 
is  consulted,  but  is  exceedingly  helpful  in  the  future  management  of  the 
child.  He  may  thus  know  the  individual  peculiarities  and  special  path- 
ological tendencies.  The  laity  attach  great  importance,  and  justly  so, 
to  advice  from  the  physician  who  "knows  the  child's  constitution." 
Such  a  history  should  be  taken  at  the  first  opportunity  after  the  physi- 
.  cian  is  placed  in  charge  of  a  child,  and  with  note-book  in  hand,  or  haK 
its  value  will  be  lost. 

Famvty^.  History. — This  should  begin  with  the  parents,  going  farther 
back,  if  possible,  in  many  cases  of  liereditary  disease.  One  must  knoAV 
-  regarding  tuberculosis,  syphilis,  rheumatism,  or  alcoholism,  the  general 
vigor  of  constitution  and  physical  condition  of  both  father  and  mother. 
Health  during  pregnancy,  and  previous  miscarriages,  if  any,  are  im- 
portant facts  in  the  mother's  history.  One  should  know  the  number 
of  other  children  living  and  their  general  health,  the  number  dead  and 
from  what  causes.  A  knowledge  of  the  surroundings  in  which  the  cliild 
has  lived  may  be  necessary  to  appreciate  the  chances  of  exposure  to 
tuberculosis,  malaria,  and  many  other  forms  of  infection. 

Patient's  Previous  History. — This  should  begin  with  birth.  One 
should  inquire  whether  the  child  was  premature  or  born  at  term,  regard- 
ing the  character  of  the  labor,  whether  natural  or  nistnmiental,  tedious 
or  complicated,  the  condition  and  vigor  of  the  child  at  birth,  primary 
respirations,  early  convulsions,  and  the  nutrition  during  the  early  days. 


SYMPTOMATOLOGY  AND  DIAGNOSIS  33 

Next  the  methods  of  feeding  should  be  taken  up — how  long  entirely 
and  how  long  partly  breast  fed,  the  date  of  weaning  and  the  form  of 
artificial  feeding  then  employed.  If  the  patient  is  an  infant,  and  the 
problem  presented  is  one  of  its  nutrition,  all  the  reliable  data  relating 
to  the  feeding  should  be  obtained,  even  to  the  minutest  detail.  This 
may  be  wearisome  and  consume  time,  but  in  no  other  way  can  one  ap- 
preciate the  conditions  present.  The  best  idea  of  the  child's  growth  and 
development  may  be  obtained  from  a  weight  record  if  one  has  been 
kept.  If  not  available,  one  must  depend  upon  general  statements  as 
to  how  the  child  thrived  at  different  periods.  The  date  of  the  appear- 
ance of  the  first  teeth  and  the  time  and  the  order  in  which  the  teeth  came, 
are  significant.  The  general  muscular  development  may  be  best  de- 
termined by  learning  when  the  child  could  first  hold  the  head  erect, 
sit  alone  upon  the  floor,  bear  the  weight  upon  the  feet,  creep  or  Avalk 
alone;  the  mental  development,  by  learning  as  to  early  recognition  of 
mother  or  nurse,  knowing  the  bottle,  understanding  the  meaning  of 
words,  speaking  in  words  or  sentences.  The  muscular  and  mental  de- 
velopment of  a  normal  child  during  the  first  two  years  is  a  subject 
with  which  the  •  physician  should  be  familiar  if  he  would  detect  early 
those  differences,  often  slight  at  this  age,  in  children  whose  development 
is  backward  owing  to  cerebral  lesions. 

All  previous  attacks  of  acute  illness  of  whatever  character  should  be 
noted,  particularly  the  infectious  diseases — measles,  scarlet  fever,  diph- 
theria, pertussis,  and  influenza — with  dates  and  details  as  to  duration, 
severity,  and  complications.  One  should  learn  whether  the  child  is  espe- 
cially prone  to  disorders  of  digestion  or  those  of  the  respiratory  system. 
Under  the  former  head  are  included  early  difficulties  in  feeding,  acute 
attacks  of  indigestion,  diarrhea,  or  dysentery,  also  chronic  disturbances 
of  the  stomach  or  bowels;  under  the  latter  head,  frequent  catarrhal 
colds,  earache  or  otitis,  catarrhal  croup,  bronchitis,  pneumonia,  or 
pleurisy.  Other  points  to  be  investigated  relate  to  attacks  of  tonsillitis, 
operations  for  the  removal  of  hypertrophied  tonsils  or  adenoids,  and 
previous  disorders  of  the  nervous  system.  In  infants,  particularly  im- 
portant are  extreme  restlessness,  insomnia,  convulsions,  or  attacks  of 
night  terrors;  in  those  who  are  older,  hysterical  manifestations,  epilepsy, 
or  chorea.  Finally,  one  sbould  know  the  date  of  successful  vaccination. 
Inquiry  should  also  be  made  concerning  any  recent  exposure  to  infection 
in  the  community,  school,  or  home. 

Present  Illness. — :One  should  first  note  the  chief  complaints  as  stated 
by  mother  or  nurse.  It  is  important  to  obtain  as  definite  statements  as 
possible  as  to  the  time  when  the  child  was  quite  well,  and  whether  the 
onset  of  the  illness  was  abrupt  or  gradual,  and  with  what  particular 
symptoms.     In  all  digestive  disorders  one  should  know  exactly  concern- 


34  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

ing  the  child's  food  at  the  time  of  the  onset,  its  quantity,  character,  and 
preparation ;  also  any  recent  change  in  diet,  the  presence  or  absence  of 
vomiting,  and  the  condition  of  the  bowels,  whether  loose  or  constipated, 
the  frequency  and  ciiaracter  of  the  stools.  General  questions  as  to 
Avhether  the  bowels  are  regular  or  the  stools  normal  are  of  no  value, 
since  the  informant  often  is  not  capable  of  judging  correctly. 

Kervous  symptoms,  like  the  others,  should  be  elicited  in  response  to 
direct  questions  regarding  sleep,  restlessness,  moaning,  crying  out,  or 
other  evidences  of  pain,  excitement,  delirium,  or  convulsions,  or  unnat- 
ural drowsiness.  In  any  acute  illness  other  important  symptoms  are 
fever,  sweating,  dyspnea,  cough,  hoarseness,  nasal  discharge,  and  the 
amount  and  character  of  the  urine. 

The  Examination. — With  infants,  quite  a  different  method  should  be 
followed  from  that  pursued  with  adults.     It  may  well  begin  with: 

General  Inspection. — What  is  learned  in  this  way  will  depend  almost 
entirely  upon  the  acuteness  of  observation  of  the  physician,  but  much 
that  is  of  value  can  be  ascertained  before  the  clothing  is  removed  for 
the  physical  examination  by  simply  watching  the  patient,  whether  asleep 
or  awake,  for  several  minutes.  In  acute  disease,  the  following  points 
should  be  noted  especially : 

1.  Nutrition  and  general  development :  whether  the  child  is  well 
nourished  or  the  features  pinched  and  wasted. 

2.  The  facial  expression :  whether  it  is  bright  and  intelligent  or  dull 
and  stupid,  peaceful  or  anxious,  quiet  or  disturbed,  and  whether  the 
features  are  contracted  from  time  to  time,  as  if  from  pain. 

3.  The  character  of  the  respiration:  whether  it  is  rapid  or  slow,  easy 
or  difficult;  whether  there  is  nasal  obstruction,  as  indicated  by  snoring 
and  mouth-breathing,  suggesting  in  infants  acute  rhinitis,  syphilis,  or 
retropharyngeal  abscess;  in  older  children,  diphtheria,  scarlet  fever,  or 
adenoids.  Marked  dyspnea  is  usually  accompanied  by  active  dilatation 
of  the  alae  nasi. 

4.  The  posture :  whether  the  child  lies  upon  the  back,  side,  or  face ; 
whether  the  head  is  drawn  back  with  general  flexion  of  the  extremities 
as  in  meningitis. 

5.  The  nervous  condition:  whether  the  chihl  is  restless,  excitable,  or 
drowsy  and  apathetic;  if  asleep,  the  nature  of  the  sleep  should  be 
observed.  "%; 

6.  The  color  of  the  skin  of  the  face:  whether  pale  or  cyanotic;  £tnd 
the  lips,  whether  fissured  or  excoriated. 

7.  The  amount  of  prostration:  a  practiced  eye  can  usually  tell  with 
older  children  whether  the  condition  is  grave  or  not,  but  infants  not 
infrequently  deceive  even  the  most  experienced  observer. 

8.  The  cry :  in  conditions  of  restlessness  or  irritability,  much  infor- 


SYMPTOMATOLOGY  AND  DIAGNOSIS  35 

mation  may  be  obtained  from  its  character.  It  is  important,  but  not 
always  easy,  to  determine  whether  a  child  cries  from  fright,  as  at  the 
approach  of  a  stranger,  from  nervousness  or  bad  training,  from  general 
irritability  which  may  come  from  any  acute  disease,  or  from  actual 
pain.  The  cry  of  fright  is  usually  evident,  because  it  comes  with  the 
physician's  approach  and  ceases  Avhen  he  goes  away.  Children  of  highly 
neurotic  parents  and  those  who  have  been  much  indulged  and  badly 
trained  will  often  cry  when  anything  out  of  the  usual  routine  occurs. 
The  cry  of  pain  may  be  very  distinctive ;  it  may  be  sharp  and  acute  and 
accompanied  by  some  attempt  at  localization,  as  when  a  child  puts  his 
hand  to  an  inflamed  part,  but  in  infancy  the  pain  of  acute  inflammation 
is  often  indicated  only  by  general  restlessness  and  irritability.  This  is 
frequently  true  of  acute  otitis.  The  cry  of  pain  is  usually  accompanied 
by  contraction  of  the  features  and  other  evidences  of  distress. 

The  cry  of  some  diseases  is  quite  characteristic,  as  the  short,  catchy 
cry  of  acute  pneumonia  or  bronchitis;  the  hoarse  cry  of  laryngitis, 
whether  catarrhal,  membranous,  or  syphilitic;  the  feeble  whine  of  ex- 
treme exhaustion  or  marasmus;  the  moaning  cry  of  intestinal  disease; 
and  the  sharp  cry  of  a  child  with  scurvy  whenever  its  bed  or  body  is 
touched. 

Measurements. — ^These,  though  of  greatest  value  in  chronic  diseases, 
particularly  disturbances  of  nutrition,  may  be  of  assistance  also  in  acute 
conditions.  The  important  measurements  are  the  circumference  of  the 
head,  chest,  and  body  length.  The  circumference  of  the  abdomen  is  at 
times  important,  but  varies  so  much  with  the  degree  of  distention  that 
it  is  not  significant  as  to  the  general  development.  The  measurements 
and  weight  furnish  reliable  data  which  are  not  only  of  assistance  in  the 
diagnosis  of  existing  disease,  but  if  recorded  are  useful  for  future  com- 
parison. 

In  taking  the  circumference  of  the  head  the  largest  measurement 
(over  the  occipital  and  frontal  eminences)  is  preferable.  The  measure- 
ment of  the  chest  is  usually  taken  over  the  nipples.  The  body  length 
of  infants  is  best  taken  with  a  tape  as  the  child  lies  upon  his  back  upon 
a  table  or  a  firm  bed.  For  older  children  a  special  measuring  stick  is 
convenient. 

To  estimate  properly  the  significance  of  measurements  they  should 
be  compared  with  the  normal  averages  and  with  each  other.  It  should 
be  remembered  that  the  head  is  normally  larger  than  the  chest  until  near 
the  end  of  the  second  year;  after  this  time,  with  a  normal  development, 
the  chest  should  be  larger.  Any  great  disproportion  lietween  the  size 
of  the  head  and  chest  is  suggestive  of  disease.  The  large  head  and  the 
small  chest  belong  especially  to  rickets.  The  measurements  form  im- 
portant means  of  recognizing  early  such  abnormalities  as  cretinism  and 


36  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

chondrodystrophy,  the  variations  often  being  marked  before  the  other 
symptoms  are  prominent.  One  who  forms  the  habit  of  taking  regular 
measurements  soon  appreciates  the  variations  from  the  normal^  and  gains 
great  assistance  from  these  data.  Such  a  record  made  from  year  to 
year  in  children  whose  development  is  in  any  way  abnormal  is  of  great 
value  in  indicating  what  should  be  done  in  the  way  of  exercise  to  correct 
faulty  conditions. 

Vital  Signs. — -Pulse,  Eespiration,  and  Temperature. — The  signifi- 
cance of  these  signs  is  not  to  be  measured  by  adult  standards,  since  the 
susceptible  nervous  system  of  infants  and  very  young  children  greatly 
exaggerates  their  reaction  to  all  forms  of  acute  infection. 

The  rate,  regularity,  quality,  and  tension  of  the  pulse  should  be  noted. 
In  young  children,  the  rate  of  the  pulse  is  of  less  importance  than  its 
force  and  quality.  A  slow,  irregular  pulse  is  always  significant,  and 
should  suggest  meningitis  or  brain  tumor;  a  slight  irregularity  of  the 
pulse  during  sleep  has  no  special  significance.  The  pulse  rate  is  much 
increased  from  slight  disturbances;  the  approach  of  a  stranger  or  the 
examination  by  the  physician  may  cause  it  to  rise  20  or  30  beats.  In 
acute  disease,  a  pulse  rate  of  150  is  common,  and  170  or  180  is  often  seen 
where  other  symptoms  are  not  particularly  severe. 

The  rate,  depth,  and  rhythm  of  respiration  should  be  noted.  The 
last  often  cannot  be  determined  except  by  attentively  watching  the  child 
for  several  minutes.  In  premature  and  very  young  infants  a  rather 
marked  irregularity  may  be  seen,  often  approaching  the  Cheyne-Stokes 
type.  It  is  not  to  be  taken  as  indicating  a  cerebral  lesion,  but  seems 
rather  to  be  due  to  the  fact  that  the  respiratory  center  is  not  yet  fully 
able  to  control  the  movements.  Eespiration  of  this  type  is  seen  only 
during  the  first  weeks  of  life.  Irregularity  of  rhythm  at  other  times 
should  suggest  cerebral  disease,  usually  meningitis.  The  respiration  rate 
is  proportionately  greater  in  infants  than  in  adults.  In  acute  diseases 
of  the  lungs  it  not  infrequently  rises  to  70  or  80,  and  occasionally  it  may 
be  over  100  a  minute.  The  rate  is  generally  in  projoortion  to  the  extent 
of  the  pulmonary  lesion. 

The  temperature  of  infants  and  very  young  children  should  he  taken 
in  the  rectum,  since  groin  or  axillary  temperatures  are  untrustworthy 
and  those  in  the  mouth  difficult  to  obtain.  Immediately  after  lurth  the 
temperature  of  the  child  is  about  the  same  as  that  of  the  mother,  or  a 
little  higher.  It  falls  from  1°  to  3°  F.  in  the  course  of  the  first  few 
hours.     Soon  it  again  rises  to  98.5°  or  99°  F. 

From  a  large  number  of  personal  observations  upon  healthy  infants, 
we  have  found  that  the  rectal  temperature  under  normal  conditions  varies 
between  98°  and  99.5°  F. ;  occasionally  the  range  may  be  as  wide  as 
97.5°  to  100.5°  F.  in  apparently  perfect  health.     The  heat-regulating 


SYMPTOMATOLOGY  AND  DIAGNOSIS  37 

center  in  the  l^rain  acts  only  imperfectly  in  the  young  infant,  and  slight 
causes  are  enough  to  disturb  the  temperature. 

The  temperature  in  infants  is  always  higher  than  from  corresponding 
causes  in  adults.  Moreover,  very  high  temperatures  may  be  met  with  in 
cases  not  serious,  and  not  infrequently  when  no  explanation  can  be 
found  even  after  thorough  examination.  In  such  cases  the  temperature 
seldom  remains  at  a  high  point  for  more  than  a  few  hours.  It  is  a 
continuous  high  temperature  rather  than  a  single  rise  which  is  significant 
of  disease  in  infancy.  Nothing  is  more  perplexing  to  the  young  practi- 
tioner than  the  frequency  with  which  a  high  temperature  is  seen  in 
infants  in  cases  of  comparatively  mild  illness.  r- 

It  is  common  in  chronic  wasting  diseases,  in  delicate  infants  and  in 
those  prematurely  born,  to  find  the  temperature  one  or  two  degrees  below 
the  normal;  95°  and  96°  F.  are  of  almost  daily  occurrence  in  hospitals, 
and  much  lower  ones  ire  not  rare.  Daily  observations  should  be  made 
with  the  thermometer  in  such  conditions,  Just  as  in  fever. 

Puzzling  and  apparently  alarming  temperatures  are  seen  in  infants 
as  a  result  of  the  application  of  artificial  heat.  In  one  of  our  patients, 
an  infant  two  days  old,  a  temperature  of  107°  F.  was  caused  by  the 
close  proximity  of  two  large  hot-water  bags  placed  in  the  baby's  basket. 
The  younger  and  feebler  the  child  the  more  readily  are  such  temperatures 
produced. 

Muscular  and  Mental  Development. — The  general  muscular  develop- 
ment is  determined  by  seeing  how  w^ell  the  children  can  hold  up  the  head, 
sit  alone,  stand,  or  walk;  the  mental  development  in  young  infants,  by 
the  intelligence  of  expression,  the  manner  in  which  they  respond  to 
stimuli,  the  recognition  of  objects,  fright  at  strangers,  etc. ;  later  in  the 
first  year,  by  the  use  of  their  hands,  their  understanding  of  speech,  and 
their  ability  to  pronounce  words. 

Local  Examination. — For  the  purpose  of  making  a  complete  routine 
examination  of  an  infant  the  entire  clothing,  with  the  exception  of  the 
napkin,  should  be  removed,  and  the  infant  placed  preferably  upon  the 
nurse's  lap  upon  a  blanket.  With  older  children  the  clothing  may  be 
removed  and  the  body  examined,  one  part  at  a  time,  but  with  all  children 
it  is  essential  that  the  examination  be  complete.  A  warm  room  is  indis- 
pensable, and  a  table  covered  with  a  blanket  in  many  respects  better 
than  the  nurse's  lap,  although  the  latter  has  usually  to  be  employed. 
The  local  examination  should  be  deliberate,  the  physician  should  pro- 
ceed cautiously,  winning  the  child  by  gradual  approaches,  and  avoiding 
excitement,  force,  or  anything  which  may  cause  pain. 

Skin. — The  skin  shoidd  first  be  inspected  for  eruptions,  and  it  is 
important  that  the  entire  eruption  be  examined  in  order  that  the  distri- 
bution as  well  as  the  character  of  the  lesion  may  be  seen.     Marked  wrin- 


38  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

kling  or  loss  of  elasticity  of  the  skin  is  one  of  the  best  indications  of  loss 
in  weight.  Bedsores  are  more  frequently  seen  over  the  occiput  than 
over  the  sacrum.    Any  large  veins  should  be  noted. 

External  glands  should  now  be  examined,  especially  the  cervical, 
axillary,  ingaiinal,  and  epitrochlear.  The  cause  of  a  marked  enlarge- 
ment of  any  of  these  groups  should  be  sought  in  the  skin  or  mucous 
membranes  with  which  they  are  connected.  Marked  swelling  of  the 
cervical  glands  may  indicate  diphtheria,  scarlet  fever,  or  a  simple  acute 
inflammation  dependent  upon  a  rhinopharyngitis.  Enlargement  of  the 
epitrochlear  glands  is  especially  significant  of  syphilis.  General  enlarge- 
ment of  all  the  glands  to  a  slight  degree  is  seen  in  most  cases  of  mal- 
]iutrition  and  in  many  acute  infectious  diseases. 

Head.- — One  should  first  note  whether  the  sutures  are  ossified,  un- 
naturally open  or  separated;  also  whether  the  fontanel  is  closed,  or,  if 
open,  whether  it  is  depressed  or  bulging.  Prominences  of  the  frontal 
or  parietal  regions  when  symmetrical  are  indicative  of  rickets.  Irregular 
prominences  of  a  smaller  size,  when  present,  are  usually  syphilitic.  In 
the  newly  born,  a  tumor  on  the  head,  if  in  the  median  line,  may  indi- 
cate an  encephalocele ;  if  limited  to  either  the  parietal  or  occipital  bone 
it  is  usually  a  cephalhematoma. 

Eyes. — The  condition  of  the  conjunctivae  and  lids  should  be  noted, 
also  the  presence  of  ptosis,  strabismus,  or  other  paralysis,  but  particularly 
the  condition  of  the  pupils,  whether  contracted  or  dilated,  and  the  nature 
of  their  response  to  light.  One  should  look  also  for  the  presence  of 
corneal  ulcers  or  of  interstitial  keratitis  frequently  seen  in  late  hereditary 
syphilis. 

Ea/rs. — The  presence  of  a  discharge  may  be  recognized  by  sight  or 
by  the  odor.  In  any  acute  febrile  condition  one  should  look  for  tender- 
ness or  swelling  over  the  ear  or  mastoid.  The  ears  should  invariably  be 
examined  otoscopically  in  all  forms  of  febrile  disturbance  whose  cause 
is  doubtful  and  from  time  to  time  in  pneumonia,  scarlet  fever,  measles, 
diphtheria  and  other  diseases  involving  the  mouth  and  rhinopharynx. 

Nose. — The  presence  of  any  nasal  discharge  should  be  noted  and  its 
character  determined.  An  abundant  discharge  tinged  with  blood,  in 
young  infants,  should  suggest  syphilis;  in  older  children,  diphtheria;  a 
chronic  discharge,  adenoid  growths;  a  purulent  discharge  of  one  side, 
a  foreign  body. 

Mouth. — The  appearance  of  the  mucous  membrane  of  the  mouth 
and  gums  as  well  as  the  teeth  may  often  be  ascertained  by  watching 
the  child  while  he  is  crying.  It  should  be  noted  whether  the  tongue  is 
dry  or  moist,  clean  or  coated;  whether  thrush  is  present  or  any  other 
form  of  stomatitis.  If  the  gums  are  congested,  swollen,  or  hemorrhagic, 
they  should  suggest  scurvy.     The  number,  position,  and  character  of 


SYMPTOMATOLOGY  AND  DIAGNOSIS  39 

the  teeth  are  important.  The  general  color  of  the  mucous  membrane 
may  be  significant  in  cases  of  cyanosis  in  congenital  cardiac  disease,  and 
extreme  pallor  of  the  mucous  membrane  in  anemia.  On  the  mucous 
membrane  of  the  hard  palate  may  often  be  found  the  first  local  evidence 
of  scarlet  fever  in  the  form  of  a  minute  punctate  eruption,  and  on  that 
portion  of  the  cheeks  opjaosite  the  molar  teeth  should  be  sought  Koplik's 
sign,  the  earliest  reliable  symptom  of  measles. 

Throat. — A  careful  examination  of  the  pharynx  and  tonsils  should 
never  be  omitted  in  any  acute  illness,  no  matter  what  other  symptoms 
may  be  present.  Not  only  tonsillitis,  but  often  diphtheria,  is  overlooked 
from  a  failure  to  observe  this  as  an  invariable  rule.  A  good  light  is 
essential,  and  one  must  train  himself  to  take  in  all  the  appearances  at 
a  single  glance.  Marked  general  redness  of  the  pharynx  may  be  asso- 
ciated with  scarlet  fever,  influenza,  or  simple  acute  pharyngitis.  If  other 
symptoms  are  present  pointing  to  chronic  nasal  obstruction  or  to  a 
catarrhal  process  of  the  rhinopharynx,  a  digital  examination  should  be 
made  to  determine  the  presence  of  adenoids.  Dyspnea  with  mouth- 
breathing  when  associated  with  difficulty  in  swallowing  should,  in  an 
infant,  always  suggest  retropharyngeal  abscess.  The  examination  of  the 
mouth  and  throat  may  wisely  be  made  the  last  step,  since  it  usually 
disturbs  a  child  so  as  to  embarrass  further  investigation. 

Neck. — One  should  consider  the  position  in  which  the  head  is  held 
and  the  amount  of  rigidity  of  the  cervical  muscles.  Opisthotonus  may  be 
associated  with  meningitis  or  old  cerebral  palsy.  A  marked  rigidity  may 
indicate  cervical  Point's  disease  or,  if  accompanied  by  torticollis,  may 
l)e  of  rheumatic  origan. 

CheM. — In  young! children  particular  importance  should  be  attached 
to  the  shape  of  the  chest.  Symmetrical  deformities  are  usually  due  to 
rickets.  Contraction  of  one  side  only  is  most  frequently  the  result  of 
an  old  empyema  or  an  extensive  interstitial  pneumonia.  Bulging  of  the 
precordial  region  is  frequent  in  cardiac  disease.  One  should  notice  also 
the  recession  of  the  soft  parts — intercostal  spaces,  the  suprasternal  notch, 
or  the  epigastrium;  the  amount  of  this  is  usually  the  best  means  of 
judging  the  severity  of  obstructive  dyspnea.  Details  regarding  the 
physical  examination  of  the  lungs  are  discussed  in  the  introductory  chap- 
ter to  Pulmonary  Diseases. 

Heart. — It  should  be  remembered  that  under  two  years  old  loud 
murmurs  are  almost  invariably  of  congenital  origin,  that  soft  murmurs 
at  the  base  are  very  frequently  functional,  and  that  acquired  cardiac 
disease  is  rare  until  after  three  years.  For  further  details  in  the  ex- 
amination the  reader  is  referred  to  the  chapters  upon  Diseases  of  the 
Heart. 

Ahdoinen.- — There  should  he  noted  the  presence  or  absence  of  tym- 


40  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

panites  or  abdominal  tenderness,  whether  general  or  localized,  and  the 
existence  of  retraction  of  the  abdominal  walls  as  in  meningitis.  The 
size  and  position  of  the  liver  and  spleen  are  best  determined  by  palpa- 
tion. The  lower  border  of  the  liver  is  usually  slightly  below  the  free 
border  of  the  ribs.  If  the  spleen  can  be  easily  felt  below  the  ribs,  it  is, 
as  a  rule,  enlarged.  If  it  can  not  be  felt  in  a  satisfactory  examination, 
it  is  not  sufficiently  enlarged  to  be  of  any  diagnostic  importance.  In 
acute  disease  a  large  spleen  suggests  malaria,  typhoid,  or  tuberculosis; 
in  chronic  disease,  rickets,  malaria,  syphilis,  leukemia,  or  anemia. 

Spine.— The  most  frequent  spinal  curves  seen  in  infancy  are  those 
due  to  muscular  weakness.  These  disappear  by  placing  the  child  in  a 
prone  position.  Eachitic  curvatures  are  of  the  same  general  character, 
but  as  they  have  usually  lasted  a  longer  time  the  spine  is  less  flexible 
and  the  curvatures  may  not  entirely  disappear  by  change  of  posture.  An 
angular  deformity  or  even  marked  rigidity  of  the  spine  should  suggest 
Pott's  disease. 

Extremities. — The  color  of  the  skin  and  the  character  of  the  periph- 
eral circulation  should  be  noted  especially  in  pneumonia,  diphtheria,  and 
other  diseases  attended  by  weakened  heart.  Clubbing  of  the  fingers  or 
toes  may  be  due  to  congenital  heart  disease  or  to  chronic  disease  of  the 
lungs.  Desquamation  of  the  palms  or  soles  may  indicate  hereditary 
syphilis  or  scarlet  fever,  even  though  no  other  evidence  may  be  present. 
The  finger-nails  may  give  valuable  information  in  hereditary  syphilis. 
In  examining  the  extremities  one  should  note  especially  the  presence 
of  tenderness,  flaccidity,  or  rigidity  of  muscles,  whether  the  limbs 
are  wasted  or  plump,  and  the  degree  of  muscular  power;  also  any 
abnormal  swelling  on  the  shaft  or  near  the  extremities  of  the  bones,  and, 
finally,  the  function  of  the  joints.  A  general  relaxation  of  the  liga- 
ments is  common  in  rickets,  in  paralytic  (x^nditions,  and  in  the  Mon- 
golian type  of  mental  deficiency.  Flabbiness  of  the  muscles  belongs  to 
malnutrition  and  rickets;  rigidity,  if  chronic,  is  usuall}^  indicative  of 
cerebral  palsy.  Weakness  of  special  groups,  with  atrophy  and  flaccid 
muscles,  suggests  poliomyelitis.  Acute  tenderness  of  the  legs  in  in- 
fants should  suggest  scurvy;  in  older  children,  osteomyelitis  or  rheuma- 
tism. Eachitic  deformities  are  almost  invariably  bilateral.  Tuber- 
culous bone  disease  affects  the  epiphyses,  while  syphilis  usually  involves 
the  shafts,  the  only  exception  to  this  being  the  epiphyseal  separation 
which  may  occur  in  the  first  months  of  life. 

The  refiexes  may  be  somewhat  difficult  to  obtain  in  infants  and  when 
exaggerated  may  indicate  cerebral  palsy,  meningitis,  or,  as  in  tetany,  only 
an  extreme  irritability  of  the  nervous  centers  without  organic  disease. 
The  plantar  reflex  of  Babinski  has  little  significance  in  infants,  and  in 
older  children  it  is  present  in  many  conditions.     Kernig's  sign  is  a  form 


PATHOLOGY  41 

of  muscular  spasm  almost  invariably  present  in  meningitis,  but  often 
seen  in  other  diseases. 

Genital  Organs. — Male  children  should  be  examined  to  determine  the 
presence  of  phimosis  or  of  undescended  testicles.  Hydrocele  of  the  cord 
is  a  frequent  condition,  and  may  be  mistaken  for  hernia.  Both  inguinal 
and  umbilical  herniae  are  very  common.  In  female  children  it  should  be 
remembered  that  preputial  adhesions  may  be  considered  normal,  and  are 
seldom  the  cause  of  the  nervous  symptoms  attributed  to  them.  Every 
vaginal  discharge  is  significant,  and  if  purulent  should  be  examined 
bacteriologically.  The  great  frequency  of  gonococcus  infections  is  not 
appreciated,  and  they  may  be  found  when  least  expected. 

The  examination  is  not  complete  without  the  inspection  of  the  stools^ 
the  chemical  and  microscopical  examination  of  the  urine,  and  an  exami- 
nation of  the  Hood.     All  are  more  fully  considered  in  special  chapters. 

PATHOLOGY 

The  pathological  processes  which  result  from  intra-uterine  disease 
and  those  which  are  connected  with  delivery  are  peculiar  to  early  life. 
They  have  already  been  referred  to  in  the  section  on  etiology.  Of  the 
processes  of  early  life  which  begin  after  birth,  the  first  in  frequency 
are  those  of  the  mucous  membranes  resulting  from  the  various  forms  of 
irritation  and  infection.  In  summer,  it  is  the  stomach  and  intestines 
which  suffer  chiefly;  in  winter,  the  respiratory  tract. 

The  serous  membranes  are  rarely  the  seat  of  primary  inflammation. 
The  pleura  is  seldom  the  seat  of  primary  disease,  but  is  very  often  in- 
volved secondarily  to  disease  of  the  lung  itself.  Affections  of  the  peri- 
cardium and  peritoneum  are  quite  rare.  Meningitis  is  fairly  common, 
especially  the  tuberculous  form. 

Diseases  of  the  lymph  nodes  (lymphatic  glands)  play  an  important 
part  in  connection  with  the  acute  diseases  of  the  mucous  membranes, 
with  many  affections  of  the  skin,  and  even  of  the  viscera.  Acute  infec- 
tion tends  to  excite  suppurative  inflammation,  particularly  in  infants;  a 
less  active  process  leads  to  chronic  hyperplasia  in  the  mesenteric,  medias- 
tinal, and  cervical  glands,  in  the  tonsils,  adenoid  tissue  of  the  pharynx, 
etc.  The  lymph  nodes  in  the  neck  and  thorax  are  frequently  the  earliest 
seat  of  tuberculous  deposits,  and  in  very  many  cases  they  are  the  foci 
from  which  secondary  infection  of  the  lungs,  brain,  or  joints  may  occur. 

Of  the  visceral  inflammations  those  of  the  lungs  are  the  most  com- 
mon, it  being  rare  to  find  the  lungs  normal  at  autopsy  after  any  acute 
infectious  disease  which  has  lasted  a  week.     Up  to  the  third  or  fourth  I 
year  of  life  the  heart  usually  escapes.     In  older  children  it  may  be  in-  k 
volved,  as  in  adults,  in  the  rheumatic  diseases.     The  liver  and  spleen-'' 


42  PECULIARITIES  OF  DISEASE  IN  CHILDRJIN 

are  not  often  the  seat  of  organic  disease  in  early  life,  nor  is  serious  disease 
of  the  kidney  likely  to  be  met  with  except  in  connection  with  scarlet 
fever.  Organic  disease  of  the  brain  itself  is  rare,  as  is  also  organic 
disease  of  the  spinal  cord,  with  the  exception  of  poliomyelitis.  Chronic 
diseases  of  the  different  viscera  are  decidedly  rare,  except  when  resulting 
from  acute  processes.  Diseases  of  the  bones  and  joints  are  common,  and 
of  extreme  importance.    They  are  usually  of  tuberculous,  less  frequently 

The  following  table  gives  in  a  general  way  a  very  good  idea  of  the  relative 
frequency  of  diseases  of  the  different  organs  in  infancy.  It  is  based  upon  seven 
hundred  and  twenty-six  consecutive  autopsies  in  the  New  York  Infant  Asylum, 
extending  over  a  period  of  eight  years  during  our  connection  with  that  institution. 
Of  these  children  seventy-two  per  cent  were  under  one  year,  twenty-five  per 
cent  between  one  and  two  years,  and  only  three  per  cent  were  over  two  years. 
The  institution  did  not  receive  infants  under  one  month,  hence  the  absence  of 
lesions  peculiar  to  the  newly-born: 

Table  showing  principal  lesions  in  seven  hundred  and  twenty-six  con- 
semdive  autopsies  in  the  New  York  Infant  Asylum. 
Lungs : 

Pneumonia — Primary 139 

Complicating  other  acute   infectious    diseases 112 

Complicating  other  conditions 71 

Noted  to  be  present  in 322 

Pleurisy —     No  case  uncomplicated  with  disease  of  lungs. 

Empyema  5 

Serous  pleurisy  1 

Dry  pleurisy  in  nearly  all  the  severe  cases  of  pneu- 
monia. 

Atelectasis  (congenital)  6 

Pulmonary  abscess  (always  with  pneumonia)    7 

Pulmonary  gangrene  (always  with  pneumonia) 2 

Pulmonary  tuberculosis 56 

Mouth: 

Noma 1 

Peritoneum : 

Acute  peritonitis  (localized  2,  with  acute  pneumonia  and  pleiu'isy 

2)    4 

Kidneys: 

Acute  nephritis  (complicating  scarlet  fever  4,  diphtheria  1,  pneu- 
monia 4,  measles  1,  pertussis  1,  ileocolitis  2,  pyonephrosis  1, 

apparently  primary  5)   19 

Malformations  of  the  kidney 7 

Stomach  and  Intestines: 

Acute  ileocolitis,  with  or  without  gastritis 116 

Acute  gastritis  (without  intestinal  lesions)  None 

Acute  diarrheal  disease  (without  gross  lesions) 72 

Intussusception 1 


PROC4NOSIS  AND  INFANT  MORTALITY 


43 


of  syphilitic,  origin.  Diseases  of  the  blood  are  quite  common,  but  as 
yet  but  little  understood.  New  growths  are  rare.  The  parts  most  fre- 
quently aliected  are  the  kidneys  and  the  bones.  Disorders  of  nutrition 
are  extremely  common  and  of  gTeat  imjDortance;,  particularly  rickets  and 
scurvy. 

PROGNOSIS  AND  INFANT  MORTALITY 


The  younger  the  patient  the  worse  the  prognosis  in  all  tiie  diseases  of 
childhood.  This  is  in  consequence  of  the  feeble  resistance  of  the  infan- 
tile organism  to  all  diseases,  particularly  those  which  are  of  an  acute 
nature.  On  the  other  hand,  the  rapid  metabolism  of  childhood  makes 
it  possible  for  many  conditions  of  an  organic  nature  to  disappear  with 
time,  or,  as  the  phrase  is,  to  be  "outgrown,"  provided  the  patient  can 
be  so  placed  that  the  general  nutrition  can  be  carried  to  the  highest 
point. 

The  accompanying  chart  (Plate  I)  shows  the  mortality  of  New  York 
City  by  months  during  three  consecutive  years,  representing  a  total 
mortality  of  128,136. 

The  following  table  gives  comparatiye  figures  of  actual  deaths  for 
four  periods  of  three  years  each,  and  shows  the  reduction  in  infant  and 
child  mortality  which  has  taken  place  in  the  last  twenty-five  years : 

Deaths — New  York  City  {Boroughs  of  Manhattan  and  Bronx) 


1890-1892. 

1898-1900. 

1907-1909. 

1912-1914. 

Under  1  year. 

1  to    2  years  . 

2  "    5     " 
5  "  15     " 
Over  15  « 

32,916  =  26% 

10,547=   8% 

9,794=   7% 

5,470=   5% 

69,409  =  54% 

29,326  =  24% 
9,012=  7% 
7,292=  6% 
6,922=   5% 

71,024  =  58% 

30,626  =  22.5% 
8,298=  6.0% 
6,579=  5.0% 
4,902=    3.5% 

85,741  =  63.0% 

25,015  =  19.1% 

6,527=   5.0% 

5,408=   4.1% 

4,.5.33=   3.5% 

89,341=68.3% 

Total.  .'.  .  . 

128,136 

123,576 

136,146 

130,824 

Heart  : 

Pericarditis  (all  with  acute  pneumonia)  3 

Congenital  malformations    3 

Acute  or  chronic  endocarditis None 

Brain : 

Acute  meningitis  (7  with  pneumonia,  2  cerebrospinal) 14 

Tuberculous  meningitis  11 

Acute  encephalitis 1 

Chronic  pachymeningitis 5 

Chronic  meningitis  '. 1 

Chronic  hydrocephalus   3 

There  were  twenty-six  deaths  from  marasnms  without  gross  lesioQS. 


44 


PECULIARITIES  OF  DISEASE  IN  CHILDEEN 


The  deaths  per  1,000  of  population  show  the  same  reduction.  The 
curves  for  the  different  age  periods  are  indicated  in. the  accompanying 
chart   (Fig.  4). 

The  reduction  in  infant -mortality  in  New  York  has  been  chiefly  in 
acute  gastro-intestinal  diseases,  marasmus  and  debility,  especially  in 
those  over  three  months  old.  In  older  children  it  has  been  chiefly  in 
acute   infectious   diseases,   espocitiUy    diphtheria.      The   mortality   from 


1887    1890  1893   1896  1899   1902    1905   1908 

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certain  other  causes  is  increasing,  notably  acute  respiratory  diseases  and 
prematurity. 

The  only  age  in  which  the  mortality  is  increased  during  the  summer 
months  is  the  first  year.  In  Fig.  5  are  given  the  curves  indicating  the 
deaths  under  one  year  and  from  one  to  five  years  l)y  months. 

The  rise  in  the  summer  mortality  during  the  first  year  is  chiefly 
due  to  diarrheal  diseases.  As  a  result  of  the  organized  campaign  for 
the  reduction  of  infant  mortality  in  New  York  which  has  been  in  full 
operation  since  1911,  the  number  of  infant  deaths  has  steadily  fallen. 
That  part  of  the  mortality  curve  chiefly  afl^ected  has  been  the  sharp 
summer  rise  which  has  been  almost  obliterated.  It  will  be  noted  that 
the  curve  for  children  from  one  to  five  years  of  age  touches  the  highest 
point  in  the  late  winter  and  early  spring  months,  the  time  when  pneu- 
monia and  the  common  contagious  diseases  are  most  prevalent.     The 


PLATE  I 


Chaet  Showing  by  Months  the  Moktality   of   New  York   City   for  the   Dif- 
ferent Ages  for  Three  Consecutive  Years.     Scale,  1  in.  —  2,200  deaths. 


PROGNOSIS  AXD  INFANT  MORTALITY 


45 


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46 


PECULIARITIES  OF  DISEASE  IX  CRILDPxEX 


curve  for  both  groups  is  lowest  in  the  months  of  October  and  Xovember,. 
which  may  therefore  be  considered  the  healthiest  months  in  JSTew  York. 
The  highest  mortality  is  in  the  first  month  of  age.  During  this  time 
twenty-five  per  cent  of  the  deaths  of  the  first  year  occur.  Eross,  writing 
in  1894,  states  that  from  the  records  of  sixteen  large  cities  of  Conti- 
nental Europe  nearly  ten  per  cent  of  all  the  infants  born  died  during 
the  first  month.  These  figures  have  been  considerably  reduced  since 
that  time.^  The  first  weeks  of  life  are  the  period  of  highest  mortality, 
because  in  them  takes  place  the  adaptation  of  the  organism  to  its  environ- 
ment. After  this  period  each  month  shows  a  steadily  declining  death 
rate  to  the  end  of  the  first  year. 

Causes  of  Death,  at  Different  Periods. — The  most  frequent  causes  of 
infant  mortality,  according  to  the  combined  reports  from  the  records  of 
the  cities  of  New  York,  Philadelphia,  Boston,  and  Chicago,  making  a 
total  of  44,226  deaths  in  the  first  year,  are  shown  in  the  accompanying 
chart  (Fig.  6). 

The  group,  acute  gastro-intestinal,  includes  chiefiy  diarrheal  diseases 
in  summer.  The  proportion  of  deaths  from  this  cause  is  being  greatly 
reduced;  while  the  proportion  due  to  acute  respiratory  diseases,  chiefly 
pneumonia  and  bronchitis,  is  increasing.  Marasmus,  prematurity,  etc., 
include  also  congenital  debility,  inanition,  and  other  conditions  in  which 
the  cause  of  death  recorded  is  disorder  of  nutrition  rather  than  some 
general  or  local  disease.     The  group,  congenital  malformations,  includes 

^The  relative  frequencj^  of  the  causes  of  death  in  the  newly  born  has  been 
greatly  altered  since  the  introduction  of  antiseptic  midwifer3^  Some  idea  of  the 
importance  of  the  different  factors  has  been  gained  from  a  study  of  the  records 
of  the  Sloane  Hospital  for  Women  for  a  period  of  six  years  (1908-1914),  embrac- 
ing 10,000  consecutive  births. 

CAUSES  OF  DEATH  DURING  FIRST  FOURTEEN  DAYS 


Congenital  weakness . 
Accidents  of  labor . . . 

Pneumonia 

Atelectasis 

Congenital  syphilis . . 

Malformations 

Hemorrhage 

Sepsis 

Asphyxia 

Accidental .' 

Undetermined 


Totals 102     38 


Under 
One  Day 


93 

1 


Under 
I?  Days 


130 
1 
3 
3 
6 


135     98 


Seven  to 
14  Days 


14 

3 
1 

6 


24     34 


Total  Under 
14  Days 


134 
1 

6 

4 

12 

2 


159  132 


CJrand 
Totals 


143 
33 
28 
25 
13 
12 
10 
9 


291 


Ten  thousand  confinements:     Abortions,  253;  stillbirths,  429;  living  births,  9,318.     (Prematures, 
heavy  type.)     Holt  and  Babbitt,  Jour.  American  Med.  Assn.,  .Jan.  25,  1915. 

Nearly  half  of  the  total  mortality  for  the  period  covered  was  ascribed  to 
congenital  weakness,  chiefly  due  to  prematurity. 


PROGXOSIS  AND  IXFAXT  MORTALITY  47 

also  deaths  from  accidents  during  birth.  Whooping  cough  is  the  most 
important  member  of  the  group  of  acute  infectious  diseases,  diphtheria 
coming  next.  Tuberculosis  should,  we  believe,  be  rated  higher  than  is 
shown  in  these  figures.  The  mortality  records  of  the  Babies'  Hospital 
show  that  the  deaths  from  tuberculosis  constitute  5.G  per  cent  of  the 
first-year  mortality  of  that  institution. 

The  figures  and  charts  preceding  indicate  that  a  very  marked  re- 
duction in  infant  and  child  mortality  has  taken  place  especially  within 
the  last  twenty  years.  Many  causes  have  united  to  bring  about  this 
result.     .\mon<2-  those  which  have  affected  infants  may  be  mentioned: 


CHIEF  CAUSES  OF   DEATH    FIRST  YEAR. 

ACUTE  GASTRO  INTESTINAL  28.0   PER  CENT 

MARASMUS,  PREMATURITY,  ETC.  25.5       ■■ 


ACUTE   RESPIRATORY 


18.5       '■ 


CONGENITAL  MALFORMATION,  ETC.       5.8  •■ 

ACUTE  INFECTIOUS  ,                           5.4  •' 

CONVULSIONS  3.4  " 

TUBERCULOSIS            ,  2.0  '< 

— 

SYPHILIS  1.2  " 

•    ALL  OTHERS  10.2  " 


Fig.  6. 


A  wider  dili'usion  of  knowledge  of  infant-feeding  and  hygiene;  a  great 
improvement  in  the  general  milk  supply;  the  furnishing  of  pure,  whole 
milk  and  of  modified  milk  gratis,  or  at  small  cost,  from  milk  depots;  a 
general  adoption  during  hot  weather  of  some  form  of  milk  sterilization; 
the  sending  of  a  large  numljer  of  infants  into  the  country  in  summer ; 
the  closer  supervision  of  infants  in  cities  during  the  summer  by  visiting 
physicians  and  nurses,  and  the  opera'iion  of  many  other  agencies  to  im- 
prove sanitary  conditions.  Besides  these  important  factors  in  preventing 
disease  there  must  be  considered  the  recent  advances  in  pediatrics  and 
the  more  rational  treatment  of  the  sick  infant  by  the  average  physician. 
During  the  second  year  the  diseases  of  the  gastro-intestinal  tract  are 
still  a  large  factor  in  the  death  rate,  also  the  acute  diseases  of  the  lungs 
and  the  acute  infectious  diseases,  especially  measles,  diphtheria,  and  per- 


48  PECULIARITIES  OF  DISEASE  IN  CHILDEEN 

tussis.  Deaths  from  scarlet  fever  are  much  less  numerous.  General 
tuberculosis  and  tuberculous  meningitis  are  frequent. 

From  the  second  to  the  fifth  year  the  deaths  are  mainly  from  acute 
infectious  diseases — chiefly  diphtheria  and  scarlet  fever — much  less  fre- 
quently from  measles  or  pertussis.  In  the  next  group  come  the  acute 
diseases  of  the  lungs,  general  tuberculosis,  and  tuberculous  meningitis. 

From  the  fifth  to  the  fifteenth  year  the  mortality  in  childhood  is 
remarkably  small,  diphtheria  and  scarlet  fever  being  still  in  the  front 
rank  in  point  of  frequency.  Next  come  the  acute  diseases  of  the  lungs, 
meningitis,  diseases  of  the  bones,  appendicitis,  rheumatism,  and  cardiac 
disease. 

By  far  the  largest  single  factor  in  reducing  mortality  after  the  first 
year  is  without  doubt  the  use  of  diphtheria  antitoxin.  The  serum  treat- 
ment of  cerebrospinal  meningitis  is  important,  but  not  influential  in 
vital  statistics,  as  cases  are  relatively  infrequent. 

Sudden  Death. — This  is  not  a  very  uncommon  occurrence  in  infants 
who  are  apparently  healthy.  They  are  sometimes  found  dead  in  bed 
under  circumstances  in  which  grave  suspicion  may  unjustly  rest  upon 
the  attendants.  This  usually  happens  with  those  who  are  delicate  or 
suffering  from  malnutrition,  especially  in  institutions  Avhere  sudden 
death  is  by  no  means  rare.  The  most  frequent  causes  in  infants  are  the 
following: 

1.  Malformations. — While  in  most  cases  malformations  of  a  serious 
nature  give  rise  to  symptoms,  they  may  be  absent,  or  may  be  so  slight 
as  to  be  overlooked.  Infants  may  succumb  during  the  first  few  days  of 
life  from  malformations  of  the  heart,  lungs,  kidneys,  stomach  or  in- 
testines, and  sometimes  from  diaphragmatic  or  umbilical  hernia. 

2.  Internal  Hemorrhage. — This  is  chiefly  limited  to  the  first  two 
weeks  of  life.  In  the  cases  that  have  come  to  our  notice  the  cause  has 
been  rupture  of  some  subperitoneal  hemorrhage  into  the  general  abdomi- 
nal cavity,  or  meningeal  hemorrhage.  Such  cases  are  reported  in  the 
chapter  upon  Visceral  Hemorrhages  in  the  Newly  Born.  Under  these 
circumstances  no  symptoms  may  exist  until  the  occurrence  of  collapse, 
with  death  in  a  few  hours. 

3.  Asphyxia  from  Overlying. — This  is  not  common,  except  among 
the  lower  classes,  and  is  most  frequently  due  to  intoxication  on  the  part 
of  the  mother.  Such  infants  after  death  present  the  usual  lesions  of 
death  from  asphyxia,  but  without  any  evidence  of  violence.  It  is  not 
improbable  that  overlying  has  been  held  responsible  for  many  deaths  that 
were  in  reality  due  to  other  causes. 

4.  Asphyxia  from  Aspiration  of  Food  into  the  Larynx  or  Trachea. 
— This  may  be  due  to  vomiting  or  to  the  regurgitation  of  food  during 
sleep ;  in  a  very  weak  infant  it  may  occur  while  awake.     This  is  usually 


PROGNOSIS  AND  INFANT  MORTALITY  49 

seen  in  infants  who  are  less  than  a  year  old,  and  most  of  the  reported 
cases  have  been  under  six  months.  Such  children  are  usually  delicate. 
There  seems  to  have  been  vomiting  with  an  attempt  at  crying,  during 
whieli  the  food  is  drawn  into  the  air  passages.  In  some  cases,  as  that 
reported  by  Demme,  a  single  large  curd  of  milk  has  been  found  in  the 
larynx.  In  others,  food  is  found  in  the  larynx,  trachea,  and  large  bronchi. 
Cases  have  also  been  reported  by  Partridge  and  by  Parrot,  and  we  have 
met  with  at  least  three.  The  infants  have  generally  been  found  dead  in 
bed  within  a  few  hours  after  feeding.  This  accident  is  more  likely  to 
happen  when  an  infant  lies  upon  his  back. 

5.  Enlargement  of  the  Thymus. — Although  these  cases  are  very  im- 
perfectly understood,  they  are  not  rare.  We  see  tAvo  or  three  each  year. 
The  condition  is  most  frequent  in  infancy,  but  is  not  confined  to  this 
period.  When  a  child  is  suffering  from  some  minor  illness,  often  bron- 
chitis, severe  attacks  of  asphyxia  may  develop  and  sometimes  convulsions 
may  unexpectedly  occur  and  death  soon  follow.  Or  the  first  attack  may 
not  be  fatal.  Sometimes  sudden  death  follows  the  administration  of  an 
anesthetic,  particularly  chloroform.  In  most  cases  there  is  found  besides 
an  enlarged  thymus,  a  general  hyperplasia  of  the  lymphatic  tissues 
throughout  the  body  known  as  status  lymphaticus,  more  fully  discussed 
elsewhere. 

G.  Atelectasis.— in  very  young  infants  there  may  be  no  symptoms 
noticed  except  those  of  general  malnutrition  until  sudden  death  occurs, 
sometimes  with  convulsions  and  sometimes  without  any  such  symptoms. 
(See  Atelectasis.) 

7.  Marasmus.- — In  this  class  of  cases  sudden  death  is  of  very  common 
occurrence.  These  children  are  often  apparently  as  well  two  or  three 
hours  before  death  as  for  several  weeks.  Death  frequently  occurs  at  night, 
the  children  being  found  dead  in  bed  in  the  morning.  In  some  of  the 
cases  the  exciting  cause  seems  to  be  the  lowering  of  the  temperature,  while 
in  many  no  exciting  cause  can  be  found ;  the  vital  spark  simply  goes  out 
after  burning  for  some  time  with  a  feeble  intensity.  In  some  of  these 
cases  the  autopsy  reveals  atelectasis,  but  in  many  cases  nothing  abnormal 
is  found,  death  apparently  resulting  from  heart  failure. 

8.  Convulsions  in  Children  Previously  Showing  no  Special  Signs  of 
Disease. — ^^Many  of  these  cases  are  seen  in  children  who  were  previously 
rachitic;  some  are  associated  with  the  status  lymphaticus,  and  many  are 
manifestations  of  tetany.  The  autopsy  may  show  no  lesion  except  cere- 
bral hyperemia.  It  is  extremely  rare  for  cerebral  hemorrhage  to  produce 
death  in  this  way.  In  some  rachitic  cases  death  is  due  to  spasm  of  the 
glottis. 

9.  Aspli.yxia  in  Older  Infants  and  Young  Children. — This  may  re- 
sult from  tlie  pressure  of  a  retropharyngeal  al)scess  upon  the  larynx  or 


50  PECULTARITTES  OF  DISEASE  IN  CHILDEEN 

trachea,  or  from  the  rupture  of  such  an  abscess  into  the  air  passages. 
Previous  symptoms  may  have  been  wanting.  Pressure  upon  the  pneu- 
mogastric  nerve  leading  to  fatal  asphyxia  may  be  caused  by  tuberculous 
bronchial  nodes,  or  by  abscesses  in  the  posterior  mediastinum  connected 
with  caries  of  the  spine.  Sudden  death  may  occur  Mdth  spinal  caries 
from  dislocation  of  the  upper  cervical  vertebrae. 

Sudden  asphyxia  may  follow  the  ulceration  of  tuberculous  lymph 
nodes  and  the  escape  of  cheesy  masses  into  the  trachea  or  primary 
bronchi.    This  usually  occurs  in  children  from  two  to  five  years  old. 

10.  Death  after  a  Few  Hours'  Illness,  in  ivhick  the  Chief  Symptom 
is  High  Temperature- — This  is  not  an  uncommon  occurrence.  Infants 
apparently  well  may  be  taken  with  great  prostration  and  a  high  tempera- 
ture, which  may  rise  rapidly  to  106°  or  even  107°  P.,  and  death  follow 
in  from  six  to  twelve  hours,  sometimes  preceded  by  convulsions.  These 
are  often  examples  of  acute  septicemia,  most  frequently  from  the  pneu- 
mococcus,  sometimes  from  the  streptococcus,  or  other  organisms.  In 
older  children  death  may  be  due  to  malignant  scarlet  fever  or  epidemic 
meningitis ;  however,  unless  these  diseases  are  prevailing  epidemically,  it 
is  somewhat  hazardous  to  make  such  a  diagnosis. 

It  does  not  fall  v/ithin  the  scope  of  this  chapter  to  consider  such  cases 
of  sudden  death  as  those  which  occur  from  heart  failure  after  diphtheria, 
with  pleurisy  with  efEusion,  or  with  myocarditis.  These  will  be  discussed 
elsewhere. 


PROPHYLAXIS 

There  is  no  more  promising  field  in  medicine  than  the  prevention  of 
disease  in  childhood.  The  majority  of  the  ailments  from  which  children 
die  it  is  within  the  power  of  man  in  great  measure  to  prevent.  Prophy- 
laxis should  aim  at  the  solution  of  two  distinct  problems:  (1)  The  re- 
moval of  the  causes  which  interfere  with  the  proper  growth  and  de- 
velopment of  children;  (2)  the  prevention  of  infection.  The  former 
can  come  only  through  the  education  of  the  profession  and  of  the 
general  public,  in  the  fundamental  principles  of  infant  feeding  and 
hygiene.  This  is  a  department  Avhich  has  received  altogether  too  small 
a  place  in  medical  education.  The  latter  must  come  through  the  pro- 
fession and  through  legislation  the  purpose  of  which  shall  be  more 
rigid  quarantine,  more  thorough  disinfection,  and  improved  sanitation 
in  all  its  departments.  The  subject  of  prophylaxis  will  be  discussed  in 
connection  with  the  different  diseases  treated  elsewhere. 


THERAPEUTICS  51 


THERAPEUTICS 


Therapeutics  in  infancy  consists  in  something  more  than  a  graduated 
dosage  of  drugs.  Many  therapeutic  means  which  are  valuable  in  adults 
are  useless  in  children,  and  many  others  which  are  of  little  value  in 
adults  are  extremely  useful  in  children.  Children  in  the  past  have 
sufEered  much  from  overzealous  treatment,  particularly  from  drug- 
giving.  In  early  life  more  than  at  any  other  period  the  old  dictum 
non  nocere  should  be  heeded.  It  should  be  a  fundamental  principle 
never  to  give  a  dose  of  medicine  without  a  clear  and  definite  indication. 
If  this  rule  is  followed,  it  is  surprising  to  find  how  often  medication 
can  be  dispensed  with.  A  second  rule  is  equally  important:  never  to 
give  a  nauseous  dose  when  one  that  is  palatable  will  answer  the  purpose 
equally  well.  The  simpler  prescriptions  are  made,  the  better.  As  a 
rule,  infants  revolt  against  most  of  the  highly  seasoned  sirups  and 
elixirs  which  are  used  to  disguise  the  taste  of  unpleasant  doses.  Bitter 
medicines,  when  mixed  with  water,  are  frequently  administered  without 
difficulty. 

It  is  a  common  mistake  to  underestimate  the  importance  of  the 
hygienic  surroundings  of  the  patient,  the  value  of  good  nursing,  careful 
feeding!,  and  Judicious  stimulation,  Just  as  it  is  to  overestimate  the 
beneficial  effects  of  drugs.  In  the  great  majority  of  acute  ailments  not 
serious  in  character,  for  which  a  physician  is  called,  the  patient  recovers 
quite  as  promptly  without  drugs  as  with  them.  This  does  not  mean  that 
such  children  require  no  treatment,  but  that  the  least  important  part  of 
the  treatment  is  drug-giving.  In  cases  of  severe  illness,  in  infants 
especially,  we  must  avoid  all  unnecessary  medication,  in  order  that  the 
stomach  may  not  be  disturbed.  Hence  the  importance  of  relying  as  far 
as  possible  upon  local  measures.  The  strong  tendency  to  recovery  from 
all  acute  processes,  while  seen  in  adult  life,  is  even  more  striking  in 
childhood,  where,  if  we  can  but  remove  that  which  hampers  the  bodily 
functions.  Nature  vfill  usually  conduct  the  case  to  a  satisfactory  termi- 
nation. Thus,  after  an  attack  of  bronchitis,  it  is  often  seen  that  the 
disturbance  of  the  stomach  and  intestines  can  be  directly  traced  to  the 
drugs  employed,  and  continues  long  after  the  original  disease  has  sub- 
sided. In  diseases  of  the  stomach  and  intestines  especially  there  is  a 
great  amount  of  unnecessary  medication.  In  all  chronic  disturbances 
of  nutrition — chronic  indigestion,  malnutrition,  and  anemia — no  tonic 
is  so  good  as  a  change  of  air  and  surroundings. 

Antipyretics. — The  indications  for  the  employment  of  antipyretics  in 
children  are  somewhat  different  from  those  in  adults.  It  is  to  be  borne 
in  mind  that,  where  the  cause  is  similar,  all  temperatures  in  children  arc 


52  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

higher  than  in  adults.  Thus  conditions,  adiich  in  an  adult  would  pro- 
duce a  rise  of  temperature  of  only  100°  or  101°  ¥.,  in  a  child  are  not 
infrequently  accompanied  by  a  temperature  of  104°,  or  even  105°  F.  The 
height  of  the  temperature,  as  measured  by  the  thermometer,  is  not  to 
be  taken  as  the  only  or  even  the  best  guide  for  the  employment  of  anti- 
pyretics. The  nervous  disturbance  which  accompanies  such  a  tempera- 
ture is  much  more  important.  The  temperature  may  be  104°,  or  even 
105°  F.,  and  yet  the  child  exhibit  no  signs  of  unusual  discomfort.  Such 
a  temperature  manifestly  does  not  call  for  interference.  High  tem- 
perature from  apparently  trivial  causes  is  very  common.  It  is  only  a 
continuously  high  temperature  or  a  recurring  high  temperature  which 
indicates  serious  illness.  Whenever  the  temperatvire  is  found  to  be  much 
above  the  normal  it  should  be  carefully  watched,  but  not  interfered  with 
until  a  diagnosis  has  been  made,  unless  the  symptoms  urgently  demand 
it;  otherwise  the  physician  may  lose  one  of  the  most  valuable  aids  to 
diagnosis,  since  it  is  not  the  height  of  the  temperature  but  its  course 
which  is  significant.  In  many  cases  it  is  very  important  to  know  whether 
the  temperature  uninfluenced  by  drugs  is  remittent,  intermittent,  or 
steadily  high,  and  hence  the  advantage  of  waiting  until  a  diagnosis 
has  been  made  before  disturbing  the  temperature  curve.  This  is,  of 
course,  not  admissible  when  the  temperature  is  itself  a  source  of  real 
danger,  which  after  all  is  seldom  the  case.  Since  the  cause  of  a  great 
man}^  obscure  temperatures  is  found  in  the  stomach  and  intestines,  it 
very  often  happens  that  a  purgative,  stomach-washing,  or  intestinal 
irrigation  may  be  the  most  efficient  antipyretic.  In  cases  of  moderate 
elevation  of  temperature  we  need  go  no  further  than  cold  sponging. 

The  most  reliable  antipyretic  measure  for  children  is  the  use  of  cold. 
This  may  be  employed — 

(1)  As  an  Ice  Cap  to  tlie  Head. — In  many  cases  of  quite  high  tem- 
perature and  restlessness  in  infants  this  alone  will  reduce  the  tem- 
perature one  or  two  degrees  and  allay  the  nervous  symptoms. 

(2)  Cold  Sponging, — For  this  purpose  water  at  about  80°  to  85°  F., 
equal  parts  of  alcohol  and  water,  or  equal  parts  of  vinegar  and  water  may 
be  employed.  In  the  case  of  infants,  all  the  clothing  except  the  diaper 
should  be  removed  and  the  child  laid  upon  a  blanket.  The  body  should 
be  sponged  for  from  ten  to  twenty  minutes,  and  then  wrap^Jed  in  a 
blanket  without  further  dressing.  Cold  sponging  must  be  very  frequently 
employed  in  order  to  be  efficient  in  reducing  high  temperature.  Its 
great  value  in  allaying  nervous  symptoms,  even  when  the  temperature  is 
not  very  high,  is  not  sufficiently  appreciated.  Its  efl^ect  is  often  more 
satisfactory  than  that  of  an  anodyne. 

(3)  Cold  Pack. — The  child  should  be  stripped  and  laid  upon  a 
blanket.     The  entire  trunk  should  then  be  enveloped  in  a  small  sheet 


THERAPEUTICS  53 

wrung  from  water  at  a  temperature  of  100°  F.  Upon  the  outside  of 
this,  ice  may  now  be  rul)bed  over  the  entire  trunk,  first  in  front  and 
then  behind.  By  this  method  there  is  no  shock  and  no  fright,  and  any 
ordinary  temperature  can  usually  be  readily  reduced. 

The  rubbing  with  ice  should  be  repeated  in  from  five  to  thirty  min- 
utes, after  which  the  child  may  be  rolled  in  the  blanket  upon  which  he 
is  lying  without  the  removal  of  the  wet  pack.  The  head  should  be 
sponged  with  cold  water  while  this  is  being  carried  on,  and  artificial 
heat,  if  necessary,  should  be  applied  to  the  feet.  The  pack  is  continued 
from  one  to  twenty-four  hours,  according  to  circumstances. 

(4)  Cold  Bath. — The  child  is  put  into  a  bath  at  a  temperature  of 
100°  F.,  the  temperature  being  gradually  lowered  by  the  addition  of 
ice  or  cold  water  to  75°  or  80°  F.  The  body  should  be  well  rubbed  while 
the  child  is  in  the  bath  and  water  should  also  be  applied  to  the  head. 
On  removal  from  the  bath,  the  body  should  be  quickly  dried  and  rolled  in 
a  warm  blanket.    The  bath  is  usually  continued  from  five  to  ten  minutes. 

(5)  Evaporation  Bath. — The  trunk  is  closely  enveloped  in  two 
layers  of  surgeon's  gauze,  or  some  loosely  woven  equivalent,  which  is 
moistened  from  time  to  time  with  water  at  a  temperature  of  95°  F., 
continuous  evaporation  being  kept  up  by  means  of  a  hand,  or  better 
electric,  fan.  The  evaporation  bath  would  seem  to  possess  some  impor- 
tant advantages  in  the  case  of  infants  and  young  children,  in  that  it  is 
more  efficient  than  sponging,  involves  little  disturbance  of  the  patient, 
and  causes  no  shock  or  fright.  Hot  applications  should  constantly  be 
made  to  the  extremities. 

(6)  Rectal  Irrigations. — These  are  easily  given,  disturb  the  patient 
very  little,  and  are  effective  in  reducing  the  temperature.  A  double  tube 
or  two  catheters  may  be  employed.  It  is  best  to  use  at  first  water  at  a 
temperature  of  90°  F.,  and  gradually  reduce  this  to  70°  F.  The  irriga- 
tion should  be  continued  for  ten  or  fifteen  minutes,  or  even  longer  if  the 
desired  fall  in  temperature  is  not  obtained,  and  may  be  repeated  as  often 
as  every  three  hours. 

Antipyretic  Drugs. — Except  in  cases  of  malaria,  quinin  should  not 
be  employed  for  the  reduction  of  temperature  in  children. 

Of  the  many  coal-tar  derivatives  employed,  phenacetin  lias  the  ad- 
vantage for  children  of  being  tasteless  and  causing  little  depression,  but 
the  slight  disadvantage  of  practical  insolubility.  None  of  the  drugs  of 
this  group  is,  however,  to  be  employed  in  large  doses  with  the  sole  pur- 
pose of  reducing  the  temperature.  Their  great  value  in  pediatrics  con- 
sists rather  in  allaying  the  nervous  symptoms  which  accompany  fever, 
and  this  purpose  can  be  accomplished  by  the  use  of  comparatively  small 
doses.  To  an  infant  of  one  year,  phenacetin  can  be  given  in  one-grain 
doses  every  hour  or  two  hours  until  the  desired  effect  is  produced.     For 


54  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

a  child  of  five  years  a  dose  of  two  grains  may  be  given  in  the  same  man- 
ner. When  used  as  indicated,  these  drugs  are  of  very  great  value  in 
making  the  patient  more  comfortable,  in  promoting  sleep,  and  in  allaying 
headache  and  general  pains.  In  cases  of  hyperpyrexia  they  are,  however, 
much  less  certain  and  less  safe  than  the  use  of  cold. 

Sedatives. — For  most  of  the  milder  conditions  where  sedatives  are 
required  bromids  are  to  be  preferred.  A  preference  should  be  given  to 
the  sodium  salt.  Young  children  require  relatively  large  doses :  e.  g.,  in 
convulsive  conditions  five  grains  every  two  hours  are  often  necessary  at 
three  months.  Chloral  is  usually  well  borne  even  by  quite  young  infants. 
Since  it  is  often  irritating  to  the  stomach  it  may  be  advantageously  given 
by  the  rectum.  After  rectal  administration  its  effects  are  usually  jnan- 
ifest  in  half  an  hour,  and  sometimes  sooner.  The  rectal  dose  for  an 
infant  of  one  month  is  one  grain;  three  months,  two  grains;  one  year, 
three  to  five  grains.  It  may  be  repeated  every  two  to  four  hours,  accord- 
ing to  indications.  Doses  by  mouth  should  be  about  half  as  large.  Other 
drugs  may  replace  this  in  most  diseases,  but  in  the  case  of  infantile  con- 
vulsions nothing  is  so  reliable  as  chloral. 

Belladonna  is  well  borne  by  children,  and  in  relatively  larger  doses 
than  most  drugs.  The  eruption  is  more  readily  produced  than  the  other 
physiological  effects,  and  even  quite  small  doses  may  be  sufficient  to  bring 
out  a  very  abundant  blush.  The  parents  should  be  advised  of  this  fact, 
lest  undue  alarm  be  felt. 

The  drugs  classed  as  antipyretics — phenacetin  and  antipyrin — are 
exceedingly  valuable  in  the  treatment  of  many  diseases  of  infancy  where 
irritative  nervous  symptoms  are  prominent.  In  many  oases  they  may 
advantageously  take  the  place  of  opium  except  when  pain  is  present.  In 
all  conditions  where  spasm  is  a  prominent  symptom,  whether  of  the 
larynx  or  bronchi,  or  local  or  general  convulsions,  antipyrin  is  especially 
valuable. 

Stimulants. — Alcoholic  stimulants  are  well  tolerated  even  by  young 
infants ;  yet  all  stimulants,  alcohol  in  particular,  are  very  greatly  abused 
in  the  hands  of  practitioners,  and  their  indiscriminate  and  protracted  use 
can  not  be  too  strongly  condemned. 

The  indications  for  the  employment  of  stimulants  are  much  the  same 
in  young  children  as  in  adults.  In  most  of  the  acute  fevers  tliey  are 
not  to  be  given  early  in  the  disease,  and  in  many  cases  they  are  not  re- 
quired at  all.  They  must  often  be  used  very  sparingly  while  the  tem- 
perature is  high,  but  may  be  necessary  as  soon  as  it  falls.  In  many  acute 
febrile  diseases  stimulants  are  not  called  for  at  any  period. 

The  method  of  administering  alcohol  is  of  no  little  importance. 
Brandy  and  whisky  are  in  most  cases  to  be  preferred  to  the  wines,  but 
not  always.     For  infants  under  one  year  old,  brandy  should  be  diluted 


THEKAPEUTICS 


55 


with  at  least  twenty  parts  of  water.  Altogether  the  best  method  of  ad- 
ministration is  to  determine  the  amount  to  be  given  in  every  twenty-four 
hourS;,  have  it  diluted  sufficiently,  and  then  administer  it  in  small  doses 
at  short  intervals. 

An  infant  one  year  old  for  whom  alcohol  is  indicated  should  not  be 
given  to  begin  with  more  than  one-fourth  of  an  ounce  of  brandy  or  whisky 
during  the  twenty-four  hours,  and  even  in  bad  conditions  it  is  rarely 
advisable  to  give  more  than  twice  this  quantity,  except  for  a  very  short 
period.  In  children  four  years  old  double  the  amount  may  be  employed 
in  the  corresponding  conditions.  Little  good  and  much  harm  is  likely 
to  follow  such  amounts  as  four  or  five  ounces  daily  of  brandy  or  whisky 
for  children  of  two  or  three  years.  There  certainly  is  a  strong  tendency 
at  the  present  time  to  use  less  and  less  alcohol  in  therapeutics  and  many 
would  abandon  it  altogether. 

Other  stimulants,  caffein,  camphor,  strychnin,  digitalis,  strophan- 
thus,  etc.,  are  .used  in  children  with  much  the  same  indications  as  in 
adults.  Their  application  is  more  fully  discussed  in  the  diiferent  diseases 
in  which  they  are  employed.  They  may  be  used  in  the  following  doses 
at  the  different  ages  indicated: 


3  months. 


1  year. 


5  years. 


Digitalis,  tincture 

Strophanthus,  tincture 

Caffein  citrated 

Strychnin  sulphate 

Camphor  (10  per  cent  solution  in  oil) . 
Epinephrin  (1-1000  Sol.) 


TTl  i 
TTli 
Gr.  i 
Gr.  4 

m  V 

n  iii 


TTL  iii 
TTl  iii 
Gr.  i 

'-^l  •     300 

n  vi 


TIL  V 
Til  V 

Gr.  ii 

Gr    -1 

'J^-      6  0 

m  XX 

n  X 


Note.— Camphor  and  epinephrin  are  for  hypodermic  use  only. 

Tonics. — Cod-liver  oil  is  particularly  useful  in  the  convalescence  after 
acute  diseases  of  the  respiratory  tract,  in  anemia,  and  with  a  large  num- 
ber of  children  who  are  extremely  delicate.  In  these  patients  it  may  be 
advantageously  administered  throughout  the  greater  part  of  nearly  every 
winter  season.  In  convalescence  after  attacks  of  gastroenteric  disease  it 
should  be  withheld  for  a  long  time.  When  the  tongue  is  coated,  the 
digestion  poor,  and  the  stomach  easily  disturbed  it  should  not  be  given 
at  all.  In  the  case  of  infants,  as  a  rule,  the  pure  oil  is  to  be  preferred  to 
the  emulsions.  The  administration  of  small  doses — i.  e.,  ten  or  twenty 
drops  of  the  oil  three  times  a  day  continued  for  a  long  period — is  often 
better  than  the  use  of  larger  doses  for  a  shorter  time. 

Preparations  of  malt  are  sometimes  of  even  greater  value  than  cod- 
liver  oil,  for  they  can  be  used  in  many  conditions  when  the  oil  is  contra- 
indicated.     The  two  may  often  be  advantageously  combined. 

The  best  preparations  of  iron  for  very  young  children  are  the  bitter 


56 


PECULIARITIES  OF  DISEASE  IN  CHILDREN 


wine,  sweet  wine,  saccharated  carbonate,  and  tlie  wine  of  the  citrate. 
These  are  only  slightly  constipating,  and  many  of  them  can  be  given  with 
milk.  Most  of  the  organic  preparations  on  the  market  are  less  reliable 
than  those  mentioned.  For  older  children  nothing  is  better  than  reduced 
iron  or  Bland's  pills. 

iVrsenic  is  second  only  to  iron  in  the  treatment  of  the  anemia  of  chil- 
dren, and  in  very  many  cases  it  is  to  be  preferred  to  iron.  The  tablet 
triturates  of  arsenious  acid,  one  one-hundredth  of  a  grain,  may  be  given 
immediately  after  meals  three  times  a  day,  or  one  or  two  drops  of 
Fowler's  solution  largely  diluted  with  Avater. 

Alcohol  is  useful  in  combination  with  some  of  the  bitters,  either  small 
doses  of  quinin,  nux  vomica,  or  the  bitter  wine  of  iron,  l^sually  Avines, 
especially  sherry,  are  to  be  preferred  to  spirits,  although  some  children 
take  spirits  better.  When  combined  with  a  bitter  there  is  little  danger  of 
the  formation  of  the  alcoholic  habit,  even  though  its  use  may  be  long 
continued. 

Of  the  bitter  tonics,  nux  vomica  is  easily  superior  to  all  others. 

Opiates. — Strong  objections  have  been  urged  by  many  against  the 
employment  of  opimn  in  the  diseases  of  infancy.  While  opiates  have  no 
doubt  been  abused,  the  fact  remains  that  opium  is  almost  as  valuable  a 
remedy  in  the  treatment  of  disease  during  the  first  five  years  as  at  any 
other  period  of  life.  For  infants  relatively  smaller  doses  are  required 
than  of  most  drugs.  If  the  physician  will  accustom  himself  to  the  use 
of  small  doses,  he  will  be  surprised  to  see  how  satisfactory  are  the  effects 
produced. 

The  most  useful  preparations  for  young  children  are  paregoric, 
Dover's  powder,  the  deodorized  tincture,  morphin,  and  codein.  The  fol- 
lowing table  gives  what  may  be  considered  safe  initial  doses  at  the  differ- 
ent ages : 


Paregoric 

Deodorized  tincture 
Dover's  powder .  .  .  . 

Morphin 

Codein 


1  month. 


m  i 

Gr.  JO 
Gr.  ^h 
Gr.  vi. 


3  months. 


ni  ii 

m  j\j 

Gr.  h 

Gr.  yiVj 


1  year. 


Ill  V  to  X 
TTlitoi 

Gr.  i 
Gr.  sV 
Gr.  A 


o  years. 


TTl  XXX  to  xl 

tTl  ii  to  iii 
Gr.  ii  to  iii 
Gr.  :, 
Gr.  ,'0  to  -h 


Ordinarily  doses  like  the  above  should  not  be  repeated  oftener  than 
every  two  hours.  In  exceptional  circumstances,  as  when  very  great  pain 
is  present,  the  dose  may  be  given  more  frequently.  In  the  hypodermic 
use  of  morphin  it  should  be  remembered  that  its  effects  are  always  more 
uniform  and  striking  than  when  the  drug  is  administered  by  the  mouth, 
and  the  dose  should  therefore  be  smaller.    In  every  inst^mce  where  a  full 


THERAPEUTICS  57 

(lose  of  opium  has  been  given  the  physician  should  wait  until  the  effects 
have  subsided  before  the  dose  is  repeated. 

Drags  Well  Borne  by  Children. — In  this  list  may  be  mentioned 
belladonna,  the  bromids,  the  iodids,  chloral,  quinin,  calomel — in  fact^  all 
mercurials — and  opium  also,  though  not  all  of  its  products. 

The  drugs  not  well  borne  include  particularly  cocain  and  heroin.  In 
the  case  of  many  others,  while  the  constitutional  effects  are  well  tolerated, 
they  must  be  given  carefully  to  young  infants,,  since  they  are  irritants  to 
the  stomach.  In  this  class  may  be  mentioned  the  salicylates,  salol,  the 
astringent  preparations  of  iron,  and  the  acids. 

Vaccines. — These  are  suspensions  of  dead  bacteria  in  a  normal  salt 
solution.  Their  application  in  pediatrics  is  confined  to  therapeutics; 
as  a  prophylactic  measure  they  are  seldom  called  for,  except  for  the  pre- 
vention of  typhoid  fever.  Vaccine  therapy  has  been  employed  in  almost 
every  form  of  bacterial  infection.  In  the  great  majority  of  these  the 
results  have  been  disappointing.  They  are  of  unquestioned  value  in 
localized  staphylococcus  infections,  particularly  those  of  the  skin,  e.  g., 
general  furunculosis  and  larger  multiple  abscesses.  In  other  staphylo- 
coccus infections  they  are  sometimes  useful,  but  results  are  very  uncer- 
tain. In  streptococcus  infections  whether  localized  or  general  their  effect 
is  doubtful;  although  in  rare  cases  they  have  seemed  to  be  of  benefit. 
Pneumococcus  infections  are  apparently  not  at  all  influenced  by  their  use. 
Regarding  the  effect  of  vaccines  on  gonococcus  infections  of  mucous  mem- 
branes, one  must  speak  very  guardedly.  The  great  majority  of  patients 
with  gonococcus  vaginitis  so  treated  have  received  but  temporary  benefit, 
although  a  few  striking  cures  have  been  obtained.  Colon  bacillus  infec- 
tions of  the  urinary  tract  (pyelitis)  sometimes  appear  to  be  decidedly 
improved  by  vaccines.  "With  respect  to  most  other  conditions  experience 
thus  far  does  not  warrant  one  in  forming  a  sanguine  opinion  of  their 
value.  For  the  technic  of  vaccine  treatment  special  works  should  be 
consulted. 

Counterirritants. — These  are  of  great  value  in  a  large  variety  of  dis- 
eases. 

The  mustard  pmte  is  probably  the  most  satisfactory  means  of  pro- 
ducing quick  counterirritation  over  a  large  surface.  To  make  a  mustard 
paste :  Take  one  part  powdered  mustard  and  six  parts  of  wheat  flour,  mix 
with  lukewarm  water,  and  spread  between  two  layers  of  muslin.  This 
should  be  removed  as  soon  as  a  thorough  redness  of  the  skin  has  been 
produced — in  most  cases  from  five  to  eight  minutes,  according  to  the 
strength  of  the  mustard  employed.  This  may  be  repeated  as  often  as 
every  three  hours,  and  continued  for  a  week  if  necessary,  without  pro- 
'  ducing  excoriations  of  the  skin.  For  older  children  the  paste  may  be 
made  one  part  mustard  to  four  parts  flour.     In  pulmonary  diseases  it 


58  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

should  be  large  enough  to  surround  the  chest.  When  it  is  used  to  produce 
general  reaction  in  heart  failure  it  should  cover  the  entire  trunk. 

The  Mustard  Pack. — The  child  is  stripped  and  laid  upon  a  blanket, 
and  the  trunk  is  surrounded  by  a  large  towel  or  sheet  saturated  with 
mustard  water.  This  is  made  as  follows :  One  tablespoonf ul  of  mustard 
to  one  quart  of  tepid  water.  In  this  a  towel  is  dipped,  and  while  drip- 
ping woimd  around  the  entire  body.  The  patient  should  then  be  rolled 
in  the  blanket.  This  pack  may  be  continued  for  ten  or  fifteen  minutes, 
at  the  end  of  which  time  there  will  usually  be  a  very  decided  redness  of 
the  whole  body.  It  may  be  repeated  according  to  indications.  Where  it 
is  desired  to 'produce  a  general  counterirritation,  the  mustard  pack  is  not 
quite  as  efficient  as  the  mustard  bath,  but  it  has  the  advantage  in  causing 
much  less  disturbance  to  the  patient.  The  mustard  pack  is  useful  in  the 
condition  of  collapse  or  of  great  prostration  from  any  cause  whatever,  in 
convulsions,  and  in  cerebral  or  pulmonary  congestion. 

The  turpentine  stupe  is  made  by  wringing  a  piece  of  fiannel  out  of 
water  as  hot  as  can  be  borne  by  the  hand.  Upon  this  is  sprinkled  ten  or 
fifteen  drops  of  the  spirits  of  turpentine.  The  stupe  is  then  applied  to 
the  body  and  covered  with  oiled  silk  or  dry  flannel.  It  is  useful  chiefly 
in  abdominal  pains  or  inflammations,  but  in  infancy  must  be  carefully 
watched  or  vesication  will  be  produced.  For  frequent  use  it  is  not  so 
valuable  as  the  mustard  paste. 

Stimulating  liniments  containing  turpentine  and  other  irritants  are 
useful  in  inflammations  of  the  chest,  although  less  reliable  than  the  mus- 
tard paste.  One  of  the  mildest  and  most  useful  preparations  is  camphor- 
ated oil.  Another  is  olive  oil  four  parts  and  turpentine  one  part.  These 
may  either  be  rubbed  upon  the  surface,  or  a  piece  of  flannel  may  be  satu- 
rated with  them  and  then  applied  to  the  skin. 

Local  Blood-letting. — Leeches  are  sometimes  useful  in  the  early  stages 
of  acute  inflammations  of  the  mastoid  or  middle  ear.  They  may  also  be 
applied  to  the  precordium  in  acute  pneumonia  with  signs  of  failure  of 
the  right  heart,  viz.,  great  dyspnea  and  cyanosis. 

Dry  cups  may  be  used  even  in  young  infants,  to  relieve  acute  conges- 
tion in  pneumonia  or  bronchitis,  and  for  pulmonary  edema.  Wet  cups 
should  never  be  used  for  young  children. 

Poultices  are  much  too  frequently  employed  and  may  with  advantage 
be  omitted  in  the  treatment  of  most  local  inflammations.  Tliey  have  been 
largely  replaced  by  wet  dressings,  especially  those  of  aluminum  acetate. 
In  acute  pulmonary  inflammations  their  use  is  very  limited. 

Cold. — Cold  is  useful  in  almost  all  forms  of  local  inflammation.  In 
inflammation  of  the  cervical  lymph  glands  and  of  the  joints  it  is  of 
undoubted  value,  but  its  advantage  over  heat  is  questionable.  The  effi- 
ciency of  both  cold  and  heat  in  these  cases  depends  largely  upon  the 


THERAPEUTICS  59 

method  of  use.  The  difficulties  in  the  way  of  their  proper  application  are 
great  in  young  children.  Sometimes  in  pleurisy  much  greater  relief  is 
obtained  from  the  use  of  an  ice  bag  to  the  chest  than  frojn  hot  applica- 
tions, but  this  is  not  the  general  experience.  The  treatment  of  pneu- 
monia by  the  application  of  the  ice  bag  to  the  chest  has  many  advocates, 
although  in  our  hands  it  has  not  yielded  the  results  claimed  for  it. 
It  is  admissible  only  in  lobar  pneumonia,  and  here  chiefly  in  older  and 
stronger  children.  The  application  of  cold  in  young  or  very  delicate 
children  should  be  made  with  caution  in  all  inflammations  of  the  respira- 
tory tract. 

Cold  is  best  applied  to  the  head  by  an  ice  cap  made  like  a  helmet ;  an 
ordinary  rubber  or  flannel  bag  filled  with  ice  may  answer  the  purpose. 
The  rubber  coil  filled  with  ice  water  is  also  an  excellent  method.  For 
inflamed  glands  or  joints  the  ice  bag  or  the  coil  should  be  used ;  for  the 
eyes,  cold  compresses,  changed  every  minute. 

The  Hot  Pack. — All  clothing  is  to  be  removed  and  the  child's  body 
covered  with  towels  wrung  from  water  at  a  temperature  of  from  100°  to 
108°  F.,  after  which  the  body  should  be  rolled  in  a  thick  blanket.  These 
hot  applications  may  be  changed  every  twenty  or  thirty  minutes  until  free 
perspiration  is  produced,  which  may  be  continued  as  long  as  necessary. 
This  is  mainly  useful  in  uremia. 

The  hot  bath,  like  the  mustard  pack  or  the  mustard  bath,  may  be 
used  to  promote  reaction  in  cases  of  shock  or  collapse.  The  patient  should 
be  put  into  the  bath  at  a  temperature  of  100°  F.,  the  water  being  gradu- 
ally raised  to  103°,  or  even  to  106°,  but  not  above  this  point.  The  body 
should  be  well  rubbed  while  the  patient  is  in  the  bath.  A  thermometer 
should  be  kept  in  the  water  to  see  that  the  temperature  does  not  go  too 
high.  Unless  this  precaution  is  taken  the  danger  of  burning  the  child  is 
great.  During  the  bath,  in  most  cases,  cold  should  be  applied  to  the 
head. 

The  Hot-Air  or  Vapor  Bath. — All  the  clothing  should  be  removed 
and  the  patient  laid  upon  the  bed  with  the  bedclothing  raise's  above  the 
body  ten  or  twelve  inches,  and  sustained  by  means  of  a  wicker  support. 
The  bedclothing  should  be  pinned  tightly  about  the  neck,  so  that  only 
the  head  is  outside.  Beneath  the  bedclothing  hot  vapor  is  introduced 
from  a  croup  kettle  or  a  vaporizer.  This  will  usually  induce  free  per- 
spiration in  fifteen  or  twenty  minutes.  It  may  be  continued  from  twenty 
to  thirty  minutes  at  a  time.  Instead  of  vapor,  hot  air  may  be  intro- 
duced in  the  same  way.  The  air  space  about  the  body  is  indispensable. 
The  vapor  bath  is  applicable  chiefly  to  cases  of  uremia. 

The  Mustard  Bath. — Four  or  five  tablespoonfuls  of  powdered  mustard 
should  be  mixed  for  a  few  minutes  with  one  gallon  of  tepid  water.  To 
this  should  be  added  four  or  five  gallons  of  plain  water  at  a  temperature; 


60  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

of  100°  F.  The  temperature  of  the  bath  may  be  raised  by  the  addition  of 
hot  water  to  103°  or  106°  F.,  if  desired.  Nothing  is  more  efficient  than" 
the  hot  mustard  bath  for  a  general  derivative  effect  in  bringing  the  blood 
to  the  surface  in  cases  of  shock,  collapse,  heart  failure  from  any  cause,  or 
in  sudden  congestion  of  the  lungs  or  brain.  The  bath  should  not  usually 
be  continued  for  more  than  ten  minutes.  If  necessary,  it  may  be  repeated 
in  an  hour. 

The  Bran  Bath. — Put  one  quart  of  ordinary  wheat  bran  in  a  bag  made 
of  coarse  muslin  or  cheese  cloth  and  place  this  in  four  or  five  gallons  of 
water.  The  bran  bag  should  be  frequently  squeezed  and  moved  about 
until  the  bath  water  resembles  a  thin  porridge.  It  may  be  of  any  tem- 
perature desired,  but  usually  about  90°  to  95°  F.  is  best.  A  bran  bath  is 
of  great  value  in  cases  of  eczema,  excoriations  about  the  buttocks,  or  in 
other  cases  where  the  skin  is  very  delicate,  and  plain  water  seems  to 
irritate  it. 

The  tepid  bath  may  be  given  at  a  temperature  of  95°  to  100°  F.  It 
is  very  useful  in  many  conditions  of  excitement  or  extreme  nervous  irri- 
tability.   To  induce  sleep  it  is  often  more  efficient  than  drugs. 

The  cold  spong-e  or  the  shower  bath  should  be  given  in  the  morning 
before  breakfast,  and  in  a  warm  room.  The  child  should  stand  in  a 
tub  containing  warm  water  enough  to  cover  the  feet,  then  a  large 
sponge  holding  half  a  pint  of  water  at  a  temperature  of  from  40°  to  60° 
F.  should  be  squeezed  three  or  four  times  over  the  chest,  shoulders,  and 
spine  of  the  child,  the  skin  being  rubbed  meanwhile.  The  bath  should 
not  last  more  than  half  a  minute.  It  should  be  followed  by  a  brisk  rub- 
bing until  a  thorough  reaction  is  established.  This  is  very  useful  at  all 
ages,  but  it  is  a  particularly  valuable  tonic  in  delicate  children.  It  may 
be  used  in  those  only  eighteen  months  old.  Not  the  least  of  the  beneficial 
results  is  the  full  expansion  of  the  lungs  from  the  strong  cry  which  the 
bath  usually  excites.  In  younger  infants  a  cold  plunge  may  be  substi- 
tuted. This  should  be  merely  a  single  dip  of  the  entire  body  in  water  at 
a  temperature  of  50°  to  60°  F.  In  order  that  beneficial  effects  shall 
follow  the  cold  plunge  or  cold  sponging,  a  good  reaction  must  be  estab- 
lished. If  children  lack  sufficient  vitality  to  secure  this,  and  if  they 
remain  pale,  pinched  and  blue  for  some  time  after  the  bath,  it  must  be 
discontinued  altogether,  or  water  of  a  higher  temperature  used. 

Nasal  Spray. — This  may  be  either  of  an  aqueous  or  an  oily  solution. 
For  the  oil  spray  an  atomizer  should  be  employed.  It  is  valuable  in 
cases  of  dry  catarrh,  where  there  is  a  formation  of  crusts  in  the  nose. 
A  variety  of  oils  may  be  used,  benzoinol  being  perhaps  as  satisfactory 
as  any. 

There  are  many  forms  of  hand  atomizers  to  be  found  in  the  market 
for  the  production  of  aqueous  or  oil  sprays.    For  a  cleansing  nasal  spray. 


THEKAPEUTICS  61 

Dobell's  solution.  Seller's  solution,  or  a  two-per-cent  solution  of  boric 
acid  may  be  used. 

Nasal  Irrigation. — In  cases  of  considerable  nasal  obstruction  and  in 
tbe  more  serious  affections  of  the  rhinopharynx,  only  the  syringe  can  be 
considered  an  efficient  means  of  cleansing  the  cavity. 

The  fountain  syringe  has  the  advantage  of  being  easily  regulated  as 
to  the  force  employed,  this  being  determined  by  the  height  at  which  the 
bag  is  suspended  above  the  bed.  For  ordinary  purposes  an  elevation  of 
one  or  two  feet  is  sufficient,  and  rarely  is  a  greater  pressure  than  thre6 
feet  advisable.  The  last  is  desirable  when  a  thorough  flushing  of  the 
rhinopharynx  is  required.  The  danger  of  forcing  fluid  into  the  middle 
ear  is  greatly  lessened  if  the  patient  keeps  the  mouth  wide  open. 

Where  a  smaller  amount  of  fluid  is  sufficient  a  piston  sj^ringe  may  be 
employed.  This  should  be  small  enough  to  be  easily  worked  with  one 
hand.  It  should  have  a  soft  rubber  tip,  to  prevent  injuring  the  nasal 
mucous  membrane,  and  the  tip  should  be  large  enough  to  fill  the  nostril. 
The  piston  syringe  for  nasal  use  is  made  either  of  glass  or  hard  rub- 
ber, and  fulfils  all  the  conditions  mentioned.  It  is  easy  of  action,  can 
be  readily  cleansed,  and  holds  about  half  an  ounce.  The  same  syringe 
should  not  be  used  for  more  than  one  patient,  unless  it  has  been  very 
thoroughly  disinfected.  In  hospitals,  and  even  in  private  practice,  nasal 
syringes  are  frequent  carriers  of  infection. 

Either  of  two  positions  may  be  used  in  nasal  syringing.  In  diph- 
theria, scarlet .  fever,  or  any  constitutional  disease  attended  by  great 
depression,  the  child  should  not  be  removed  from  the  bed.  The  syringing 
may  be  done  by  a  single  nurse,  who  stands  at  the  head  of  the  bed,  alter- 
nately syringing  the  right  and  left  nostril,  turning  the  head  from  side 
to  side.  The  other  method  is  to  hold  the  child  erect  on  the  lap,  with  the 
head  inclined  somewhat  forward,  the  syringing  being  done  by  a  second 
person  standing  behind.  In  either  position  the  child's  arms  and  hands 
should  be  securely  pinioned  to  the  sides  by  a  sheet.  To  make  sure  that 
the  rhinopharynx  has  been  reached  the  water  should  return  through  the 
opposite  nostril  or  the  mouth.  When  properly  done,  no  prostration  and 
very  little  irritation  are  caused.  The  bulb  (Davison)  syringe  should  not 
be  employed  for  nasal  irrigation ;  as  the  pressure  can  not  be  satisfactorily 
regulated,  fluids  are  likely  to  be  forced  into  the  Eustachian  tubes. 

Syringing  the  mouth,  and  pharynx  is  useful  in  many  pathological 
conditions  of  these  parts,  particularly  in  children  too  young  to  gargle. 
Either  the  foimtain,  piston,  or  bulb  syringe  may  be  used.  If  the  pharynx 
is  to  be  reached,  the  nozzle  is  used  as  a  tongue  depressor.  This  should 
be  placed  at  the  angle  of  the  mouth  between  the  back  teeth.  The  child 
should  lie  upon  the  side  or  be  held  in  the  sitting  posture,  with  the  head 
inclined  forward.  Only  bland  solutions  should  be  employed. 
4 


62  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

Inhalations. — These  are  of  very  great  utility  in  all  affections  of  the 
respiratory  tract.  To  be  efficient,  the  patient  should  be  put  under  a  tent. 
A  satisfactory  tent  may  be  made  by  erecting  a  T-shaped  piece  of  wood  at 
the  head  and  foot  of  the  crib  and  throwing  over  this  a  large  sheet  folded 
and  pinned  at  the  corners.  Another  method  is  to  stretch  a  cord  around 
the  top  of  each  of  the  four  posts  of  the  crib,  or  simply  from  the  center 
of  the  head  piece  to  the  center  of  the  foot  piece ;  the  sheet  should  be  used 
as  in  the  first  instance.  A  very  good  tent  may  be  improvised  by  throwing 
a  large  sheet  over  an  open  umbrella.  The  ])etter  the  tent  the  more  satis- 
factory are  the  results. 

Inhalations  may  be  in  the  form  of  vapor  or  spray.  The  apparatus 
employed  may  be  the  croup  kettle,  the  vaporizer,  or  the  steam  atomizer. 
As  all  of  these  are  used  with  alcohol  lamps,  innumeraljle  accidents  from 
fire  have  occurred  with  them.  Patients  and  nurses  should  always  be 
cautioned  regarding  this.  Whenever  possible,  the  electric  heater  should 
be  substituted.  The  ordinary  croup  kettle  is  a  clumsy  affair  and  espe- 
cially likely  to  be  the  cause  of  accidents. 

There  are  various  forms  of  apparatus  for  the  purpose  of  obtaining 
medicated  inhalations. 

Stomach-washing  or  gastric  lavage  consists  in  the  introduction  of 
water  into  the  stomach  through  a  flexible  catheter  or  stomach  tube  and 
then  siphoning  it  out.  It  is  one  of  the  most  valuable  therapeutic  meas- 
ures we  possess.  The  procedure  is  very  simple,  and  may  ))e  considered 
entirely  free  from  danger;  in  fact,  it  is  difficult  to  pass  tlie  tul^e  any- 
where else  than  into  the  esophagus.  The  amount  of  prostration  produced 
by  stomach-wasliing  may  ])e  compared  to  that  of  an  ordinary  attack  of 
vomiting. 

The  apparatus  for  gastric  lavage  consists  of  a  soft-rul)ber  catheter,  size 
10,  American  scale  (24:  French) — one  with  a  large  eye  is  preferred;  a 
glass  funnel,  holding  four  to  six  ounces ;  two  feet  of  rubber  tubing,  and  a 
few  inches  of  glass  tubing  to  join  this  to  the  catheter.  The  child  may  be 
held  in  a  sitting  posture  or  placed  upon  the  back ;  the  body  should  l)e  M^ell 
protected  by  a  rubber  sheet,  with  a  large  basin  conveniently  ]iear.  The 
catheter  should  1)C  moistened.  While  the  toiigue  is  depressed  with  the 
forefinger  of  the  left  hand,  the  catheter  is  passed  rapidly  back  into  the 
pharynx  and  down  the  esophagus.  It  is  important  that  the  first  part  of 
the  introduction  should  be  as  rapid  as  possible,  for  if  the  child  begins  to 
gag  from  the  pharyngeal  irritation  the  introduction  of  the  tuljc  may  be 
quite  difficult.  No  resistance  is  ordinarily  encoimtered  after  the  tube 
reaches  the  esophagus.  About  ten  inches  of  the  catheter  should  be  passed 
beyond  the  lips.  When  it  has  reached  the  stomach  the  funnel  should  be 
raised ^as  high  as  possible,  to  allow  the  escape  of  gases  almost  invariably 
present.     It  shonld  then  be  lowered,  in  order  io  si])hoii  out  llie  fluid  con- 


THERAPEUTICS  63 

tents.  If  nothing  escapes,  the  funnel  is  then  to  be  raised  and  from  two  to 
six  ounces  of  water  poured  into  it  from  a  pitcher;  the  funnel  is  then 
lowered  and  the  water  siphoned  out.  This  procedure  is  repeated  from 
four  to  ten  times,  or  until  the  fluid  comes  back  clear.  About  a  quart  of 
water  is  ordinarily  used.  Various  solutions  have  been  advised  for  stom- 
ach-washing, but  nothing  is  better  than  boiled  water,  used  at  the  tem- 
perature of  from  100°  to  110°  F. — the  higher  temperature  being  em- 
ployed w^hen  the  gastric  irritation  is  very  great.  If  mucus  is  present 
in  the  stomach  an  alkaline  solution  (bicarbonate  of  soda,  oj  to  Oj)  is 
preferable.  Through  the  tube  arc  easily  discharged  mucus  and  small 
curds;  larger  ones  are  gradually  broken  down  by  repeated  Avashing. 
Vomiting  may  be  induced  by  overdistending  the  stomach  with  water.  If 
there  is  great  thirst  there  is  often  an  advantage  in  leaving  one  or  two 
ounces  of  water  in  the  stomach.  To  this  water  it  is  at  times  beneficial  to 
add  lime  water. 

Gastric  lavage  in  its  application  is  practically  limited  to  children 
under  two  and  a  half  years.  It  is  easiest  in  those  under  eighteen  months. 
Children  of  three  years  and  over  are  usually  so  much  alarmed  and  strug- 
gle so  violently  as  to  make  it  ditficult  and  undesirable. 

The  indications  for  lavage  are:  (1)  Acute  gastric  indigestion, 
either  with  or  without  j)ersistent  vomiting.  Here  the  purpose  is  sim- 
ply to  clear  the  stomach  of  its  irritating  contents,  and  a  single  wash- 
ing may  be  sufficient.  (2)  Chronic  indigestion  attended  by  the  produc- 
tion of  gastric  mucus.  (3)  Dilatation  of  the  stomach,  (i)  Hypertrophic 
stenosis  of  the  pylorus.     (5)   Poisoning. 

Gavage. — Gavage  consists  in  the  introduction  of  food  into  the  stom- 
ach by  a  tube  passed  through  the  mouth.  The  same  apparatus  is  em- 
ployed as  in  lavage,  and  the  method  is  similar,  with  the  exception  that 
for  gavage  the  child  should  be  placed  upon  the  back,  the  head  being 
steadied  by  an  assistant.  With  older  children  a  mouth-gag  is  often 
necessary.  After  the  tube  has  entered  the  stomach  the  funnel  should 
be  raised  to  allow  the  gas  to  escape.  The  food  is  then  poured  into  the 
funnel;  as  soon  as  it  has  disappeared  the  tube  is  tightly  pinched  and 
quickly  withdrawn,  to  prevent  food  from  trickling  into  the  pharynx,  since 
this  is  often  a  cause  of  vomiting.  If  the  food  is  regurgitated  this  usually 
happens  at  once.  It  may  then  be  introduced  a  second  time.  After  feed- 
ing, the  child  should  be  kept  absolutely  quiet  upon  the  back. 

In  cases  where  all  the  food  is  given  by  gavage  the  interval  between 
feedings  must  be  considerably  longer  than  under  other  circumstances. 
Sometimes  the  food  given  may  be  partially  predigested,  since  digestion  in 
these  cases  is  usually  feeble.  The  stomach  should  be  washed  before  each 
feeding,  in  order  to  remove  mucus  and  to  be  sure  that  it  is  empty  before 
the  meal  is  given. 


64  PECULIARITIES  OF  DISEASE  IN  CHILDEEN 

Gavage  is  valuable  in  the  feeding  of  premature  infants  and  after  cer- 
tain operations  upon  the  mouth  and  neck.  It  is  also  useful,  first,  in  the 
case  of  some  very  young  infants,  who,  suffering  from  severe  malnutrition, 
can  not  be  induced  to  take  food  enough  to  sustain  life ;  secondly,  in  many 
acute  diseases,  particularly  in  septic  cases  where  the  child  will  not  readily 
take  the  necessary  food,  as  in  diphtheria,  scarlet  fever,  typhoid,  pneu- 
monia, etc. ;  thirdly,  in  many  cases  of  cerebral  disease  where  food  is 
refused  on  account  of  delirium  or  coma;  and,  fourthly,  in  some  cases 
of  persistent  vomiting. 

Gavage  is  a  very  simple  procedure  and  one  which  a  nurse  can  easily 
be  taught.  Not  only  may  food  be  given,  but  also  medicines  and  stimu- 
lants as  may  be  required,  with  little  or  no  trouble.  The  advantage  of 
gavage  over  the  continued  coaxing  or  holding  the  nose  and  forcing  the 
patient  to  swallow,  will  be  at  once  apparent  to  one  using  it. 

Nasal  Feeding. — The  method  is  similar  to  gavage,  the  only  difference 
being  that  the  tube  is  passed  through  the  nose,  and  consequently  a  much 
smaller  one  is  used.  No.  10  American  or  No.  16  French  scale  is  a  proper 
size.  Nasal  feeding  is  applicable  to  children  over  two  years  old,  in  whom 
the  tube  can  seldom  be  passed  through  the  mouth  without  the  use  of  a 
gag,  and  then  only  after  much  struggling.  It  is  of  value  after  intubation, 
tracheotomy,  and  other  operations  about  the  throat,  also  in  some  cases  of 
throat  paralysis,  especially  after  diphtheria. 

Irrigfation  of  the  Colon. — By  irrigation  of  the  colon  is  meant  the 
flushing  of  the  entire  large  intestine  by  fluids  injected  high  up  through 
a  catheter  or  rectal  tube. 

The  apparatus  required  for  irrigating  the  colon  is  a  fountain  syringe, 
five  or  six  feet  of  rubber  tubing,  and  a  fiexible  rectal  tube  or  soft-rubber 
catheter — No.  26  or  27,  French  scale,  being  preferred.  Kemp's  double- 
current  tube  of  hard  or  flexible  rubber  is  usefuh  The  same  result  can 
be  obtained  by  using  two  catheters,  the  larger  for  outflow,  the  smaller 
for  inflow.  The  child  is  placed  upon  the  back,  with  the  thighs  flexed 
and  the  buttocks  brought  to  the  edge  of  the  bed  or  table.  He  should  lie 
upon  a  Kelly  pad  or  a  rubber  sheet  so  arranged  as  to  form  a  trough 
emptying  into  a  large  basin  or  tub.  The  bag  containing  the  water  is 
hung  two  or  three  feet  above  the  bed.  If  a  catheter  is  used  it  is  inserted 
just  within  the  sphincter  before  the  water  is  turned  on.  As  it  flows  the 
catheter  is  gradually  pushed  upward.  The  water  distending  the  intestine 
in  advance  of  the  catheter  usually  makes  its  introduction  quite  easy.  In 
Fig.  7  is  shown  the  colon  of  an  infant  of  six  months  in  position.  It  is 
the,  peculiar  curve  and  the  great  length  of  the  sigmoid  flexure  that  make 
the  introduction  of  water  difficult,  unless  the  tube  is  inserted  for  some 
distance. 

Usually  a  pint,  and  sometimes  a  quart,  can  be  introduced  l)efore  any 


THERAPEUTICS 


water  returns.  At  least  a  gallon  of  water  should  be  used  for  a  single  irri- 
gation. The  washing  should  be  continued  until  the  water  returns  quite 
clean.  Change  of  posture  and  gentle  kneading  of  the  abdomen  should  be 
employed  during  the  irrigation,  particularly  the  early  part  of  it,  to  facili- 
tate the  introduction  of  the  water  into  the  upper  part  of  the  colon.  At  the 
end  of  the  irrigation  the  rubber  tube  is  detached  and  the  water  allowed 
to  escape  through  the  catheter,  which  remains  in  situ.  Sometimes  as 
much  as  a  pint  of  water  remains  in  the  intestine.  This  is  usually  passed 
within  half  an  hour.  As  the  irrigation  of  the  colon  almost  invariably 
excites  active  peristalsis  of  the  lower  ileum,  this  part  of  the  intestine  is 
emptied  as  well.  It  is  to  be  remem- 
bered that  the  colon  of  an  infant  six 
months  old  will  hold  about  one  pint 
without  distention,  and  at  the  age  of 
two  years  from  two  to  three  pints. 

Irrigation  of  the  colon  is  useful 
to  clear  this  part  of  the  intestine  of 
mucus,  fecal  matter,  undigested  food, 
and  decomposing  secretions.  It  may 
also  be  employed  as  a  means  of  local 
medication  in  ileocolitis.  Where  the 
object  is  simply  to  cleanse  the  intes- 
tine, a  saline  solution — a  teaspoonful 
of  common  salt  to  a  ])\nt  of  water — is 
preferred. 

The  temperature  of  the  water  used 
f@r  irrigation  may  be  varied  accord- 
ing to  the  special  indications.  For 
ordinary    purposes,    where    cleansing 

only  is  aimed  at,  a  temperature  of  from  95°  to  100°  F.  seems  to  be 
best.  When  the  body  temperature  is  high,  or  when  there  is  much  pain, 
tenesmus  and  straining,  colder  water  has .  important  advantages. 

Irrigation  under  most  circumstances  is  required  only  once  in  twenty- 
four  hours.  It  is  important  to  use  a  large  quantity  of  water.  It  must 
be  done  thoroughly  to  be  of  value,  and  either  by  the  physician  himself 
or  an  experienced  nurse. 

In  collapse  or  great  prostration  hot  saline  injections  may  be  em- 
ployed for  purposes  of  stimulation ;  the  temperature  of  these  should  be 
from  105°  to  110°  F. 

Enemata. — Simple  enemata  are  useful  in  infants  and  older  children 
for  constipation.  When  an  immediate  effect  is  desired  the  most  efficient 
is  one  containing  glycerin — e.  g.,  for  an  infant,  one  teaspoonful  to  one 
ounce  of  water.     Oil  enemata   (one-half  to  one  ounce)  are  useful  when 


Fig.  7. — Colon  op  a  Child  Six  Months 
Old,  in  Position.  (From  a  photo- 
graph.) 


66  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

the  fecal  mass  is  hard  and  dry  and  expelled  with  difficulty.  Enemata 
should  always  be  given  with  care,  and  preferably  a  rubber  catheter  should 
be  attached  to  the  nozzle  of  the  syringe. 

jSTutrient  enemata  have  a  limited  application  in  infancy,  as  the  rectum 
soon  becomes  intolerant.  The  quantity  injected  should  be  small,  rarely 
more  than  one  or  two  ounces,  and  the  interval  between  injections  should 
be  at  least  four  hours.  In  older  children  they  may  be  used  as  in  adults. 
Glucose  can  be  given  in  this  manner  when  the  stomach  is  intolerant.  It 
is  doubtful  if  other  substances  are  sufficiently  absorbed  to  be  of  much 
benefit. 

The  administration  of  drugs  per  rectum  is  useful  in  certain  cases 
when,  on  account  of  the  unpleasant  taste  or  vomiting,  the  administration 
by  mouth  is  difficult — e.  g.,  quinin  and  chloral.  As  a  diluent,  gruel  is 
preferable  to  water.  If  quiriin  is  used,  the  bisulphate  is  the  best  prepa- 
ration, but  this  must  be  well  diluted.  The  temperature  of  enemata  which 
are  to  be  retained  should  be  about  100°  F.  It  is  necessary  in  infancy  to 
press  the  buttocks  together  for  half  an  hour  afterward  to  prevent  the 
expulsion  of  the  injection.  , 

Hypodermic  Medication. — This  is  not  so  often  used  in  young  children 
as  it  should  be,  and  is  of  the  greatest  service  even  in  infancy.  The  use 
of  morphin  liypodcrmically  in  convulsions,  of  morpliiii  and  atropin  in 
cholera  infantum,  of  strychnin,  camphor,  caffein,  epiiu'i)lirin,  or  digitalis 
in  circulatory  failure,  may  be  cited  as  examples. 

Hypodermoclysis. — This  is  a  therapeutic  measure  of  murli  vahie  espe- 
cially in  infants  when  great  loss  of  fluid  has  heeu  sustained,  as,  for  in- 
stance, in  severe  diarrhea,  or  when  fluids  given  l^y  the  moiitli  cannot  be 
retained  as  in  pyloric  stenosis.  It  is  at  times  useful  in  cases  of  marasmus 
when  the  tissues  are  dry,  shriveled  and  wasted. 

The  solution  employed  is  a  normal  saline  (.9  per  cent)  prepared  with 
sterile  or  preferably  freshly  distilled  water.  The  amount  injected  may  be 
from  100  to  120  c.c.  (three  or  four  ounces)  to  an  infant  of  five  or  six 
pounds,  and  150  to  250  c.c.  (five  to  eight  ounces)  to  one  of  nine  or  ten 
pounds.  It  is  given  once  or  twice  in  twenty-four  hours.  Tlio  fluid  is 
contained  in  an  inverted  wash  bottle  suspended  a  foot  or  two  above  the 
patient  and  flows  through  a  rubber  tul)e  and  an  ordinary  liypodermic 
needle.  The  injection  may  be  made  into  the  subcutaneous  tissue  of  any 
of  the  large  areolar  planes  of  the  body,  the  back  between  the  scapulae,  or 
the  abdomen  being  preferred.  The  apparatus  should  be  sterilized  before 
using.  Before  injecting,  the  solution  should  be  warmed  to  body  tem- 
perature and  kept  warm  during  injection  by  wrapping  the  bottle  in  flan- 
nel. It  requires  from  one-half  hour  to  two  hours  for  the  solution  to 
flow  into  the  tissues.  Absorption  usually  takes  place  in  four  to  six  hours. 
Metabolism  experiments  have  shown  that  a  consiflerablc  part  not  only  of 


THERAPEUTICS  67 

the  water  but  of  the  salt  so  given  is  retained  for  two  or  three  days  by  those 
whose  tissues  need  it  most.  Healthy  infants  usually  eliminate  it  very 
quiekly,  getting  rid  of  most  of  it  within  twenty-four  hours.  A  slight  rise 
of  temperature,  rarely  over  101.5°,  occurs  a  few  hours  after  the  injection 
in  about  half  the  cases.  Hypodermoclysis  may  often  be  repeated  with 
advantage  for  several  days. 

Massage. — In  older  children  massage  is  useful  for  the  same  condi- 
tions as  those  for  which  it  is  employed  in  adults ;  the  most  important  are 
anemia,  general  malnutrition  and  chronic  constipation.  It  is  necessary 
that  in  the  beginning  only  the  mildest  movements  of  massage  should  be 
employed,  and  these  but  for  a  short  time. 

In  infancy  massage  has  a  limited  ai)plication  and  it  is -doubtful 
whether  it  really  does  more  than  can  be  accomplished  by  the  general 
friction  of  the  body.  This  rubbing,  either  with  the  bare  hand  or  with 
cocoa  butter,  or  with  some  form  of  fat,  is  useful  in  malnutrition,  in 
rickets,  and  in  wasting  diseases  when  the  circulation  is  feeble  and  the 
muscular  tone  low.  Cocoa  butter  is  cleanly  and  has  a  pleasant  odor,  and 
is,  we  think,  quite  as  valuable  as  the  more  commonly  employed  cod-liver 
oil,  which  is  exceedingly  disagreeable.  The  inunctions  should  be  given 
daily  after  the  morning  bath,  before  an  open  fire.  The  rubbing  should 
be  continued  for  fifteen  to  twenty  minutes. 

Anesthetics. — As  a  general  anesthetic  for  routine  use,  ether  is  to  be 
recommended  for  children.  Its  disadvantages  can  largely  be  overcome 
by  proper  administration ;  in  point  of  safety  it  is  immeasurably  superior 
to  chloroform  for  the  very  young.  The  administration  of  ether  to  young 
children  may  be  advantageously  preceded  by  a  few  whiffs  of  nitrous  oxid 
or  ethyl  chlorid;  both,  however,  are  to  be  used  with  caution  in  infants. 
Ether  should  be  given  slowly,  well  diluted  with  air,  and  if  used  in  this 
way  its  unpleasant  features  may  be  obviated.  This  can  best  be  accom- 
plished by  the  use  of  some  special  form  of  inhaler.  Ether  should  not  be 
selected  as  the  anesthetic  for  patients  suffering  from  nephritis,  bronchitis, 
pneumonia,  pleurisy,  or  any  other  disease  attended  by  obstructed  respira- 
tion. 

The  dangers  from  chloroform  are  greatest  when  it  is  given  too  rapidly 
or  in  too  concentrated  a  forln.  Both  are  exceedingly  likely  to  occur  when 
it  is  administered  to  a  struggling  child.  The  greatest  care  and  judgment 
should  be  exercised  at  such  times,  or  disastrous  consequences  may  follow. 
To  produce  and  maintain  the  effect  desired  with  the  minimum  amount  of 
chloroform  should  always  be  the  aim.  All  anesthetics,  but  especially 
chloroform,  are  dangerous  in  children  with  the  so-called  lyinphatic  dia- 
thesis. For  the  removal  of  tonsils  or  adenoids,  chloroform  should  not  be 
employed. 

Nitrous  oxid,  while  very  useful  in  older  children  as  in  adults  for 


68  PECULIARITIES  OF  DISEASE  IN  CHILDREN 

momentary  operations,  is  not  well  borne  by  infants.  It  produces  so  early 
and  so  deep  as^ihyxia  that  its  prolonged  use  may  be  fraught  with  serious 
danger. 

Transfusion. — Two  methods  of  performing  transfusion  are  in  use: 
The  first,  the  end-to-end  anastomosis  introduced  by  Carrel,  is  somewhat 
difficult  of  technic  and  requires  a  skilled  surgeon;  second,  the  syringe 
method  popularized  by  Lindemann,  which  is  much  simpler  and  can  be 
done  by  one  of  very  moderate  experience.  In  this  the  blood  is  drawn  from 
the  vein  of  the  donor,  preferably  a  member  of  the  family,  into  a  paraffin- 
coated  glass  syringe  and  immediately  injected  into  the  vein  of  the  child, 
usually  the  external  jugular,  but  any  available  superficial  vein  may  be 
chosen.  In  most  cases  it  can  be  done  without  any  dissection.  As  the 
blood  must  be  rapidly  passed  from  one  person  to  another  before  coagula- 
tion takes  place,  at  least  one  assistant  and  the  use  of  four  or  five  syringes 
are  needed.  The  amount  of  blood  usually  injected  into  infants  is  from 
two  to  six  ounces. 

The  indications  for  transfusion  are :  first,  in  any  acute  hemorrhage, 
especially  the  hemorrhages  of  the  newly  born,  where  it  is  usually  a  specific 
remedy  and  acts  at  once ;  secondly,  in  loss  of  blood  during  or  after  opera- 
tions. In  some  types  of  especially  severe  secondary  anemia  it  is  of  benefit. 
In  the  slowly  developing  anemias,  whether  from  disease  of  the  blood- 
forming  organs  or  as  an  accompaniment  of  malnutrition  or  marasmus,  it 
is  of  very  transient  benefit. 


PART  II 

SECTION  I 
DISEASES  OF  THE  NEWLY  BORN 

CHAPTER  I 
ASPHYXIA 

The  lungs  in  the  full-term  fetus  are  of  uniform  dark  red  color,  and 
show  very  distinctly  upon  their  surface  the  lobular  divisions.  They  are 
firm  and  solid  and  readily  sink  in  water.  The  connective  tissue  is  very 
abundant,  and  forms  distinct  fibrous  septa,  which  stretch  through  the 
lungs  in  every  direction. 

Inflation  of  the  lungs  begins  with  the  first  cry  uttered  by  the  infant 
as  it  is  born  into  the  world.  The  parts  first  expanded  are  the  anterior 
borders  of  the  lungs,  then  the  upper  lobes,  and  finally  the  lower  lobes 
posteriorly.  The  superficial  lobules  are  nearly  always  expanded  before 
those  in  the  interior  of  the  lung.  The  inflation  is  sometimes  irregular, 
because  of  the  accumulation  of  mucus  in  some  of  the  bronchial  tubes. 
The  right  lung  is  frequently  stated  to  be  expanded  earlier  than  the  left. 
Although  this  is  often  the  case,  there  is  no  uniformity  in  this  respect. 
The  important  point  to  be  remembered  is,  that  the  parts  last  inflated  are 
the  posterior  portions  of  the  lower  lobes.  The  expansion  of  the  lungs  is 
a  gradual  process,  and  in  healthy  infants  it  is  probably  not  complete 
for  two  or  three  days.  In  delicate  children  it  may  be  postponed  for 
several  days,  or  even  weeks.  The  above  statements  are  based  upon  post 
mortem  observations  upon  infants  dying  from  various  causes  during  the 
first  weeks.  It  has  often  been  a  matter  of  great  surprise  to  find  at 
autopsy  on  an  infant  two  or  three  days  old,  that  less  than  one-half  of 
the  lung  tissue  was  expanded,  although  the  child  had  breathed  well 
and  shown  no  signs  of  atelectasis.  Under  normal  conditions  at  full 
term  infiation  of  the  lungs  takes  place  very  readily,  but  not  so  readily 
in  premature  or  delicate  infants,  on  account  of  the  feebleness  of  the 
respiratory  muscles.     The  longer  it  is  postponed  after  birth  the  more 

69 


70  DISEASES  OF  THE  NEWLY  BOEN 

difficult  does  it  become,  on  account  of  the  changes  which  occur  in  the 
collapsed  air  vesicles.  The  condition  of  the  child  in  utero  may  be  de- 
scribed as  one  of  fetal  apnea,  its  oxygen  being  received  and  its  carbon 
dioxid  discharged  through  the  placenta,  which  is  essentially  the  organ  of 
respiration  at  this  period.  This  condition  is  interrupted  by  cutting  off 
the  supply  of  oxygen  and  the  accumulation  of  carbon  dioxid  in  the  blood. 
Which  of  these  is  the  important  factor  in  inducing  pulmonary  respiration 
has  been  much  debated ;  but  the  best  experimental  evidence  seems  to  show 
that  it  is  the  latter  which  stimulates  the  respiratory  centers. 

Under  the  term  "asphyxia"  may  be  included  all  cases  in  which 
primary  respiration  is  not  spontaneously  established  with  sufficient  force 
to  maintain  life.  Usually  there  is  no  attempt  at  pulmonary  respiration 
until  after  the  birth  of  the  child,  but  it  may  occur  in  utero  or  at  any 
stage  of  parturition.  Asphyxia  may  be  of  intra-uterine  or  extra-uterine 
origin. 

Etiology. — 1.  Intra-Uterine  Asphyxia. — The  maternal  causes  include 
any  disturbance  of  the  placental  circulation  during  labor — anything 
which  prolongs  the  second  stage  of  labor,  convulsions,  hemorrhage,  the 
use  of  ergot  in  the  second  stage,  or,  finally,  the  death  of  the  mother.  The 
causes  relating  to  the  child  are  pressure  upon  the  cord,  multiple  winding 
of  the  cord  about  the  neck,  early  separation  of  the  placenta,  and  pressure 
upon  the  brain.  If  the  respiratory  stimulus  comes  before  the  birth  of 
the  child,  the  effort  at  respiration  may  cause  the  entrance  into  the  mouth 
and  air  passages  of  amniotic  fluid,  mucus,  blood,  meconium,  etc. 

2.  Extra-Uterine  Asphyxia. — This  condition  is  a  much  less  common 
one.  It  arises  from  causes  quite  apart  from  those  above  mentioned,  and 
depends  upon  malformations  or  intra-uterine  disease  of  the  organs  of 
respiration,  circulation,  or  of  the  brain.  It  may  be  secondary  to  an  injury 
of  any  of  these  organs  received  during  parturition.  It  is  also  seen  in 
premature  infants,  where  it  depends  upon  the  feeble  development  of  the 
nerve  centers  and  respiratory  muscles  and  upon  the  soft,  yielding  chest 
walls. 

Lesions. — In  infants  dying  of  intra-uterine  asphyxia  there  are  seen 
the  usual  changes  found  in  death  from  suffocation,  together  with  the 
effects  of  attempts  at  breathing  in  utero.  There  is  general  congestion  of 
all  the  viscera,  particularly  of  the  brain  and  its  meninges,  the  liver,  and 
the  lungs.  They  may  show  small,  punctate  hemorrhages,  and  occasion- 
ally large  extravasations.  Blood  or  bloody  serum  may  be  found  in  any 
of  the  serous  cavities.  The  right  heart  is  overdistended  with  dark,  soft 
clots,  and  the  blood  generally  is  more  fluid  than  normal.  The  lungs  may 
contain  no  air,  but  more  frequently  there  are  small,  scattered  areas  in 
which  lobular  inflation  has  taken  place.  If  the  child  has  lived  several 
hours  there  are  larger  areas  of  expanded  lung,  especially  in  the  upper 


ASPHYXIA  71 

lobes,  and  these  may  even  be  emphysematous,  if  artificial  inflation  has 
been  employed.  In  the  mouth,  nose,  larynx,  and  even  as  far  as  the  finest 
bronchi,  there  may  be  found  aspirated  materials — amniotic  fluid,  blood, 
mucus,  or  meconium.  In  extra-uterine  asphyxia  tliere  may  be  organic 
changes  in  the  viscera — malformations  of  the  lungs  or  the  heart,  intra- 
uterine pneumonia  or  pleuritic  effusion,  malformation  of  the  diaphragm 
and  sometimes  of  the  brain. 

Symptoms. — Under  normal  conditions  the.  newly-born  infant  begins 
at  once  to  scream  and  to  use  his  limbs,  the  purplish  color  of  the  skin 
giving  place  in  a  few  moments  to  a  rosy  pink.  In  the  first  degree  of 
asphyxia — asphyxia  livicla- — the  child  is  deeply  cyanosed.  Either  no 
attempt  whatever  is  made  at  respiration,  or  it  is  superficial  and  repeated 
only  at  long  intervals.  The  pulse  is  slow,  full,  and  strong.  The  vessels 
of  the  cord  are  distended.  Muscular  tone  is  preserved,  and  also  cutaneous 
irritability,  so  that  with  the  application  of  almost  any  kind  of  external 
stimulus  respiration  is  excited  and  the  symptoms  disappear. 

In  the  second  degree — asphyxia  pallida — the  picture  is  quite  a  differ- 
ent one.  The  face  is  pale  and  deathlike,  though  the  lips  may  still  be  blue. 
The  heart's  action  is  weak,  and  by  palpation  can  rarely  be  felt  at  all.  By 
auscultation  the  sounds  are  feeble,  irregular,  and  usually  slow.  The  cord 
is  soft,  pale,  and  flaccid,  and  its  vessels  nearly  empty.  The  sphincters 
are  relaxed  and  meconium  oozes  from  the  anus.  There  is  entire  loss  of 
tone  in  the  voluntary  muscles,  so  that  the  extremities  and  entire  body 
seem  perfectly  limp.  Cutaneous  sensibility  is  abolished.  The  extrem- 
ities are  often  cold.  There  may  occur  a  few  short,  convulsive  contrac- 
tions of  the  respiratory  muscles,  but  these  are  without  effect  and  soon 
cease.  Unless  such  cases  receive  the  most  prompt  and  efficient  treatment, 
the  heart's  action  becomes  more  and  more  feeble  until  it  ceases  and  death 
occurs.  Other  cases  are  partly  resuscitated  and  may  survive  for  a  few 
hours  or  days,  when  they  gradually  sink,  respiration  becoming  more  and 
more  feeble  in  spite  of  all  efforts  to  maintain  it.  Between  these  two 
extremes  all  degrees  of  severity  are  seen. 

In  extra-uterine  asphyxia  there  may  be  some  attempts  at  voluntary 
respiration  continuing  for  several  hours,  sometimes  for  a  day  or  two, 
but  this  may  be  inadequate  to  sustain  life. 

Diagnosis. — Almost  the  only  condition  with  which  asphyxia  is  likely 
to  be  confounded  is  cerebral  compression  from  a  meningeal  hemorrhage. 
The  difficulties  in  the  case  are  much  increased  by  the  fact  that  the  two 
conditions  are  not  infrequently  associated.  It  may  then  be  impossible  to 
tell  that  in  addition  to  asphyxia,  intracranial  hemorrhage  is  present.  If 
the  hemorrhage  is  extensive  and  the  asphyxia  only  moderate,  a  diagnosis 
is  possible  in  most  of  the  cases.  In  hemorrhage  there  is  often  a  history 
of  undue  compression  during  delivery — sometimes  the  use  of  forceps. 


72  DISEASES  OF  THE  NEWLY  BOEN 

The  fontanel  is  bulging ;  there  is  coma,  and  there  may  be  paralysis.  The 
respiratory  murmur  may  be  quite  strong  for  several  hours,  but  it  grad- 
ually fails  as  the  child  becomes  completely  comatose.  Anemia  resulting 
from  a  large  hemorrhage,  like  that  due  to  rupture  of  the  cord,  may  simu- 
late the  severe  form  of  asphyxia. 

Prognosis. — This  depends  upon  the  grade  of  asphyxia  and  the  treat- 
ment employed.  There  is  but  little  tendency  to  spontaneous  recovery  in 
any  form.  In  the  milder  cases  recovery  is  almost  invariable  with  any 
intelligent  treatment.  In  the  severest  cases  the  outcome  is  always  doubt- 
ful, although  by  persistent  effort  many  infants  that  are  aj^parently  hope- 
less may  be  saved.  In  a  prognosis  as  to  the  ultimate  result,  the  frequent 
complication  of  asphyxia  with  meningeal  hemorrhage  should  always  be 
kejDt  in  mind.  Apart  from  this  complication  it  is  doubtful  whether 
asphyxia  has  anything  to  do  with  the  production  of  idiocy. 

Treatment. — In  every  case  the  first  step  is  to  clear  the  mouth  and 
pharynx  of  mucus  by  means  of  the  finger  covered  with  al^sorbent  cotton. 
In  the  milder  forms  respiration  is  usually  excited  either  by  spanking  the 
child  or  the  alternate  use  of  hot  and  cold  baths.  If  the  hot  bath  is 
employed,  the  water  should  be  from  104°  to  108°  F.  and  always  tested 
by  a  thermometer.  After  a  moment  the  child  should  be  dipped  into  very 
cold  water,  or  the  body  may  be  douched  with  it.  In  the  livid  cases  relief 
is  often  afforded  by  allowing  the  cord  to  bleed  for  a  few  moments  before 
ligation.  The  loss  of  half  an  ounce  of  blood  is  ordinarily  sufficient. 
Simply  swinging  the  child  in  the  air  is  a  powerful  stimulus  to  respira- 
tion. The  above  means  will  suffice  in  the  great  majority  of  cases.  In 
the  more  severe  forms,  however,  these  are  inadequate.  There  is  no 
response  whatever  to  external  stimulation,  either  by  heat  or  mechanical 
irritation.  In  these  cases  two  methods  of  resuscitation  may  be  employed : 
artificial  respiration  and  direct  inflation  of  the  lungs. 

One  of  the  most  Avidely  employed  methods  of  inducing  artificial 
respiration  is  that  of  Schultze.  The  infant  is  grasped  by  both  axillae  in 
such  a  Avay  that  the  thumbs  of  the  physician  rest  upon  the  anterior  sur- 
face of  the  chest,  the  index  fingers  in  the  axillae,  and  the  remaining 
fingers  extending  across  the  back.  The  child  is  thus  suspended  at  arm's 
length  between  the  knees  of  the  physician,  the  feet  downward  and  the 
face  anterior.  The  body  is  now  swung  forward  and  upward,  until  the 
physician's  arms  are  nearly  horizontal.  This  produces  the  inspiratory 
effort.  When  this  point  is  reached,  an  arrest  in  the  swinging  causes 
flexion  of  the  trunk,  the  head  now  being  directed  downward,  the  lower 
extremities  fall  toward  the  physician  until  the  whole  weight  of  tlie  body 
rests  upon  the  thumbs.  In  this  way  expiration  is  produced.  Lusk  cau- 
tions against  the  employment  of  this  method  if  the  heart's  action  is  very 
feeble,  as  it  may  cause  the  heart  to  stop  altogether.    This  method  should 


ASPHYXIA  73 

be  used  with  care  and  skill;  clumsy  and  too  forcible  manipulation  has 
resulted  in  many  serious  injuries  to  the  viscera  and  fractures  of  ribs  or 
clavicles. 

A  method  introduced  by  Dew  has  been  extensively  employed  in  Xew 
York.  The  infant  is  grasped  in  such  a  way  that  th*e  neck  rests  between 
the  thumb  and  forefinger  of  the  left  hand,  the  head  being  allowed  to 
fall  far  backward,  the  upper  portion  of  the  back  resting  upon  the  palm 
of  the  hand;  with  the  right  hand  the  knees  are  grasped  between  the 
thumb  and  fingers,  the  thighs  resting  against  the  palm  of  the  hand. 
Inspiration  is  produced  by  depressing  the  pelvis  and  lower  extremities, 
thus  causing  the  abdominal  organs  to  drag  upon  the  diaphragm,  and  at 
the  same  time  gently  bending  the  dorsal  region  of  the  spine  backward. 
In  expiration  the  movement  is  reversed,  the  head  being  brought  forward 
and  flexed  upon  the  thorax,  while  at  the  same  time  the  thighs  are  flexed 
so  as  to  bring  them  against  the  abdomen.  The  body  is  thus  alternately 
folded  upon  itself  and  unfolded  as  the  movements  are  carried  on.  If 
there  is  much  mucus  in  the  mouth,  the  movement  of  expiration  should 
first  be  made  with  the  body  completely  inverted.  This  method  is  simple, 
efficient,  and  much  less  fatiguing  than  that  of  Schultze  when  it  is  to  be 
maintained  for  a  long  time.  It  is  also  of  great  advantage  in  that  it  can 
be  carried  on  while  the  child  is  in  the  hot  bath,  one  of  the  greatest  objec- 
tions to  the  method  of  Schultze  being  the  loss  of  animal  heat  incident 
to  its  use. 

In  all  cases  where  artificial  respiration  is  used  the  first  movement 
should  be  that  of  expiration,  to  expel,  so  far  as  possible,  mucus  or  other 
foreign  substances  from  the  air  passages.  The  movements  should  be 
made  from  eight  to  twelve  times  a  minute,  and  not  too  forcibly,  the  child 
being  kept  in  the  hot  bath  between  the  movements,  and  as  much  as  possi- 
ble during  them.  As  long  as  the  heart  beats  resuscitation  is  possible, 
and  the  case  should  not  be  abandoned. 

Direct  inflation  of  the  lungs  by  the  mouth-to-mouth  method  should 
not  be  employed. 

An  ingenious  apparatus  for  artificial  inflation  of  the  lungs  has  been 
devised  by  Carrel  of  the  Eockefeller  Institute,  making  use  of  Meltzer's 
method  of  the  continuous  insufflation  of  air.  A  flexible  catheter  contain- 
ing a  wire  stylet  is  introduced  into  the  larynx.  By  means  of  a  double 
bulb  a  continuous  flow  of  air  is  maintained.  A  manometer  measures  the 
pressure  employed  and  is  a  guide  by  which  one  is  prevented  from  using 
an  excessive  amount  of  force.  When  the  pressure  employed  is  normal 
the  mercury  in  the  descending  and  ascending  arms  of  the  curved  tube 
stands  at  about  the  same  level ;  if  an  excessive  amount  of  pressure  is  used, 
the  mercury  will  be  forced  up  into  the  bulb.  Although  this  has  been  very 
little  employed  in  infants  it  has  been  extensively  used  in  resuscitating 


74  DISEASES  OF  THE  NEWLY  BORN 

animals  and  seems  to  fulfill  all  the  indications  better  than  any  apparatus 
hitherto  suggested.  It  is  so  simple  of  construction  that  it  can  easily  be 
put  together  by  any  instrument  maker. 

The  method  introduced  by  Laborde,  of  making  rhythmical  traction 
upon  the  tongue  ten"  or  twelve  times  a  minute  as  a  means  of  exciting 
respiration,  is  sometimes  very  useful  in  conjunction  with  other  methods. 
Faradization  of  the  phrenic  is  of  undoubted  value,  but  somewhat  difficult 
of  application. 

In  cases  of  asphyxia  it  is  not  enough  to  make  the  child  cry.  The 
deep  respirations  should  be  made  to  continue,  for  very  often  it  happens 
that  resuscitation  is  only  partial,  and  that  the  child  after  six  or  eight 
hours  lapses  into  its  previous  condition.  All  severe  cases  require  close 
watching  for  the  first  twenty-four  or  thirty-six  hours,  as  a  repetition  of 
the  treatment  is  often  necessary. 


CHAPTEE   II 
CONGENITAL  ATELECTASIS 

This  condition  is  one  in  which  there  is  a  persistence  of  the  fetal  state 
in  the  whole  or  in  any  part  of  the  lung. 

Atelectasis  is  the  pathological  condition  with  which  asphyxia  of  the 
newly  born  is  usually  associated.  In  most  of  the  cases  the  condition  of 
atelectasis  is  completely  overcome  by  the  means  employed  in  resuscita- 
tion ;  in  some,  however,  these  means  are  only  partially  successful,  so  that 
a  portion  of  lung  of  variable  extent  remains  in  the  fetal  condition.  These 
are  the  circumstances  in  which  most  of  the  cases  of  atelectasis  arise. 
But  there  are  others  in  which  there  is  no  history  of  early  asphyxia,  where 
the  primary  respirations,  although  taking  place  spontaneously,  have  not 
been  of  sufficient  force  and  depth  to  produce  full  pulmonary  expansion. 
This  usually  occurs  in  feeble  infants,  or  in  those  who  are  premature.  The 
causes  of  congenital  atelectasis  are  therefore,  in  the  main,  those  men- 
tioned as  producing  asphyxia. 

Lesions. — In  cases  where  the  child  dies  during  the  first  few  days  the 
amount  of  expanded  lung  is  often  small,  frequently  not  more  than  one 
fourth  of  the  pulmonary  area.  The  expanded  portion  is  usually  the 
anterior  borders  of  the  upper  lobes.  This  is  often  the  seat  of  acute 
emphysema.  The  rest  of  the  lung  is  still  in  the  fetal  state ;  it  is  of  a 
brownish-red  color,  very  vascular,  does  not  crepitate,  and  shows  the 
lobular  outlines  both  on  the  surface  and  on  section.  With  a  little  force 
the  atelectatic  lung  may  be  completely  inflated. 


CONGENITAL  ATELECTASIS  75 

If  children  have  lived  a  longer  time,  nearly  the  whole  of  the  upper 
lobes  and  the  anterior  portion  of  the  lower  lobes  are  usually  well  inflated. 
These  portions  are  either  normal  or  slightly  emphysematous.  The  pos- 
terior portion  of  the  upper  lobes  and  the  lower  lobes  are  almost  invariably 
the  seat  of  the  atelectasis.  On  the  surface  even  these  portions  may  pre- 
sent quite  a  large  area  of  expanded  vesicles,  but  the  underlying  portion 
may  be  solid  to  the  touch,  and  crepitates  but  slightly.  On  section  it  is 
seen  that  only  the  most  superficial  part  of  the  lung  is  inflated,  while  the 
interior  of  the  lobe  is  unexpanded.  Small  hemorrhages  are  frequently 
seen  beneath  the  pleura. 

It  is  usual  for  both  lungs  to  be  affected,  and  often,  but  by  no  means 
uniformly,  to  about  the  same  degree.  It  is  frequently  a  great  surprise  to 
discover  that  a  child  has  lived  for  some  weeks  without  presenting  any 
signs  of  cyanosis,  although  using  not  more  than  one-third  of  his  pul- 
monary area.  This  variety  of  atelectasis  closely  resembles  the  hypostatic 
pneumonia  of  delicate  infants,  and  very  often  the  tAvo  conditions  are 
associated.  It  may  require  the  microscope  to  decide  between  them.  If 
congenital  atelectasis  has  existed  for  a  considerable  time,  there  are  usually 
found  evidences  of  pneumonia.  Inflation  is  not  so  easy  as  in  recent  cases, 
but  with  force  the  greater  part  of  the  lung  can  usually  be  expanded.  The 
heart  commonly  shows  the  right  auricle  and  ventricle  to  be  distended  with 
dark  clots,  and  there  is  occasionally  found  a  patent  foramen  ovale  or 
some  other  form  of  congenital  lesion.  The  liver  and  spleen  are  in  most 
cases  congested,  and  the  spleen  may  be  considerably  enlarged.  The 
mucous  membrane  of  the  stomach  and  intestines  is  sometimes  deeply 
congested. 

Symptoms. — In  one  group  of  cases  the  children  are  asphyxiated  at 
birth,  but  the  attempts  at  resuscitation  have  been  only  partially  success- 
ful. Although  the  patients  may  live  for  a  few  days,  there  is  cyanosis, 
which  gradually  deepens,  and  death  takes  place  from  asphyxia,  exhaus- 
tion, or  convulsions. 

In  a  second  group  of  cases  the  infants  have  been  asphyxiated  at  birth, 
and  resuscitated  perhaps  with  difficulty,  but  to  all  appearance  completely. 
They  do  not  thrive,  however,  remaining  small  and  delicate,  gaining  very 
little  or  not  at  all  in  weight,  and  showing  poor  circulation,  cold  extrem- 
ities, and  occasionally  subnormal  temperature.  It  is  characteristic  of 
these  cases  that  the  cry  is  never  loud,  strong,  and  lusty.  Some  of  them 
will  not  cry  at  all.  Such  children  may  live  several  weeks.  There  may 
develop  at  any  time,  often  quite  suddenly  and  without  assignable  cause, 
attacks  of  cyanosis  with  prostration.  Children  may  have  several  such 
attacks,  which  do  not  excite  suspicion  since  they  pass  away  spontaneously. 
In  other  cases  the  symptoms  are  so  severe  that  they  may  result  fatally  in 
a  few  hours,  death  being  frequently  preceded  by  convulsions.     If  ener- 


76  DISEASES  OF  THE  NEWLY  BOEN 

getieally  treated  the  symptoms  may  pass  away  but,  reappearing  in  a  f6w 
hours,  or  again  after  a  week  or  more,  they  gradually  deepen  in  intensity 
until  death  occurs. 

Two  cases  that  came  under  our  observation  in  the  New  York  Infant 
Asylum  illustrate  this  point:  The  infants  were  twins,  ten  weeks  old 
and  delicate.  Suddenly  at  night  one  child  was  taken  Avith  convulsions, 
became  deeply  cyanosed,  and  died  in  two  and  a  half  hours.  He  had  been 
suffering  from  a  slight  attack  of  indigestion  for  a  week  previous.  The 
other  twin  had  been  apparently  well  on  the  previous  day.  Two  hours 
after  the  death  of  the  first  child  the  second  was  taken  with  similar  symp- 
toms, dying  in  a  few  hours.  At  autopsy  there  was  found  very  extensive 
atelectasis  involving  the  posterior  part  of  the  upper  and  the  greater  part 
of  both  lower  lobes.  The  lesions  were  almost  identical  in  the  two  cases. 
In  both,  the  stomach  was  greatly  distended  with  food  and  gas.  We  have 
repeatedly  seen  the  effect  of  overdistention  of  the  stomach  in  producing 
cyanosis  in  young  children,  and  in  this  instance  we  believe  it  to  have  been 
the  exciting  cause  of  the  final  symptoms.  It  was  subsequently  learned 
that  during  the  six  weeks  of  observation  the  nurse  had  witnessed  several 
slight  attacks  of  cyanosis  in  one  of  the  infants.  It  is  of  course  possible 
that  the  atelectasis  in  these  cases  may  have  been  in  part  at  least  acquired. 

We  have  seen  a  number  of  cases,  in  which  there  was  nothing  whatever 
to  attract  attention  to  the  lungs  until  the  final  attack  of  cyanosis  oc- 
curred. In  not  all  of  these  cases  is  there  a  history  of  asphyxia  at  birth. 
Some  are  only  puny,  delicate  or  premature,  exhibiting  during  the  early 
weeks  of  life  all  the  signs  of  feeble  vitality.  The  subsequent  course  is 
the  same  as  in  those  in  which  there  is  early  asphyxia.  The  duration  of 
life  in  these  cases  depends  chiefly  upon  the  extent  of  the  atelectasis. 

It  is  not  to  be  supposed  that  all  cases  of  congenital  atelectasis  ter- 
minate fatally.  Infants  in  whom  there  is  every  reason  to  believe  that 
atelectasis  exivsts,  from  the  occasional  attacks  during  the  first  few  weeks 
of  cyanosis,  feeble  cry,  poor  circulation,  etc.,  may  under  favorable  con- 
ditions with  improved  nutrition  recover  completely,  even  though  no 
special  treatment  is  directed  to  the  lungs. 

Diagnosis. — The  physical  signs  are  of  much  less  value  than  the  symp- 
toms. It  should  be  remembered  that  the  principal  seat  of  the  disease 
is  the  lower  lobes  posteriorly.  Percussion  usually  gives  resonance  over 
the  entire  chest,  although  this  may  be  somewhat  diminished  ]3osteriorly. 
There  is  not,  however,  so  much  change  as  one  would  expect  to  find,  for 
the  collapsed  areas  are  surrounded  by  others  which  are  overdistended,  and 
there  are  in  the  midst  of  the  collapsed  paTts,  especially  upon  the  surface, 
lobules  which  are  inflated.  If  the  two  sides  are  involved  to  about  the 
same  degree,  as  is  often  the  case,  we  can  get  no  difference  in  the  percus- 
sion note  over  the  two  lungs,  and  the  change  from  the  normal  may  be  so 


ICTEEUS  77 

slight  as  not  to  be  appreciable.  Where  only  one  lung  is  affected  a  differ- 
ence can  usually  be  made  out.  The  respiratory  murmur  is  rarely  bron- 
chial, but  generally  only  feeble  in  its  intensity,  and  rather  ruder  in 
quality  than  normal.  The  cardiac  sounds  may  be  transmitted  with 
abnormal  intensity.  As  in  the  case  of  j)ercussion,  if  only  one  lung  is 
affected,  this  is  of  some  value  in  diagnosis,  but  it  is  not  sufficiently 
marked  to  be  readily  recognized  when  both  sides  are  involved.  Occa- 
sionally rales  are  present. 

Treatment. — In  the  newly-born  child,  whether  asphyxiated  or  not, 
the  physician  should  see  to  it  that  the  infant  not  only  cries,  but  does  so 
loudly  and  strongly,  and  that  this  cry  is  repeated  every  day.  If  children 
do  not  cry  naturally  they  must  be  made  to  do  so  by  the  alternate  use  of 
the  hot  and  cold  bath,  as  in  cases  of  asphyxia,  or  by  mechanical  means, 
like  spanking.  This  should  be  repeated  at  least  twice  a  day,  and  con- 
tinued for  from  fifteen  to  thirty  minutes.  It  may  seem  cruel  but  it  is 
often  the  only  means  of  saving  life.  Expansion  of  the  lungs  is  much 
more  easily  induced  during  the  first  few  days  of  life,  becoming  more  and 
more  difficult  the  longer  it  is  delayed.  Provided  the  condition  is  recog- 
nized, treatment  is  fairly  successful.  In  institutions  where  delicate 
infants  spend  most  of  the  time  in  their  cribs,  atelectasis  is  likely  to  be 
found.  An  infant  needs  exercise,  and  this  is  often  only  to  be  obtained  by 
taking  the  child  from  its  crib  several  times  a  day,  by  general  friction, 
massage,  the  stimulus  of  fresh  air,  etc.  ISTothing  is  more  certain  to  per- 
petuate atelectasis  than  to  allow  the  infant  a  life  of  feeble  vegetative 
existence.  Food  and  feeding  must  be  carefully  attended  to,  but  even 
these  are  of  less  importance  than  the  maintenance  of  the  animal  heat. 
The  temperature  is  often  subnormal,  and  should  be  closely  watched.  If 
there  is  difficulty  in  keeping  the  child  warm  he  should  be  rolled  in  cotton 
and  surrounded  by  hot  bottles,  or  kept  in  an  incubator  during  the  first 
few  weeks.  During  attacks  of  cyanosis  the  same  means  are  to  be  em- 
ployed as  in  cases  of  asphyxia  of  the  newly  born — cutaneous  stimulation 
and  artificial  respiration — the  administration  of  drugs  being  of  little  or 
no  value,  but  oxygen  may  be  of  assistance. 


CHAPTEK  in 

ICTERUS 

Several  varieties  of  icterus  are  met  with  in  the  newly  born. 
1.  It  is  often  seen  in  the  various  forms  of  pyogenic  infection.     In 
such  cases  the  icterus  is  usually  mild. 


78  DISEASES  OF  THE  NEWLY  BORN 

2.  It  may  be  due  to  congenital  malformations  of  the  bile-ducts. 

3.  It  may  depend  upon  interstitial  hepatitis. 

•i.  The  most  frequent  of  all  varieties  is  the  so-called  idiopathic 
icterus,  sometimes  spoken  of  as  physiological  icterus. 

In  the  cases  included  under  the  first  head  icterus  is  a  minor  symptom. 
The  other  varieties  are  sufficiently  important  to  require  separate  con- 
sideration. 

Malformations  of  th.e  Bile-ducts. — The  common  bile-duct  is  the  most 
frequently  affected.  There  may  be  atresia  at  the  point  Avhere  it  opens 
into  the  intestine,  the  duct  may  be  represented  by  a  fibrous  cord,  or  it 
may  be  absent  altogether.  In  many  cases  this  is  the  only  lesion ;  in  others 
it  is  associated  with  an  impervious  hepatic  or  cystic  duct ;  in  still  others 
the  common  duct  is  normal,  but  the  cystic  or  hepatic  ducts  are  imper- 
vious. 

At  autopsy  all  the  organs  are  usually  found  intensely  jaundiced,  par- 
ticularly the  liver.  In  recent  cases  this  is  very  much  swollen,  but  pre- 
sents no  marked  organic  changes.  In  cases  which  have  lasted  several 
months  there  is  commonly  found  chronic  interstitial  hepatitis,  sometimes 
to  a  very  marked  degree.  This  was  present  in  nine  of  the  fifty  cases 
collected  by  Thomson.  The  gall-bladder  is  usually  small,  and  often 
rudimentary.  In  cases  of  atresia  of  the  common  duct  it  may  be  greatly 
distended. 

The  condition  of  the  bile-ducts  is  ascribed  to  an  error  in  development 
and  subsequent  catarrhal  inflammation.  There  does  not  seem  to  be  suffi- 
cient evidence  to  prove  that  hereditary  syphilis  is  an  etiological  factor  of 
much  importance.     This  was  present  in  but  five  of  Thomson's  cases. 

Symptoms. — The  most  striking  symptom  is  Jaundice,  which  is  usually 
noticed  a  day  or  two  after  birth,  and  steadily  increases  until  it  becomes 
intense.  The  other  symptoms  of  obstructive  jaundice  are  present.  The 
urine  is  colored  a  dark  brown  or  bronze  by  bile  pigment,  the  stools  are 
white,  and  bile  pigment  is  absent  or  present  only  in  traces,  except  in 
cases  where  malformation  is  limited  to  the  cystic  duct.  The  liver  as  a 
rule  is  much  enlarged.  The  spleen  is  often  swollen.  Hemorrhages 
beneath  the  skin  or  from  any  of  the  mucous  membranes  are  quite  com- 
mon. Vomiting  is  usually  absent.  In  most  cases  there  is  progressive 
wasting,  and  death  from  inanition  within  the  first  few  weeks.  Of  Thom- 
son's fifty  cases,  nine  lived  less  than  a  month,  and  only  eighteen  over  four 
months.  Lotze  has  reported  a  case  of  a  child  living  eight  months  with  an 
impervious  hepatic  duct.  A  frequent  cause  of  death  in  the  more  rapid 
cases  is  convulsions. 

These  malformations  cannot  be  influenced  by  any  treatment. 

Interstitial  Hepatitis. — There  is  seen  in  newly-born  children  a  form 
of  icterus  which  resembles  the  foregoing  in  many  particulars,  but  which 


ICTEEUS  79 

may  end  in  recovery.  In  three  such  cases  which  have  terminated  fatally 
we  have  found  the  lesions  of  a  general  interstitial  hepatitis,  presumably 
of  syphilitic  origin.  It  is  not  certain  that  syphilis  is  always  the  cause  of 
this  condition,  for  the  clinical  history  in  some  of  them  gives  no  evidence 
of  this  disease.  While  not  a  common  condition  we  believe  it  to  be  more 
frequent  than  congenital  malformations  of  the  bile-ducts  with  which  it  is 
often  confounded. 

The  symptoms  and  course  may  be  illustrated  by  the  following  cases : 
A  full-term,  well-developed  child  of  eight  pounds'  weight  became  jaun- 
diced on  the  second  day.  By  the  fifth  day  the  jaundice  was  intense; 
stools,  pale  yellow,  and  urine  deeply  bile-stained.  Examination  at  three 
weeks  showed  both  liver  and  spleen  much  enlarged.  The  jaimdice  was 
very  marked  for  over  a  month ;  it  was  nearly  two  months  before  it  faded 
entirely.  The  nutrition  of  the  child  was  a  matter  of  much  difficulty  for 
several  weeks.  The  enlargement  of  the  spleen  and  liver  like  the  jaundice 
disappeared  very  gradually.  There  was  no  other  evidence  of  syphilis  in 
this  patient  nor  in  the  two  other  children  of  the  family,  and  no  history 
of  this  disease  could  be  obtained  in  the  parents.  Yet  the  improvement 
which  began  with  the  use  of  mercurial  inunctions  strongly  suggested  a 
syphilitic  lesion. 

In  another  case,  the  symptoms  and  course  of  which  were  almost 
identical,  the  stools,  though  nearly  white,  never  failed  to  give  the  reac- 
tion for  bile.  A  previous  child  in  this  family  had  died  three  years  before 
at  the  age  of  six  weeks  with  persistent  jaundice,  which  had  been  diag- 
nosticated congenital  malformation  of  the  bile-duct.  There  was  no  his- 
tory of  syphilis;  but  the  mercurial  inunctions  seemed  equally  efficacious 
as  in  the  first  case  cited. 

Not  much  need  be  added  to  the  symptoms  described.  In  our  cases 
which  recovered  and  in  the  fatal  cases  there  was  no  fever  and  no  ascites ; 
but  there  was  much  tympanites.  The  application  of  the  Wassermann  test 
will  no  doubt  aid  in  clearing  up  the  etiology  of  these  cases.  Other  evi- 
dences of  syphilis  should  always  be  carefully  sought,  but  in  all  the  cases 
we  have  seen,  even  those  ending  fatally  and  with  syphilitic  lesions  at 
autopsy,  clinical  evidence  of  syphilis  during  life  was  wanting.  A  careful 
trial  of  antisyphilitic  treatment  should,  therefore,  be  made  in  every  case 
of  protracted  jaundice  in  a  newly-born  child.  One  should  not  be  too 
ready  to  make  the  diagnosis  of  malformation  of  the  bile-ducts  and  regard 
the  case  as  hopeless.  Nor  does  the  fact  that  the  child  recovers  without 
antisyphilitic  treatment  exclude  syphilis  as  the  cause,  for  one  of  Still's 
cases  recovered  from  the  jaundice  and  died  at  the  age  of  nineteen  months, 
the  autopsy  showing  lesions  evidently  syphilitic. 

Physiolo^cal  or  Idiopathic  Icterus. — In  900  consecutive  births  at  the 
Sloane  Hospital  for  Women  icterus  was  noted  in  300  cases.    In  88  it  was 


80  DISEASES  OF  THE  NEWLY  BORN 

intense^  in  212  it  was  mild.  According  to  the  statistics  of  various  lying- 
in  hospitals  of  Germany,  it  was  found  in  from  40  to  80  per  cent  of  all 
infants.  In  the  300  cases  just  referred  to,  icterus  was  noticed  on  the 
first  day  in  4,  on  the  second  day  in  19,  on  the  third  day  in  72,  on  the 
fourth  day  in  86,  on  the  fifth  day  in  67,  and  on  or  after  the  sixth  day 
in  44.  From  the  second  to  the  fifth  day  is  therefore  the  usual  period  for 
its  appearance. 

It  usually  increases  in  severity  for  one  or  two  days  and  then  slowly 
disappears.  The  average  duration  in  the  mild  cases  is  three  or  four  days ; 
in  those  of  moderate  severity  about  a  week;  in  the  most  severe  cases  it 
lasts  many  weeks.  Icterus  neonatorum  is  regularly  found  in  premature 
and  very  delicate  infants.  The  course  with  them  is  also  more  prolonged 
and  the  icterus  usually  more  severe. 

The  icterus  is  first  noticed  in  the  skin  of  the  face  and  chest,  then  in 
the  conjunctivae,  then  in  the  extremities.  The  skin  varies  in  color  from 
a  pale  to  an  intense  yellow.  The  urine  in  most  cases  is  normal.  It  some- 
times is  of  a  light  brown  color,  and  only  in  the  most  severe  cases  does  it 
contain  bile  pigment  in  appreciable  amount.  The  stools  are  unchanged, 
the  normal  yellow  evacuations  occurring  in  the  icteric  as  early  as  in 
those  not  afEected. 

According  to  some  observers,  in  infants  who  are  icteric  the  initial 
loss  in  weight  is  greater  and  the  subsequent  gain  slower  than  in  other 
children.  This  is  not  borne  out  by  the  Sloane  statistics.  The  proportion 
of  icteric  infants  who  did  well,  moderately  and  badly,  was  practically  the 
same  as  of  the  other  children  in  the  institution  not  suffering  from  icterus. 
Icterus  occurs  with  equal  frequency  in  both  sexes.  There  are  usually  no 
other  symptoms  than  icterus,  and  the'  condition  is  practically  never 
serious,  though  a  prolonged  course  may  occasion  some  concern.  With  the 
premature  and  poorly  nourished  it  is  the  general  condition  and  not  the 
icterus  that  is  dangerous.  Very  rarely  a  severe  and  fatal  form  of  icterus 
is  seen  affecting  successively  several  infants  in  a  family.  Death  takes 
place  in  a  few  days  without  sufficient  pathological  evidence  to  explain  the 
cause. 

In  jaundiced  infants  who  have  died  from  accident  or  other  causes  the 
skin  and  almost  all  the  internal  organs  are  found  icteric.  There  is  stain- 
ing of  the  internal  coat  of  the  arteries,  the  endocardium,  the  pericardium 
and  the  pericardial  fluid.  The  subcutaneous  connective  tissue  is  yellow ; 
the  spleen  and  kidneys  only  in  the  severe  cases.  The  liver  is  slightly 
discolored.  The  bile  ducts  are  normal.  There  may  be  small  hemor- 
rhages, especially  on  the  serous  surfaces.  The  brain  and  cord  are  rarely, 
and  the  cerebrospinal  fluid  never,  bile  stained. 

Few  subjects  have  given  rise  to  wider  speculation  than  this  form  of 
icterus.    It  has  been  held  that  it  is  due  to  obstruction  from  tliick  bile  in 


ICTERUS  81 

the  bile  ducts,  to  extensive  blood  changes,  and  to  various  other 
causes. 

The  researches  of  Yllpo  have  shown  that  in  the  last  month  of  fetal 
life  there  is  an  increased  production  of  bile  pigment.  Even  at  birth 
the  blood  contains  three  or  four  times  the  amount  that  the  maternal  blood 
contains.  After  birth  there  is  a  very  rapid  increase  in  the  pigment 
content  of  the  blood  which  usually  lasts  from  three  days  to  a  week;  ex- 
ceptionally for  several  weeks.  At  the  end  of  a  few  days  the  blood  may 
contain  twenty  times  as  much  pigment  as  at  birth.  Usually  after  a 
few  days  the  pigment  in  the  blood  diminishes,  rapidly  at  first,  then 
more  slowly.  The  normal  is  not  reached  for  several  weeks.  All  infants 
show  this  increased  amount  of  bile  pigment.  Those  that  subsequently 
develop  icterus  have  at  birth  a  greater  bilirubin  content  in  the  blood 
and  also  produce  more  pigment  subsequently.  Icterus  is  noticeable 
when  the  blood  contains,  roughly,  125  mgm.  of  pigment  to  each  100  cc. 
of  blood.  The  cause  of  the  increased  production  of  pigment  is  not  en- 
tirely clear.  There  is  not  yet  sufficient  evidence  that  it  is  due  to  the 
destruction  of  the  red  blood  cells.  Only  a  slight  amount  of  the  pigment 
•  can  be  excreted  by  the  kidney.  It  is  most  probable  that  the  liver  at 
this  early  stage  of  development  is  unable  to  remove  the  excess  of  pig- 
ment from  the  blood.  This  accumulates  and  when  it  reaches  a  certain 
concentration  in  the  blood,  causes  appreciable  icterus.  With  the  cessa- 
tion of  the  blood  destruction  and  the  increase  in  functional  activity  of 
the  liver,  the  pigment  is  removed.  The  difference  in  the  icteric  and  the 
non-icteric  infant  is  one  only  of  degree.  It  is  quite  proper  in  such 
circumstances  that  the  condition  should  be  spoken  of  as  "physiological 
icterus." 

Diagnosis  of  the  Different  Varieties  of  Icterus. — The  diagnosis  of 
physiological'  icterus  is  to  be  made  from  malformations  of  the  bile- 
ducts,  and  interstitial  hepatitis.  In  early  sepsis  it  is  doubtful  if  the 
infection  produces  the  icterus.  It  is  more  likely  that  the  two  conditions 
are  associated.  In  the  later  sepsis  jaundice  may  be  due  to  an  hepatic 
lesion,  usually  multiple  abscesses.  In  malformations  of  the  bile-ducts 
the  icterus  is  usually  more  intense  and  appears  almost  immediately  after 
birth;  bile  is  abs_ent  from  the  stools;  the  icterus  is  persistent,  and  the 
symptoms  go  progressively  from  bad  to  worse,  always  ending  fatally. 
In  interstitial  hepatitis  the  icterus  develops  at  about  the  same  time  as, 
but  is  generally  more  marked  than,  in  the  physiological  variety.  Both 
Liver^and  spleen  are  usually  enlarged.  The  stools  may  be  light  colored, 
but  still  give  a  faint  bile  reaction. 

Physiolo^cal  icterus  requires  no  treatment. 


82  DISEASES  OF  THE  NEWLY  BORN 

CHAPTER   IV 

THE  ACUTE  INFECTIONS  OF  THE  NEWLY  BORN 

It  is  possible  for  the  newly-born  infant  to  suffer  from  almost  any  of 
the  common  infectious  diseases.  Smallpox  probably  has  been  most  fre- 
quently observed.  Earely  pertussis,  influenza,  measles,  typhoid  fever, 
malaria,  and  pneumonia  have  occurred  in  the  first  days  of  life.  As  the 
mothers  in  many  instances  were  suffering  from  the  diseases  during  or 
just  prior  to  delivery,  the  infants  appear  to  have  been  infected  before 
birth  through  the  circulation  of  the  mother.  In  other  cases,  especially 
in  pneumonia,  influenza,  and  gastro-enteritis,  infection  may  take  place 
soon  after  birth.  The  symptoms  of  these  diseases  in  the  newly  born 
differ  very  little  from  those  occurring  in  any  other  young  infant.  In 
addition  to  the  diseases  mentioned,  there  are  other  forms  of  infection 
which  belong  especially — some  of  them  exclusively — ^to  the  newly  born. 

THE  ACUTE  PYOGENIC  DISEASES 

Under  this  head  are  grouped  various  infections  of  the  newly  born, 
due  to  the  entrance  of  the  common  pyogenic  bacteria.  They  have  been 
designated  as  puerperal  fever  of  the  child,  also  as  pyemia  or  septicemia, 
or  simply  as  sepsis  of  the  newly  horn.  A  variety  of  pathological  and 
clinical  conditions  are  met  with.  In  some  cases  there  is  only  a  localized 
external  inflammation,  often  terminating  in  abscess  formation;  some- 
times one  or  more  of  the  internal  organs  is  affected ;  occasionally  a 
general  blood  infection — a  true  septicemia — is  seen  without  any  note- 
worthy local  lesion;  finally,  there  are  the  cases  attended  by  the  pro- 
duction of  multiple  abscesses  in  the  viscera,  joints,  or  cellular  tissue 
— a  true  pyemia.  Formerly  infections  of  this  class  were  very  com- 
mon, especially  in  large  lying-in  hospitals;  but,  owing  to  the  general 
adoption  of  the  methods  of  aseptic  midwifery,  they  have  steadily  dimin- 
ished. 

Etiology. — The  source  of  infection  of  the  child  may  be  the  vaginal 
secretion  of  the  mother  or,  in  very  rare  cases,  the  mother's  milk.  Although 
it  has  been  shown  that  in  a  great  proportion  of  the  cases  the  milk  of  a 
woman  suffering  from  mastitis  or  from  septicemia  contains  pyogenic 
germs,  still  the  taking  of  these  into  the  stomach  is  not  likely  to  infect 
the  infant.  More  frequently  the  child  is  infected  by  the  nurse  in  the 
process  of  dressing  the  cord,  bathing,  or  cleansing  the  mouth  or  eyes, 
possibly  after  having  attended  to  the  needs  of  a  septic  mother  or  another 


ACUTE  PYOGENIC  DISEASES  83 

child.  Infection  may  be  carried  by  the  physician,  by  instruments,  or  by 
the  dressings  of  the  cord.  Infection  may  occur  through  any  wound  or 
abrasion  of  the  skin. 

Infection  through  the  umbilicus  may  take  place  either  before  or  after 
the  separation  of  the  cord.  The  infection  may  take  place  through  the 
umbilicus,  yet  this  may  give  no  external  evidence  of  dised,se,  although 
the  umbilical  vessels  inside  the  body  may  contain  pus.  From  this  focus 
of  infection  may  arise  peritonitis,  meningitis,  or  other  inflammations. 
Entering  through  the  mouth,  bacteria  may  lead  to  infectious  processes 
in  the  throat,  the  stomach  or  intestines,  and  rapidly  produce  death;  or 
the  alimentary  tract  may  be  the  focus  from  which  infection  of  distant 
parts  may  arise. 

The  microorganisms  chiefly  concerned  in  these  infections  are  the 
common  pyogenic  bacteria,  staphylococcus  pyogenes  aureus  and  the  strep- 
tococcus. The  next  in  importance  is  the  gonococcus,  the  role  of  which, 
especially  in  cases  accompanied  by  joint  suppuration,  has  only  recently 
been  appreciated.  Pneumococcus  infections  occasionally  complicate  the 
others  mentioned.  While  streptococcus  infections  are  in  general  more 
serious  than  those  due  to  the  staphylococcus,  some  of  the  most  severe 
ones  met  with  belong  to  the  latter  class. 

Clinical  Varieties. — Omphalitis. — In  this  variety  there  is  inflamma- 
tion of  the  umbilicus,  and  cellulitis  of  the  abdominal  wall  in  the  im- 
mediate neighborhood.  This  results  in  the  formation  of  an  umbilical 
phlegmon.  It  may  terminate  in  resolution,  in  abscess,  or  in  gangrene. 
The  usual  termination  is  in  abscess.  These  abscesses  may  be  small  and 
superficial,  or  they  may  be  more  deeply  seated  l^etween  the  abdominal 
muscles  and  the  peritoneum.  Omphalitis  usually  begins  in  the  second 
or  third  week  of  life,  before  the  umbilicus  has  cicatrized.  The  process 
may  result  in  erysipelatous  inflammation  and  it  may  spread  to  the  peri- 
toneum. 

Inflammation  of  the  Umbilical  Vessels. — This  is  one  of  the  most 
frequent  primary  processes  in  pyemic  infection.  The  umbilical  arteries 
are  more  frequently  involved  than  the  vein.  According  to  Eunge,  in- 
flammation of  the  vessels  is  always  preceded  by  inflammation  of  the 
connective  tissue  which  surrounds  them,  as  the  poison  is  taken  up  by  the 
lymphatics  and  not  by  the  blood-vessels.  Omphalitis  is  frequently  pres- 
ent, but  in  some  cases  the  umbilicus  shows  nothing  abnormal. 

In  arteritis  the  vessels  may  be  involved  to  any  degree:  sometimes 
only  a  short  distance  from  the  abdominal  wall,  sometimes  quite  to  the 
liver.  They  contain  pus,  and  often  septic  thrombi.  Saccular  dilata- 
tion is  frequently  present  at  several  points.  Pus  sometimes  exudes  from 
the  umbilical  stump  on  pressure.  The  other  lesions  accompanying 
arteritis  are  those  of  pyemic  infection,  more  or  less  widely  distributed. 


84  DISEASES  OF  THE  NEWLY  BORN 

There  are  frequently  present  peritonitis,  suppuration  of  the  joints,  ery- 
sipelas, multiple  abscesses  of  the  cellular  tissue,  sometimes  suppurative 
parotitis.  Atelectasis  is  common.  Pneumonia  was  found  in  twenty-two 
of  Eunge's  fifty-five  cases. 

In  cases  of  phlebitis,  the  umbilical  vein  is  usually  involved  for  its 
entire  length  from  the  abdominal  wall  to  the  liver.  This  may  lead  to 
an  acute  interstitial  hepatitis  going  on  to  suppuration,  or  to  phlebitis 
of  the  portal  vein  and  some  of  its  branches.  In  either  case  there  is 
more  or  less  parenchymatous  hepatitis,  and  often  multiple  abscesses  of 
the  liver,  most  of  the  patients  being  jaundiced.  Peritonitis  also  is  a  fre- 
quent complication. 

PeritonHis. — This  is  one  of  the  most  frequent  pathological  processes 
in  pyemic  infection,  and  is  very  often  the  cause  of  death.  It  is  generally 
associated  with  umbilical  arteritis,  and  often  with  erysipelas.  In  a 
considerable  number  of  cases  it  is  the  most  important  lesion  found. 
It  may  be  localized  or  general.  Localized  peritonitis  is  generally  in 
the  neighborhood  of  the  umbilicus  or  of  the  liA'er.  It  may  result  in 
adhesions,  or  in  the  formation  of  peritoneal  abscesses.  More  frequently 
the  peritonitis  is  general  and  resembles  the  septic  peritonitis  of  adults. 
There  is  a  great  outpouring  of  fibrin  coating  the  intestines  and  other 
viscera  and  the  inner  surface  of  the  abdominal  wall,  causing  adhesions 
between  the  abdominal  contents.  Collections  of  sero-pus  are  found  in 
the  pelvis  and  in  various  pockets  formed  by  the  adhesions.  Sometimes 
blood  is  present  in  the  exudation. 

The  special  symptoms  which  indicate  peritonitis  are  vomiting,  ab- 
dominal tenderness  and  distention,  and  protrusion  of  the  umbilicus. 
The  abdominal  enlargement  is  chiefly  from  gas,  but  may  be  partly  from 
fluid.  There  are  present  thoracic  respiration,  dorsal  decubitus,  flexion 
of  the  thighs  and  fixation  of  all  the  muscles,  the  child  lying  perfectly 
quiet.  The  temperature  is  usually  but  not  necessarily  high.  Marked 
leucocytosis  is  generally  present. 

Pneumonia. — The  most  common  form  seen  is  pleuropneumonia. 
There  is  an  abundant  exudate  of  grayish-yellow  fibrin  covering  the 
lung.  Occasionally  collections  of  pus  are  found  in  the  sacs  formed  by 
the  adhesions.  Serous  effusions  are  rare.  The  pulmonary  lesion  consists 
usually  in  a  bronchopneumonia,  with  consolidation  of  larger  or  smaller 
areas  in  the  lungs — more  often  in  the  upper  than  in  the  lower  lobes. 
It  is  not  uncommon  for  minute  abscesses  to  be  found  in  the  lung  at 
various  points.  There  is  a  purulent  bronchitis  of  the  larger  and  smaller 
tubes. 

The  symptoms  are  obscure  and  often  indefinite.  The  only  character- 
istic ones  are  cyanosis  and  rapid  respiration,  with  recession  of  the  chest 
walls  on  inspiration.     The  physical  signs  are  inconstant  and  uncertain. 


ACUTE  PYOGENIC  DISEASES  85 

Pneumonia  often  can  not  be  diagnosticated  during  life.  In  most  of  the 
fatal  cases  of  pyogenic  infection,  whatever  its  type,  there  is  found  some 
involvement  of  the  lungs.  The  changes  are  most  extensive  in  cases  in 
which  the  serous  membranes  are  involved. 

Pericarditis  is  rare  and  usually  associated  with  pleurisy.  Endocar- 
ditis is  very  rare.     Hirst  has,  hoAvever,  reported  a  case. 

Meningitis. — When  meningitis  is  present  it  is  often  associated  Avith 
peritonitis  or  Avith  pleurisy.  The  lesions  are  those  of  acute  purulent 
meningitis  Avith  a  copious  exudation,  sometimes  associated  with  menin- 
geal hemorrhages,  or  with  acute  encephalitis  and  the  production  of 
multiple  minute  abscesses  in  the  cortex.  The  local  symptoms  are  often 
not  marked,  and  are  sometimes  A'ery  obscure.  The  most  characteristic 
are  stupor,  dilated  pupils,  opisthotonus,  bulging  fontanel,  general  rigid- 
ity, convulsions,  and  occasionally  localized  paralyses.  The  temperature 
is  generally  high.  A  positive  diagnosis  can  generally  be  made  by  lumbar 
puncture,  by  Avhich  means  also  the  exciting  cause  of  the  meningitis  can 
usually  be  determined. 

Gastro-enteritis. — Diarrhea  is  a  frequent  symptom  in  all  septic  cases, 
constipation  being  rarely  present.  In  many  instances  vomiting  is  a 
prominent  symptom.  In  a  sinall  proportion  of  cases  the  most  important 
local  lesions  are  in  the  intestines,  generally  in  the  nature  of  a  superficial 
catarrhal  inflammation. 

Stomatitis. — Infections  of  the  oral  mucous  membranes  are  not  in- 
frequent but  sometimes  very  severe.  They  may  be  due  to  the  strepto- 
coccus, staphylococcus  aureus  or  the  gonococcus.  An  occasional  compli- 
cation of  oral  infections  is  abscess  of  the  parotid. 

Osteomyelitis. — Allard  has  reported  a  series  of  cases  in  which,  after 
the  general  and  local  symptoms  of  pyogenic  infection  had  existed  for 
some  time,  suppuration  occurred  over  various  bones,  especially  the 
humerus,  tibia,  metatarsal  bones,  sacrum,  etc.  Trephining  revealed  the 
lesions  of  osteomyelitis.  The  abscesses  usually  made  their  appearance 
between  the  fourth  and  the  sixth  Aveek.  The  most  rapid  case  terminated 
fatally  on  the  fourteenth  day,  and  none  lasted  more  than  tAvo  and  a  half 
months. 

Joint  Suppuration. — In  certain  pyemic  cases,  and  in  some  in  Avhicli 
there  are  no  other  symptoms,  acute  suppuration  in  the  Joints  occurs. 
This  may  come  on  very  acutely  in  the  first  or  second  Aveek,  or  more 
slowly  as  late  as  the  second  or  third  month.  In  the  acute  cases  it  is 
exceptional  to  have  but  one  joint  involved ;  frequently  there  are  four  or 
five.  The  small  Joints  are  rather  oftener  affected  than  the  large  ones, 
but  almost  any  articulation  in  the  body  may  be  involved.  With  multi- 
ple Joint  suppuration  there  are  present  the  general  symptoms  of  pyemia 
— high  temperature,  marked  prostration,  wasting,  and  usually  secondary 


86  DISEASES  OF  THE  NEWLY  BOEN 

visceral  inflammations  develop.  In  those  which  occur  late,  or  which 
develop  more  slowly,  fewer  joints  are  involved,  often  but  a  single  one, 
the  febrile  symptoms  are  less  marked  or  wanting.  In  our  own  experience, 
the  organism  most  frequently  found  in  these  cases  is  the  gonococcus; 
next  to  this  in  importance  is  the  streptococcus  and  occasionally  the 
pneumococcus  is  found.  The  joint  lesion  is  usually  a  superficial  one, 
the  bones  generally  escaping.  The  gonococcus  cases  probably  occur  most 
frequently  as  a  complication  of  ophthalmia ;  but  we  have  seen  several  in 
which  ophthalmia  was  not  present  and  where  the  point  of  entry  could 
not  be  determined. 

Many  of  the  abscesses  supposed  to  be  in  the  joints  are  shown  at  opera- 
tion to  be  at  the  epiphyses;  from  this  source  the  joints  may  be  involved 
secondarily.  A  point  to  be  remembered  in  the  diagnosis  of  these  joint 
inflammations  is  their  resemblance  to  the  epiphysitis  of  hereditary  syph- 
ilis and  other  symptoms  of  that  disease  should  be  looked  for.  The  con- 
fusion is  increased  by  the  fact  that  in  syphilitic  cases  abscesses  may 
follow  as  a  consequence  of  a  secondary  infection. 

Abscesses  in  the  Cellular  Tissue. — These  are  quite  frequent,  and  may 
occur  with  suppuration  in  the  joints  or  the  Internal  organs,  or  they  may 
exist  as  the  only  lesion.  They  are  nearly  always  multiple  and  may  be 
found  in  almost  any  location.  They  vary  in  size  from  one  containing 
a  few  drops  to  half  an  ounce  of  pus.  They  are  due  to  the  introduction 
of  pyogenic  germs,  usually  staphylococci.  Their  course  is  benign,  and 
they  require  no  treatment  except  incision  and  cleanliness.  When  there 
is  a  disposition  to  their  continued  formation,  the  skin  should  be  washed 
with  an  antiseptic  solution  and  vaccines  should  be  administered. 

Erysipelas. — This  is  seen  especially  during  the  first  two  weeks  of 
life  and  usually  starts  from  the  umbilicus  or  some  abrasion  of  the  skin, 
most  frequently  about  the  genitals  or  the  scalp.  When  originating  at 
the  umbilicus  it  is  generally  complicated  by  other  lesions,  such  as  peri- 
tonitis and  umbilical  phlebitis.  If  it  starts  from  any  other  part  of  the 
body  it  may  be  uncomplicated.  Erysipelas  beginning  at  the  umbilicus 
gives  rise  to  an  area  of  induration  and  a  circumscribed  erythema.  At 
first  it  may  resemble  a  simple  cellulitis ;  but  the  steadily  increasing  area 
of  elevated  induration  and  redness  soon  indicates  the  nature  of  the  in- 
flammation. From  whatever  point  starting,  the  erysipelatous  inflam- 
mation, owing  to  the  feeble  resistance  of  the  tissues,  in  most  cases 
spreads  widely.  The  entire  abdomen,  chest,  and  back  may  be  involved, 
and  it  may  even  spread  to  the  extremities.  Nearly  the  whole  trunk  may 
be  affected  in  four  or  five  days.  It  usually  involves  only  the  skin  and 
superficial  cellular  tissue;  but  it  may  involve  the  deeper  areolar  planes 
and  terminate  in  diffuse  suppuration,  or  even  in  gangrene. 

The  constitutional  symptoms  are  severe:  great  prostration,  continu- 


ACUTE  PYOGENIC  DISEASES  -  87 

ously  high  temperature — 102°  to  105°  F. — rapid  wasting,  and  frequently- 
vomiting,  diarrhea,  or  convulsions  are  present.  The  disease  is  always 
serious^  and  usually  fatal.  It  is  often  complicated  by  bronchopneu- 
monia. General  edema  of  the  affected  parts  may  persist  for  a  few  weeks 
after  the  inflammation  subsides. 

Distribution  of  the  Lesions. — The  frequency  of  the  difl'erent  visceral 
lesions  in  eighty-seven  autopsies  published  by  Bednar  was  as  follows: 
Peritonitis  in  twenty-nine,  pneumonia  in  fifteen,  pleurisy  in  ten,  menin- 
gitis in  nine,  meningeal  hemorrhage  in  eight,  encephalitis  in  eight,  cere- 
bral hemorrhage  in  four,  enterocolitis  in  five,  pericarditis  in  four.  In 
thirty-one  cases  there  was  umbilical  arteritis,  and  in  nine  cases  umbilical 
phlebitis.  There  was  one  case  each  of  pulmonary  hemorrhage,  pleural 
hemorrhage,  acute  hydrocephalus,  acute  bronchitis,  and  suppuration  in 
the  cellular  tissue.  Eunge's  later  observations  of  thirty-six  cases  showed 
umbilical  arteritis  in  thirty,  umbilical  phlebitis  in  three,  and  normal 
umbilicus  in  three.  He  found  pneumonia  in  twenty-two  of  fifty-five 
cases.  Other  lesions  frequently  associated  are  atelectasis,  swelling  and 
softening  of  the  spleen,  cloudy  swelling  of  the  liver  and  kidneys,  occa- 
sionally with  foci  of  suppuration  in  these  organs. 

General  Symptoms. — These  may  begin  at  any  time  during  the  first 
ten  days — very  rarely  after  the  twelfth  day.  Fever  is  an  exceedingly 
variable  symptom — it  may  be  very  high;  it  may  be  almost  absent;  oc- 
casionally there  is  subnormal  temperature.  The  course  of  the  tempera- 
ture is  very  irregular.  Wasting  is  constant  and  quite  rapid.  It  depends 
upon  the  inability  to  take  and  digest  food,  upon  the  intestinal  complica- 
tions, and  upon  infection.  In  quite  a  number  of  cases  wasting  is  almost 
the  only  symptom.  Icterus  is  common;  in  many  of  the  worst  cases  it 
is  intense.  It  is  met  with  where  the  liver  is  the  seat  of  an  acute  paren- 
chymatous or  acute  suppurative  inflammation,  and  in  many  other  cases 
where  it  depends  apparently  upon  the  blood  changes.  Hemorrhages 
are  common,  and  may  be  the  direct  cause  of  death.  They  may  come 
from  the  umbilicus,  the  intestine,  or  almost  any  mucous  membrane. 
They  are  sometimes  subcutaneous,  causing  a  general  hemorrhagic  erup- 
tion. Nervous  symptoms  are  generally  present,  and  are  sometimes 
marked.  They  are  restlessness,  rolling  of  the  head,  a  constant  whining 
cry,  twitchings  of  the  muscles  of  the  extremities  or  face,  stiffening  of 
the  body,  more  rarely  general  convulsions.  Late  in  the  disease,  dulness 
and  stupor  are  present.  The  pulse  is  rapid  and  weak  and  the  respirations 
are  often  irregular,  even  when  there  is  no  cerebral  complication.  Diar- 
rhea is  frequent;  the  stools  are  green,  brown,  sometimes  black  from 
the  presence  of  blood,  and  are  often  very  foul.  Vomiting  is  less  com- 
mon. In  addition  to  these  there  are  symptoms  due  to  the  various  forms 
of  local   inflammation — peritonitis,   meningitis,   pneumonia,   erysipelas, 


88  DISEASES  OF  THE  NEWLY  BORN 

subcutaneous  suppuration  and  gangrene,  these  all  being  found  in  vary- 
ing degrees  and  in  various  combinations. 

Prophylaxis. — Pyogenic  infection  of  the  child,  like  puerperal  fever  in 
the  mother,  may  be  considered  a  preventable  disease.  Its  occurrence  is 
usually  due  to  a  failure  to  carry  out  proper  rules  regarding  cleanliness 
and  asepsis  in  connection  with  delivery.  The  statistics  of  the  Moscow 
Lying-in  Asylum,  published  by  Miller  in  1888,  show  that  previous  to 
the  general  introduction  of  aseptic  methods,  from  six  to  eight  per  cent 
of  all  infants  born  in  the  institution  died  from  some  variety  of  infection. 
In  twenty-three  hundred  successive  labors  at  the  Sloane  Hospital  for 
Women,  covering  about  eight  years,  not  a  single  marked  case  occurred. 
From  these  figures  it  will  be  evident  that  in  the  vast  majority  of  cases 
the  occurrence  of  a  case  of  infection  of  a  serious  nature  is  the  fault  of 
the  physician  or  nurse  in  attendance. 

The  umbilicus  should  be  cleansed  and  treated  like  any  other  fresh 
wound.  Dry  dressing  should  invariably  be  employed,  and  sterilized 
gauze  or  salicylated  cotton  in  preference  to  household  linen.  If  suppu- 
ration occurs  at  the  time  the  cord  separates,  the  parts  should  be  cleansed 
daily  with  a  bichlorid  solution,  and  a  wet  dressing  of  the  same  applied. 
The  ligatures  and  everything  which  comes  in  contact  with  the  umbilical 
wound  should  be  sterilized.  Careful  attention  should  be  given  to  the 
mouth,  genitals,  and  all  the  mucocutaneous  surfaces,  to  prevent  excoria- 
tions and  intertrigo.  Finally,  every  septic  case  occurring  in  an  insti- 
tution should  be  immediately  isolated.  A  nurse  in  charge  of  a  septic 
mother  should  not  have  the  care  of  the  infant. 

Prognosis. — Pyogenic  infections  in  the  newly  born,  even  in  their 
mildest  forms,  are  serious,  and  in  their  most  severe  forms  almost  always 
fatal.  Very  few  cases  recover  in  which  erysipelas  or  any  important 
visceral  inflammation  is  present.  The  resistance  of  these  patients  is  so 
feeble  that  the  tendency  of  every  inflammation  is  to  spread,  until  they 
die  from  exhaustion.  Only  patients  with  localized  inflammations,  such 
as  those  of  joints,  skin,  etc.,  are  likely  to  get  well. 

Treatment. — This  practically  resolves  itself  into  the  treatment  of  in- 
dividual symptoms  as  they  arise.  Wherever  suppuration  occurs,  external 
abscesses  should  be  evacuated  and  treated  antiseptically.  For  the  local 
inflammations  of  the  lungs,  peritoneum,  and  brain,  little  or  nothing  can 
be  done  in  the  way  of  direct  treatment.  Such  inflammations  are  to  be 
prevented,  but  can  seldom  be  cured.  The  general  indications  are  to  look 
closely  to  the  child's  general  nutrition  by  careful  attention  to  all  details 
of  nursing  and  feeding,  using  stimulants  whenever  required  by  the  con- 
dition of  the  circulation.  For  a  local  application  in  erysipelas,  nothing  in 
our  experience  has  proven  better  than  ichthyol  ointment,  ten  to  twenty- 
five  per  cent  strength.    It  should  be  applied  daily,  spread  upon  muslin, 


OPHTHALMIA  89 

which  is  then  covered  by  gutta-percha  tissue  to  prevent  drying.  Vac- 
cines have  been  much  employed  in  erysipelas ;  our  own  experience,  how- 
ever, coincides  with  that  of  most  observers  that  there  is  very  little  evi- 
dence that  they  have  any  value. 

OPHTHALMIA 

Ophthalmia  of  the  newly  born  is  to  be  classed  among  the  pyogenic 
diseases.  It  usually  consists  in  a  purulent  conjunctivitis.  In  the  more 
severe  cases  there  may  be  ulceration  of  the  cornea,  and  even  perforation 
into  the  anterior  chamber  of  the  eye. 

The  highly  infectious  nature  of  this  ophthalmia  is  established.  In 
the  most  severe  cases  the  microb'^ganism  generally  found  has  been  the 
gonococcus;  but  in  the  milder  forms  the  gonococcus  may  be  absent,  and 
any  of  the  common  pyogenic  germs  may  be  found.  In  the  gonococcus 
cases  the  infection  occurs  during  labor,  from  the  secretions  of  the 
mother,  from  the  examining  lingers  of  the  physician,  or  from  instru- 
ments; or  after  birth  from  infected  cloths  and  other  materials  which 
come  in  contact  with  the  eye.  Healthy  lochia  produce  only  a  catarrhal 
inflammation.  The  infection  occurring 'after  birth  may  take  place  at 
any  time.  That  due  to  gonococcus  infection  from  the  mother  is  gen- 
erally manifested  on  the  third  day,  and  is  often  virulent  from  the  outset. 

The  symptoms  are,  swelling  of  the  lids,  chemosis,  copious  purulent 
discharge,  sometimes  hemorrhages  from  the  lids,  ulceration,  and  there 
may  even  be  sloughing  of  the  cornea.  The  course  of  the  disease  depends 
upon  the  cause  and-  upon  the  treatment  employed.  In  the  cases  not 
due  to  the  gonococcus  the  course  is  generally  benign,  and  with  ordinary 
cleanliness  usually  ends  in  recovery  without  any  permanent  damage 
to  the  sight.  The  gonococcus  cases,  unless  energetically  treated  from 
the  outset,  are  very  frequently  followed  by  permanent  loss  of  vision.  The 
best  statistics  upon  the  causes  of  blindness  in  adults  show  that  from 
twenty-five  to  thirty  per  cent  of  such  cases  are  due  to  ophthalmia  in 
the  newly  born.  This  disease  is  occasionally  complicated  by  other  symp- 
toms of  gonococcus  infection  of  a  pyemic  nature.  Many  cases  followed 
by  acute  articular  symptoms  have  been  observed. 

Prophylaxis  is  of  the  utmost  importance.  Crede's  statistics  show  that 
in  187-i  the  frequency  of  ophthalmia  in  his  lying-in  hospital  was  13.6 
per  cent.  In  the  three  years  ending  1883,  among  1,1  (JO  newly-l)orn 
children,  only  one  or  two  cases  occurred.  The  method  of  prophylaxis 
which  he  adopted  consists  in  dropping  into  the  eyes  of  every  child,  im- 
mediately after  birth,  one  or  two  drops  of  a  two-per-cent  solution  of 
nitrate  of  silver.  The  general  adoption  of  Crede's  method,  or  of  some 
similar  means  of  disinfection,  has  resulted  in  a  very  great  diminution  in 


90  DISEASES  OF  THE  NEWLY  BORN 

the  frequency  of  ophthalmia  throughout  the  world.  Tliese  prophylactic 
means  should  be  obligatory  in  all  institutions,  and  should  be  used  in 
all  cases  in  private  practice  wherever  there  is  any  possible  suspicion  of 
the  existence  of  gonorrhea.  In  all  other  cases  the  eyes  should  be  care- 
fully cleansed  vl^ith  a  ten-per-cent  solution  of  argyrol.  The  use  before 
delivery  of  an  antiseptic  vaginal  douche  is  theoretically  indicated;,  but 
practically  it  has  been  found  to  be  inadequate  for  the  prevention  of  the 
disease. 

Treatment. — Everything  which  comes  in  contact  with  the  eyes  should 
be  carefully  disinfected.  All  cloths,  cotton,  etc.,  used  for  cleansing 
should  be  immediately  burned.  The  strictest  antiseptic  precautions 
should  be  insisted  on  to  prevent  the  spread  of  the  infection  by  nurses. 
In  institutions  containing  infants,  severe  cases  of  ophthalmia  should 
always  be  isolated.  The  most  important  thing  is  to  keep  the  eyes  clean. 
In  severe  cases  they  must  be  cleansed  every  twenty  minutes,  night  and 
day.  It  may  be  done  by  irrigation,  or  by  using  an  eye-dropper  with  a 
bulbous  tip,  inserted  alternately  at  the  inner  and  the  outer  angle .  of 
the  eye,  and  the  fluid  injected  with  force  sufficient  to  empty  thoroughly 
the  conjunctival  sac.  Either  a  saturated  solution  of  boric  acid,  or  a 
1-5,000  solution  of  bichlorid,  may  be  used  in  this  way.  Once  or  twice 
in  twenty-four  hours  two  or  three  drops  of  a  ten-per-cent  solution  of 
argyrol  should  be  used  in  each  eye  after  cleansing  with  sterile  water. 
Next  to  these  measures  is  the  use  of  cold.  It  may  be  applied  as  ice 
compresses  which  are  changed  every  minute  or  two  from  a  block  of  ice 
to  the  eye.  These  may  be  continued  one-fourth  of  the  time  in  the  milder 
cases ;  in  the  severe  ones  almost  constantly.  Wlien  the  cornea  is  involved 
the  pupil  should  be  dilated  by  atropin.  If  only  one  eye  is  affected  the 
sound  one  should  be  protected  by  covering  it  with  a  compress  kept  wet 
with  an  antiseptic  solution. 

TETANUS 

Tetanus  is  an  acute  infectious  disease  characterized  by  tonic  muscular 
spasm,  which  increases  in  severity  by  paroxysms  occurring  at  longer  or 
shorter  intervals.  It  may  be  limited  to  the  muscles  of  the  jaw  (trismus), 
or  may  affect  all  the  muscles  of  the  trunk,  extremities,  and  neck. 

The  germ  of  tetanus  usually  gains  access  to  the  body  of  the  infant 
through  the  umbilical  wound.  It  exists  in  the  soil,  and  the  disease 
prevails  endemically  in  certain  localities.  It  is  common  in  certain  parts 
of  Long  Island  and  New  Jersey.  Among  the  negroes  in  some  parts  of 
the  South  it  has  for  many  years  occurred  with  great  frequency.  It  is 
stated  that  on  one  of  the  islands  of  the  Hebrides  every  fourth  or  fifth 
child  dies  of  tetanus.    In  a  single  house  in  Copenhagen  eighteen  cases 


TETANUS  91 

were  observed.  Tetanus  presents  no  essential  lesions.  It  is  rare  except 
where  dirt  and  filth  prevail ;  but  these  alone  are  not  sufficient  to  produce 
the  disease.     It  is  rare  in  the  tenements  of  New  York. 

Symptoms. — These,  as  a  rule,  begin  on  the  fifth  or  sixth  day,  or  at 
the  time  of  the  separation  of  the  cord.  The  first  s}'mptoms  may  not 
appear  until  the  tenth  or  twelfth  day,  but  rarely  later  than  this.  Gen- 
erally the  first  thing  noticed  is  difficulty  in  nursing,  which  on  examina- 
tion is  found  to  be  due  to  rigidity  of  the  jaws  (trismus).  Nursing  may 
be  impossible  on  this  account.  The  muscles  of  the  Jaw  feel  hard,  the  lips 
pout,  and  all  the  muscles  of  the  face  seem  firm.  Soon  a  slight  stiffening 
of  the  body  occurs,  the  child  straightening  the  back  as  he  lies  upon  the 
lap  and  continuing  rigid  for  a  moment  or  two.  In  the  interval  he  is  at 
first  completely  relaxed.  These  paroxysms  soon  increase  in  frequency 
until  they  may  come  on  every  few  minutes,  being  excited  by  any  move- 
ment of  the  body.  The  relaxation  is  then  only  partial,  and  the  neck  and 
extremities  and  sometimes  nearly  the  whole  body  may  become  rigid  and 
stiff  as  a  piece  of  wood.  The  arms  are  extended,  the  thumbs  adducted, 
and  the  hands  clenched.  The  thighs  and  legs  are  extended,  and  no 
motion  is  possible  at  the  hip  or  knee.  The  jaws  can  be  separated  slightly 
or  not  at  all.  The  firm  contractions  of  the  facial  muscles  give  a  peculiar 
expression  to  the  features.  There  is  a  low,  whining  cry.  Swallowing  is 
difficult,  sometimes  impossible.  The  pulse  is  rapid  and  soon  becomes 
weak.  The  temperature  at  first  is  normal,  but  in  the  most  acute  cases 
rises  rapidly  to  104°  or  even  106°  F. ;  in  the  milder  cases  it  does  not 
go  above  101°  F. 

Death  may  l)e  due  to  exhaustion,  to  fixation  of  the  respiratory  muscles, 
or  to  spasm  of  the  larynx.  In  the  less  severe  cases  all  the  symptoms  are 
milder, 'and  there  may  be  intervals  in  which  the  rigidity  is  scarcely  no- 
ticeable, so  that  respiration  and  deglutition  may  be  carried  on  for  some 
time.  In  cases  whicli  terminate  in  recovery  the  temperature  is  but 
slightly  elevated.  The  tonic  contractions  gradually  become  less  severe, 
and  the  paroxysms  less  frequent.  The  children  usually  suffer  for  sev- 
eral weeks  from  the  general  symptoms  of  malnutrition,  which  are  pro- 
portionate to  the  severity  of  the  attack.  Of  eighty-eight  fatal  cases 
which  are  reported  by  Stadtfeldt  all  but  five  died  between  the  ages  of 
six  and  ten  days.  The  duration  of  the  disease  in  the  fatal  cases  is  seldom 
more  than  forty-eight  hours,  often  less  than  twenty-four  hours;  in 
those  terminating  in  recovery,  between  one  and  three  weeks. 

Prognosis. — Few  diseases  of  infancy  are  more  fatal  than  tetanus. 
Where  it  prevails  endemically  it  is  regarded  by  the  laity  as  so  uniformly 
fatal  that  usually  no  physician  is  called.  Scattered  through  medical  lit- 
erature are  quite  a  large  number  of  isolated  cases  in  which  recovery  has 
occurred.     At  the  present  time  the  proportion  of  fatal  cases  is  probaljly 


92  DISEASES  OF  THE  NEWLY  BORN 

between  ninety  and  ninety-five  per  cent.  Sporadic  cases  more  frequently 
recover  than  those  occurring  in  districts  where  the  disease  is  endemic. 
The  later  the  development  of  the  symptoms,  the  slower  their  course,  and 
the  lower  the  temperature,  the  more  likely  is  the  case  to  recover. 

Prophylaxis. — A  proper  understanding  of  the  nature  of  the  disease 
has  brought  with  it  the  means  of  rational  prevention.  The  first  essen- 
tial is  obstetrical  cleanliness,  which  must  include  scissors,  hands,  dress- 
ings, ligatures — in  short,  everything  which  comes  in  contact  with  the 
umbilical  wound.  In  districts  where  tetanus  is  endemic,  thorough  asep- 
tic treatment  of  the  umbilicus  should  be  insisted  upon,  both  at  the  first 
dressing  and  later,  particularly  at  the  time  of  the  separation  of  the  cord. 

Treatment. — All  drugs  whose  physiological  action  is  that  of  motor 
depressants  of  the  ,spinal  cord  have  a  certain  amount  of  value  in  tetanus. 
The  most  important  ones  are  chloral  and  the  bromids.  Xearly  all  the 
reported  cures  have  been  by  one  of  these  drugs  or  a  combination  of 
them.  The  mistake  usually  made  is  in  using  too  small  doses.  Enough 
to  produce  the  physiological  efilects  of  the  drug  must  be  given.  The 
initial  dose  should  not  be  large,  but  it  should  be  repeated  until  the  full 
effects  are  obtained.  Chloral,  however,  has  been  the  drug  most  gen- 
erally relied  upon.  An  hourly  dose  of  one  or  two  grains  is  usually 
required.  If  no  effect  is  visible  in  ten  or  twelve  hours  the  dose  may  be 
further  increased,  as  the  patient  is  in  much  greater  danger  from  the 
disease  than  he  can  possibly  be  from  the  drug.  Chloral  may  be  given 
by  the  mouth  or  by  the  rectum,  but  must  always  be  well  diluted.  The 
single  case  of  recovery  which  we  have  seen  was  one  treated  by  the 
bromid  of  potassium.  This  infant  took  eight  grains  every  two  hours 
for  three  days,  afterward  smaller  doses.  The  child  must  at  all  times  be 
kept  as  quiet  as  possible,  without  unnecessary  handling  or  bathing.  If 
nursing  or  feeding  by  the  mouth  is  impossible,  because  the  jaws  cannot 
be  separated,  the  child  may  be  fed  by  a  tube  passed  through  the  nose. 
This  is  greatly  to  be  preferred  to  rectal  alimentation.  Drugs  may  be 
administered  in  the  same  way. 

The  Antitoxin  Treatment. — This  is  of  especial  value  in  proph3'laxis. 
To  be  efficient  as  a  curative  measure  it  must  be  used  early,  for  after  the 
disease  has  developed  it  is  very  doubtful  whether  much  can  be  accom- 
plished by  its  use ;  but  as  it  is  harmless,  it  should  be  employed  and  given 
both  intraspinally  and  intravenously. 


EPIDEMIC  HEMOGLOBINURIA  (Winckel's  Disease) 

The  essential  features  of  this  disease  are  hemoglobinuria  with  icterus 
and  cyanosis,  this  combination  giving  the  skin  a  deeply  bronzed  hue 


FATTY  DEGENERATION  OF  THE  NEWLY  BORN  93 

{maladie  hronzee).  It  is  a  rare  disease,  but  has  generally  occurred  epi- 
demically in  institutions.  It  is  usually  fatal.  It  is,  without  doubt,  in- 
fectious, but  its  cause  has  not  been  discovered.  Although  generally 
called  by  the  name  of  Winckel,  who  in  1879  made  a  report  upon  an 
epidemic  of  twenty-three  cases,  the  disease  was  quite  well  described  by 
Charrin  in  1873,  with  a  report  of  fourteen  cases,  and  observed  by  Bige- 
low,  in  Boston,  in  1875.  All  the  cases  included  in  Winckel's  report 
occurred  in  one  institution,  affecting  one-fourth  of  the  children  born 
during  the  period. 

There  is  cyanosis,  with  a  more  or  less  intense  icterus  of  the  skin  and 
internal  organs.  The  umbilical  vessels  are  usually  normal.  The  kid- 
neys are  swollen,  show  small  hemorrhages  into  their  substance,  and 
under  the  microscope  the  straight  tubes  are  seen  to  be  filled  with  crys- 
tals of  hemoglobin,  but  contain  no  blood-cells.  The  bladder  frequently 
contains  brownish,  smoky  urine.  The  spleen  is  swollen  and  filled  with 
blood  pigment,  which  is  diffused  throughout  the  cells  of  the  pulp,  and 
free  in  the  blood-vessels.  Punctate  hemorrhages  are  seen  in  most  of 
the  other  viscera. 

The  sym23toms  usually  begin  from  the  fourth  to  the  eighth  day  after 
birth,  and  are  fulminating  in  character,  seldom  lasting  more  than  two 
days.  There  are  rapid  pulse  and  respiration,  general  restlessness,  pros- 
tration, cyanosis,  and  general  icterus,  which  may  be  intense.  The  tem- 
perature is  normal  or  slightly  elevated.  There  is  rapid  asthenia,  often 
terminating  in  coma  or  convulsions.  The  urine  is  passed  frequently,  in 
small  quantities.  It  is  of  a  smoky  color,  and  contains  hemoglobin 
in  considerable  quantity,  renal  epithelium,  and  sometimes  granular  casts 
and  blood-cells,  but  does  not  contain  bile  pigment.  Albumin  is  some- 
times present,  but  not  in  large  quantity. 

Treatment  is  of  little  avail,  since  all  severe  cases  are  fatal. 


FATTY  DEGENERATION  OF  THE  NEWLY  BORN  (Buhl's  Disease) 

A  disease  has  been  described  by  the  author  whose  name  it  bears,  the 
essential  nature  and  causation  of  which  are  unknown.  It  occurs  as 
isolated  cases,  and  is  characterized  by  inflammatory  changes  leading  to 
fatty  degeneration  in  the  viscera,  especially  the  heart,  liver,  and  kidneys ; 
it  seldom  lasts  more  than  two  weeks,  and  is  almost  invariably  fatal. 
Many  of  the  lesions  are  similar  to  the  ordinary  post  mortem  changes, 
and  when  found  they  should  not  be  interpreted  as  pathological  unless 
the  autopsy  is  made  within  twelve  hours  after  death. 

The  clinical  features  of  this  disease,  as  described,  resemble  those  of 
pyogenic  infection ;  and  since  the  observations  were  made  before  modern 
5 


94  DISEASES  OF  THE  NEWLY  BORN 

methods  of  bacteriological  study,  it  is  highly  probable,  that  Buhl's  disease 
is  merely  a  form  of  pyogenic  infection  in  the  newly  born. 


PEMPHIGUS  NEONATORUM— BULLOUS  IMPETIGO 

Pemphigus  is  a  term  which  designates  a  lesion  rather  than  a  disease. 
By  it  is  meant  an  eruption  of  bullae  occurring  usually  upon  a  red  base, 
the  contents  being  in  most  cases  clear  serum.  A  condition  somewhat 
resembling  pemphigus  sometimes  follows  the  use  in  the  newly  born  of 
too  hot  baths.  Again,  bullae  are  seen  as  one  of  the  lesions  of  congenital 
syphilis;  they  are  then  usually  present  at  birth  or  appear  soon  after. 
They  are  most  frequently  seen  upon  the  palms  and  soles.  Infants  so 
affected  are  generally  in  wretched  condition,   and  soon  die. 

The  only  condition  to  which  the  term  pemphigus  neonatorum  should 
be  applied  is  quite  different  from  both  the  preceding,  and  it  has  iiothing 
in  common  with  the  pemphigus  of  later  life.  A  better  name  is  bullous 
impetigo,  for  its  identity  with  impetigo  contagiosa  seen  in  older  patients 
is  now  generally  admitted.  The  disease  is  infectious,  somewhat  con- 
tagious, and  occasionally  occurs  in  small  epidemics  in  institutions.  Its 
spread  in  communities  has  been  traced  to  midwives.  The  only  important 
difference  between  this  disease  and  the  common  impetigo  contagiosa 
seen  in  older  children,  is  its  severity  and  its  association  with  visceral 
infections.  Most  patients  with  bullous  impetigo  are  delicate,  neglected, 
and  living  in  dirty  surroundings;  but  not  all  are.  We  have  seen  it  in 
robust  infants  who  had  received  fairly  good  care. 

The  greater  number  of  cases  studied  thus  far  have  shown  the  j^res- 
ence  in  the  blebs  of  the  staphylococcus  pyogenes  aureus;  less  frequently 
the  streptococcus  has  been  the  cause.  The  staphylococcus  aureus  was 
found  in  several  typical  cases  occurring  in  our  own  hospital  service.  In 
one  of  these  which  came  to  autopsy,  a  general  staphylococcus  septicemia 
was  present. 

The  clinical  picture  presented  by  pemphigus  neonatorum  is  so  strik- 
ing that  it  can  scarcely  be  mistaken.  The  symptoms  begin  in  most 
cases  between  the  fourth  and  tenth  day  of  life.  The  bullae  first  appear- 
ing are  scattered  and  often  not  larger  than  one-fourth  or  one-half  inch 
in  diameter.  They  may  be  seen  upon  any  part  of  the  body,  but  are 
especially  frequent  about  the  face,  hands,  and  other  exposed  parts.  They 
rupture  or  dry  and  form  crusts  without  suppuration.  The  small  bullae 
may  gradually  increase  in  size  or  several  may  coalesce  until  tliey  cover 
an  area  two  or  three  inches  in  diameter.  As  the  disease  jirogresses,  new 
bullae  may  appear  over  almost  any  part  of  the  body.  The  skin  is  at  first 
slightly  reddened,  then  an  exudation  of  serum  occurs  beneath  the  epi- 


PEMPHIGUS  NEONATORUM 


95 


dermis  which  loosens  and  slides  upon  the  trvie  skin.  After  rupture  of 
the  large  bullae,  the  epidermis  at  the  margin  forms  a  thin  filmy  l)order 
or  hangs  m  shreds  easily  detached.  The  base  of  the  large  vesicles  is 
a  moist  bright-red  surface.  When  many  have  formed  the  appearance 
closely  resembles  that  seen  after  an  extensive  burn. 

The  course  of  the  local  symptoms  is  at  first  slow ;  then  the  bullae  may 
spread  with  great  rapidity  and  death  occur  in  from  twenty-four  to  forty- 
eight  hours.  In  less  severe  cases  the  course  is  more  prolonged,  the  blebs 
are  smaller,  and  recovery  may  take  place. 

The  constitutional  symptoms  are  at  first  wanting,  but  increase  with 
the  number  and  extent  of  the  bullae.  There  may  be  a  slight  rise  of 
tem})erature  or  it  may  be  subnormal.    There  is  progressive  weakness  and 


Fig.  8. — Pemphigus  Neonatorum.  Symptoms  began  on  1.3th  day;  death  on  16th  day  of 
asthenia;  temperature  subnormal.  The  dark  areas  in  the  picture  are  entirely  denuded 
of  epidermis;  they  were  formed  by  the  coalescence  of  large  bullae. 


great  depression,  much  like  that  following  a  burn,  and  death  occurs 
from  exhaustion  or  from  some  visceral  inflammation  such  as  pneumonia 
or  meningitis. 

A  disease  very  closely  allied  to  pemphigus  neonatorum  in  its  etiology 
and  clinical  symptoms  is  dermatitis  exfoliativa  (Eitter).  This  also 
is  due  to  infection  with  staphylococci  which  are  found  not  only  in  the 
skin  but  often  in  the  blood  and  viscera.  The  cutaneous  lesions  when 
typical  may  readily  be  differentiated  from  pemphigus,  but  there  are 
many  instances  in  which  the  lesions  of  both  conditions  may  be  present 
at  the  same  time.  A  further  similarity  is  found  in  the  fact  that  in 
institutional  epidemics  both  forms  of  disease  may  occur  side  by  side, 
pemphigus  in  some  infants,  dermatitis  exfoliativa  in  others.  There  is 
at  first  a  redness  and  slight  swelling  of  the  skin  which  usually  occurs 
first  around  the  mouth,  spreading  upon  the  face,  and  then  appears 
upon  the  extremities  and  trunk.  The  skin  seems  as  if  macerated  and 
eventually  exfoliates  in  large  masses,  leaving  exposed  the  red  corium 
from  which  some  serous  exudation  takes  place  but  there  is  no  accumula- 


96  DISEASES  OF  THE  NEWLY  BORN 

tion  of  fluid  beneath  the  epidermis  before  the  separation  of  the  overlying 
skin.  The  area  denuded  may  be  very  great,  sometimes  fully  half  the 
body  being  thus  exposed.  Death  often  results  in  two  or  three  days.  In 
other  cases,  it  is  delayed  for  a  week  or  ten  days.  In  some,  recovery 
occurs.     The  general  symptoms  are  similar  to  those  seen  in  pemphigus. 

It  is  important  to  distinguish  pemphigus  neonatorum  from  congenital 
syphilis.  In  syphilitic  cases,  the  liver  and  spleen  are  usually  markedly 
enlarged,  and  other  characteristic  changes  may  be  present  in  the  nails, 
mucous  membranes,  or  elsewhere. 

Treatment  is  of  little  avail  in  the  most  severe  cases,  Avhen  the  bullae 
cover  a  considerable  part  of  the  surface  of  the  body.  The  bullae  should 
be  opened  and  drained,  and  the  surfaces  dressed  with  gauze  covered  with 
a  two-per-cent  ointment  of  white  precipitate.  There  is  little  danger  of 
mercurial  poisoning.  When  dressings  are  changed  the  skin  should  be 
sponged  with  a  bichlorid  solution,  1-5,000  strength,  or  a  one-per-cent 
solution  of  ichthyol  or  permanganate  of  potash.  On  account  of  the  con- 
tagious nature  of  the  disease  cases  occurring  in  institutions  should  be 
isolated. 


CHAPTER   V 

HEMORRHAGES 

Hemoerhages  are  quite  frequent  during  the  first  days  of  life,  and 
are  important  not  only  from  the  fact  that  they  are  often  the  cause  of 
death,  but,  when  the  brain  is  the  seat,  from  their  remote  eifects.  There 
are  several  conditions  in  the  newly  born  which  predispose  to  bleeding — 
the  extreme  delicacy  of  the  blood-vessels,  and  the  great  changes  taking 
place  in  the  blood  itself  and  in  the  circulation  in  the  transition  from 
intra-uterine  to  extra-uterine  life.  Hemorrhages  may  complicate  many 
of  the  diseases  of  the  early  days  of  life,  such  as  syphilis  or  sepsis,  or  they 
may  exist  alone. 

The  cases  may  be  divided  into  two  groups:  (1)  Traumatic  or  Acci- 
dental Hemorrhages,  which  depend  upon  causes  connected  with  delivery ; 
(2)  Spontaneous  Hemorrhages,  or  The  Hemorrhagic  Disease  of  the 
Newly  Born. 

TRAUMATIC  OR  ACCIDENTAL  HEMORRHAGES 

These  are  mainly  due  to  pressure  in  natural  labor,  or  to  means  em- 
ployed in  artificial  delivery,  but  some  of  them  may  possibly  result  from 
injuries  received  before  birth.    They  are  more  frequent  in  large  children, 


HEMATOMA  OF  THE  STERNOMASTOID  97 

in  difficult  labors,  and  where  from  any  cause  the  body  of  the  child  has 
been  subjected  to  undue  pressure. 

Hematoma  of  the  Stemomastoid. — Hematoma  of  the  sternomastoid 
muscle  leads  to  the  formation  of  a  tumor  in  the  belly  of  the  muscle. 
It  is  a  rather  rare  condition,  usually  noticed  in  the  second  or  third  week 
of  life,  and  it  disappears  spontaneously,  rarely  causing  any  permanent 
deformity.  The  tumor  varies  from  three  quarters  of  an  inch  to  one 
inch  and  a  half  in  length,  being  about  the  size  and  shape  of  a  pigeon's 
egg.  It  is  movable,  almost  cartilaginous  to  the  touch,  and  sometimes 
slightly  tender.  The  situation  of  the  tumor  is  usually  about  the  center 
of  the  muscle.     There  is  no  discoloration  of  the  skin. 

In  about  two-thirds  of  the  cases  it  occurs  after  breech  presentations. 
It  is  much  more  frequent  upon  the  right  than  upon  the  left  side.  In 
twenty-seven  cases  collected  by  Henoch  the  right  side  was  involved  in 
twenty-one  and  the  left  in  only  six  cases.  The  explanation  of  this  differ- 
ence is  to  be  found  in  the  obstetrical  position.  Barely,  both  sides  may 
be  involved.  The  head  is  usually  slightly  inclined  toward  the  shoulder 
of  the  affected  side  and  rotated  toward  the  opposite  side.  The  swelling 
slowly  diminishes  in  size,  and  in  most,  cases  by  the  end  of  the  third 
month  has  nearly  or  quite  disappeared.  Occasionally  a  slight  torticollis 
remains  for  a  longer  time,  but  in  the  majority  of  cases  the  recovery  is 
perfect.  Hematoma  of  the  sternomastoid  is  due  to  the  twisting  of  the 
head  during  parturition.  It  is  not  an  evidence  of  the  employment  of 
any  improper  force  in  delivery.  The  twisting  of  the  head  produces 
laceration  of  some  of  the  blood-vessels  of  the  muscle,  and  in  some  cases 
there  is  doubtless  rupture  of  some  of  the  fibers  of  the  muscle  itself. 
Following  this  there  occurs  a  certain  amount  of  inflammation  of  the 
muscle  and  its  sheath.  The  tumor  is  due  partly  to  blood-extravasation 
and  partly  to  inflammatory  products.  In  one  or  two  recent  cases  in 
which  the  sheath  of  the  muscle  has  been  opened  it  has  been  found  filled 
with  blood. 

The  condition  requires  no  treatment.  Operative  interference  is  posi- 
tively contra-indicated. 

Cephalhematoma. — This  is  a  tumor  containing  blood,  situated  upon 
the  head,  usually  over  one  parietal  bone,  and  tending  to  spontaneous 
disappearance  by  absorption.  The  source  of  the  blood  is  the  rupture  of 
the  small  vessels  of  the  pericranium. 

Etiology. — Cephalhematoma  is  sometimes  due  to  a  distinct  trauma- 
tism like  the  application  of  forceps  or  to  some  other  injury  during 
labor,  in  the  majority  of  cases,  however,  there  is  no  evidence  of  such 
injury.  Besides  the  conditions  predisposing  to  all  hemorrhages,  there 
is  the  increased  pressure  in  the  blood-vessels  of  the  head  during  delivery, 
especially  when  labor  is  prolonged  or  difficult;  there  may  be  changes  in 


98 


DISEASES  OF  THE  NEWT.Y  BORN 


the  bone,  such  as  an  imperfect  development  of  the  external  table;  and, 
finally,  there  may  be  changes  in  the  blood  itself.  Cephalhematoma  is 
a  comparatively  rare  condition;  it  was  present  according-  to  the  statis- 
tics of  the  Sloane  Hospital  for  Women,  in  20  of  1,300  consecutive  births, 
or  1.6  per  cent.  The  condition  is  more  common  after  first  or  difficult 
labors,  and  in  vertex  presentations;  occurring  twice  as  often  in  males 
as  in  females,  probably  from  the  greater  size  of  the  head. 

Lesions.— In  the  20  Sloane  cases,  the  situation  was  over  the  right 
parietal  bone  in  12 ;  over  the  left  in  2 ;  over  both  parietals  in  4;  over  the 
occipital  in  2.  The  location  of  the  tumor  seems  to  have  a  very  close 
relation  to  the  position  of  the  head  in  the  pelvis.    In  8  of  the  right-sided 

cases  the  head  was  in  the  left 
occipito-anterior  position.  Of 
the  cases  with  occipital  tumors, 
both  were  breech  presentations. 
Of  the  16  cases  with  a  single 
tumor  the  labor  was  natural  in 
10,  tedious  in  -1,  and  in  2  for- 
ceps were  used.  Of  the  1  double 
cases,  2  were  forceps  deliveries. 
In  rare  cases  triple  tumors 
are  met  with,  one  over  each 
parietal  and  one  over  the  occip- 
ital bone  (Fig.  9).  The  attach- 
ment of  the  periosteum  along 
the  sutures  usually  limits  the/ 
tumor  to  the  surface  of  one  bone. 
It  never  extends  across  tlie  su- 
tures or  over  the  fontanel.  In 
cases  where  there  is  a  more  definite  injury,  such  as  that  from  forceps,  the 
tumor  may  be  present  over  any  one  of  the  cranial  bones,  liut  more  fre- 
qiiently  over  the  parietal.  The  seat  of  the  hemorrhage  is  between  the 
periosteum  and  the  cranium.  The  scalp  shows  punctate  hemorrhages  and 
sometimes  infiltration  with  blood.  In  recent  cases  the  blood  is  fluid ;  later 
it  is  coagulated.  The  amount  of  extravasated  blood  is  usually  from  half 
an  ounce  to  an  ounce.  The  cases  following  natural  delivery  are  generally 
uncomplicated.  The  traumatic  cases  may  be  complicated  by  extrava- 
sations between  the  bone  and  the  dura  (internal  cephalhematoma),  or 
l)y  meningeal  or  cerebral  hemorrhages.  If  there  is  a  wound,  infection 
may  be  followed  hy  purulent  meningitis  and  even  by  cerebral  a])st'ess. 

Symptoms. — The  tumor  is  usually  noticed  from  the  first  to  tlie 
fourth  day  after  birth,  appearing  as  a  slight  prominence  in  one  of 
the  positions  mentioned.     Gradually  increasing  in   size,  it  attains   its 


Fig.  9. — Triple  Cephalhematoma 
seven  days  old. 


Infant, 


CEPHALHEMATOMA  99 

maximum  at  the  end  of  a  few  days,  and  then  slowly  diminishes.  In 
size  and  shape  the  usual  tumor  may  be  compared  to  the  bowl  of  a 
tablespoon.  In  marked  cases  it  may  be  one-third  the  size  of  the  child's 
head.  To  the  touch  it  is  soft,  elastic,  fluctuating,  and  irreducible. 
It  does  not  increase  with  the  cry  or  cough.  There  is  no  extra  heat 
and  no  signs  of  inflammation.  Usually  the  tumor  does  not  pulsate, 
although  in  rare  instances  pulsating  cephalhematomata  have  been  seen. 
Very  soon  the  tumor  is  surrounded  by  a  marginal  ridge.  At  first 
this  is  apparently  from  coagulation  of  blood,  but  later  it  may  be  bony. 
The  prominent  ridge  with  the  soft  center  gives  a  sensation  some- 
what like  that  of  a  depressed  fracture.  Sometimes  on  pressure  there  is 
obtained  a  sort  of  parchment-crackling.  This  is  generally  found  as  the 
swelling  is  subsiding,  and  is  sometimes  clearly  due  to  the  formation 
of  minute  l)ony  plates  upon  the  inner  surface  of  the  periosteum.  It 
may  be  found  when  there  is  nothing  but  thin  coagula  to  explain  it.  In 
certain  cases  following  severe  traumatism,  cephalhematoma  may  be 
complicated  with  wounds  of  the  scalp,  fracture  of  the  skull,  and  even 
lacerations  of  the  dura  mater  or  the  brain.  In  such  cases  the  tumor 
may  become  inflamed,  but  in  the  sponta;neous  cases  this  is  extremely  rare. 
The  usual  signs  of  abscess  develop,  which  may  open  externally  or  bur- 
row.    Fortunately  this  termination  is  seldom  seen. 

As  a  rule,  without  any  interference  the  uncomplicated  cases  go  on 
to  recovery.  The  complete  disappearance  of  the  tumor,  may  be  expected 
in  from  six  weeks  to  three  months,  depending  on  its  size;  but  a  hard, 
uneven  elevation  may  remain  at  its  site  for  a  longer  time.  The  cases 
due  to  severe  traumatism  are  more  serious,  the  gravity  depending  not 
upon  the   cephalhematoma   but   upon  the   complicating  lesions. 

Diagnosis. — Cephalhematoma  may  be  confounded  with  encephalocele. 
This,  however,  occurs  along  the  line  of  the  sutures  or  at  the  fontanels,  is 
partially  reducible,  pressure  causes  cerebral  symptoms,  and  frequently 
the  tumor  increases  with  respiratory  movements.  Caput  succedaneum 
often  appears  in  the  same  place  as  a  cephalhematoma  and  at  the  same 
time,  but  this  is  an  edematous,  not  a  fluctuating  tumor,  and  begins  to 
disappear  by  the  second  or  third  day.  From  a  depressed  fracture  of 
the  skull,  it  is  differentiated  by  the  fact  that  in  cephalhematoma  there 
is  a  tumor  and  not  a  depression;  the  prominent  margin  which  is  raised 
above  the  contour  of  the  skull  is  not  osseous  and  the  skull  can  be  felt 
at  the  bottom  of  the  center  of  the  tumor. 

Treatment. — The  treatment  in  the  uncomplicated  cases  is  simply 
protective,  all  such  cases  tending  to  spontaneous  recovery.  No  local  or 
general  treatment  to  promote  absorption  is  required.  The  child  should 
be  so  placed  and  so  handled  that  no  injury  may  be  done  to  the  affected 
part.     Compresses  are  unnecessary.     If  complications  exist,  such  as  in- 


100  DISEASES  OF  THE  NEWLY  BORN 

jury  to  the  bones,  dura,  or  brain,  they  are  to  be  treated  in  accordance 
with  general  surgical  principles.  Operative  interference  is  called  for 
only  when  suppuration  has  occurred,  or  when  there  are  brain  symptoms 
which  point  to  the  existence  of  internal  as  well  as  external  cephalhema- 
toma. 

Visceral  Hemorrhages. — While  these  are  most  frequent  in  large  chil- 
dren and  follpwing  difficult  labors,  they  may  occur  in  small  children 
and  where  the  labor  has  been  easy  and  normal — their  occurrence  here 
being  due  to  the  feeble  resistance  of  the  blood-vessels.  From  one  hun- 
dred and  thirty  autopsies  upon  still-born  children  or  those  dying  soon 
after  birth,  Spencer  concludes  that  intracranial  hemorrhages  are  more 
frequent  in  heacl-forceps  than  in  breech  cases,  and  more  frequent  in 
breecfe  than  in  natural  vertex  deliveries.  Other  visceral  hemorrhages 
are  much  more  frequent  in  breech  cases. 

Not  all  visceral  hemorrhages  are  to  be  classed  as  traumatic.  They 
are  often  seen  with  the  spontaneous  hemorrhages  from  the  skin  or 
mucous  membranes.  When,  however,  they  are  single,  they  seem  to  be 
of  traumatic  rather  than  of  pathological  origin. 

The  most  important  of  the  visceral  hemorrhages  are  intracranial. 
These  are  discussed  in  the  chapter  devoted  to  Birth  Paralyses.  Earely 
there  may  be  large  hemorrhages  into  the  lung.  Here  the  blood  fills  the 
air  vesicles  and  the  small  bronchi,  and  coagula  may  be  found  even  in  the 
larger  bronchi.  A  large  part  of  a  lobe  or  an  entire  lobe  may  be  involved. 
On  section  the  condition  resembles  atelectasis,  and  it  may  give  the  phjsi- 
cal  signs  of  consolidation. 

The  abdominal  viscera  sufEer  more  than  those  of  the  thorax  because 
less  protected  against  pressure.  Small  hemorrhages  are  not  uncommon 
upon  the  surface  of  any  of  the  viscera  covered  by  peritoneum.  Intra- 
peritoneal hemorrhages  are  rare,  but  may  be  very  extensive,  amounting 
to  six  or  eight  ounces.  Sometimes  no  ruptured  vessel  can  be  found.  The 
hemorrhage  may  be  primarily  in  the  peritoneal  cavity,  or  it  may  result 
from  rupture  of  one  of  the  viscera,  especially  the  suprarenal  capsule.  It 
may  be  large  enough  to  produce  death  from  loss  of  blood. 

Small  surface  hemorrhages  of  the  liver  are  not  infrequent.  Occa- 
sionally one  of  considerable  size  occurs  separating  the  peritoneal  cover- 
ing and  forming  a  tumor  generally  upon  the  superior  surface.  Such 
laceration  may  be  produced  during  labor,  and  a  slow  accumulation  of 
blood  may  take  place  beneath  the  capsule,  death  resulting  from  rupture 
into  the  peritoneal  cavity.  Laceration  of  the  capsule  of  the  liver  in -a 
still-born  infant  has  been  reported.  Of  the  large  hemorrhages,  those 
into  the  suprarenal  capsules  are  perhaps  the  most  frequent.  The  cap- 
sule may  be  distended  to  nearly  the  size  of  an  orange,  the  kidney  being 
surrounded  by  a  mass  of  blood-clots.     Blood  may  be  extravasated  into 


SPONTANEOUS  HEMORRHAGES  '    101 

the  retroperitoneal  connective  tissne  and  rnptnre  may  take  place  into 
the   peritoneal   cavity. 

Except  in  the  intracranial  variety,  visceral  hemorrhages  cause  fcAV 
symptoms,  and  in  the  great  majority  of  cases  the  diagnosis  is  not  made. 
Intrapulmonary  hemorrhages  have  given  rise  to  the  signs  of  consolida- 
tion of  the  lung  and  even  to  hemoptysis.  The  abdominal  hemorrhages 
are  the  most  obscure.  There  may  be  a  general  abdominal  distention 
with  the  usual  symptoms  of  loss  of  blood,  or  there  may  be  a  circum- 
scribed swelling.  In  many  cases  nothing  is  noticed  until  rupture  of  a 
subperitoneal  hemorrhage  takes  place  into  the  general  peritoneal  cavity, 
when  there  may  be  sudden  collapse  and  death. 

The  visceral  hemorrhages  are  not  amenable  to  treatment.  The  prog- 
nosis depends  upon  the  size  and  position  of  the  hemorrhage.  In  the  cases 
of  abdominal  hemorrhage  the  diagnosis  is  extremely  obscure  and  is  rarely 
made  during  life. 


SPONTANEOUS  HEMORRHAGES— THE  HEMORRHAGIC  DISEASE  OF 

THE  NEWLY  BORN 

A  disposition  to  bleeding  is  seen  with  many  diseases  of  the  first  few 
days  of  life,  especially  those  of  an  infectious  character  like  syphilis  and 
pyemia.  With  most  of  these,  however,  the  hemorrhages  are  small  and 
the  condition  may  be  compared  to  the  hemorrhagic  tendency  seen  in 
certain  forms  of  infection  of  later  life,  such  as  measles,  smallpox,  and 
malignant  endocarditis.  There  is,  however,  a  class  of  cases  in  which  the 
hemorrhages  are  not  associated  with  any  other  known  process,  and  in 
which  the  escape  of  blood  from  the  small  blood-vessels  is  the  chief  or 
essential  symptom.  In  these  cases  the  bleeding  is  much  more  extensive 
than  in  the  others  mentioned.  These  hemorrhages  are  characterized 
by  the  fact  that  they  are  spontaneous  in  origin,  having  no  connection 
with  delivery,  they  are  multiple  in  location,  they  tend  to  cease  spon- 
taneously after  quite  a  limited  time,  but  they  are  often  greatly  influenced 
by  treatment.  They  are  most  often  from  the  mucous  membranes  of 
the  stomach  and  intestines,  or  from  the  umbilicus  or  beneath  the  skin, 
Imt  they  may  be  from  almost  any  mucous  surface  or  into  any  organ  of 
the  body. 

Etiology. — These  hemorrhages  are  not  common,  and  are  met  with 
more  often  in  institutions  than  in  private  practice.  In  5,235  births  in 
the  Boston  Lying-in  Asylum,  Townsend  reports  32  cases  of  hemor- 
rhage, or  0.6  per  cent.  In  the  Lying-in  Asylum  of  Prague,  Eitter  ob- 
served 190  cases  in  13,000  births,  or  1.4  per  cent.  In  the  Foundling 
Asylum  of  Prague,  Epstein  reports  hemorrhages  in  8  per  cent  of  7-10 
infants. 


102  DISEASES  OF  THE  NEWLY  BORN 

The  condition  is  not  a  manifestation  of  hemophilia.  Only  12  of 
576  bleeders  whose  histories  were  collected  by  Grandidier  had  a  his- 
tory of  hemorrhage  at  the  time  of  the  falling  off  of  the  cord,  and  symp- 
toms very  rarely  appeared  before  the  end  of  the  first  year.  Hemorrhages 
in  the  newly  born  are  only  slightty  more  frequent  in  males,  while  in 
hemophilia  they  predominate  13  to  1.  The  hemorrhagic  disease  of  the 
newly  born  is  self-limited,  and  runs  a  definite  course  to  recovery  or 
death.  The  tendency  to  bleed  does  not  extend  beyond  a  few  weeks,  and 
often  lasts  but  a  few  days.  Circumcision  has  been  done  within  a  few 
days  after  the  cessation  of  the  hemorrhages  without  any  unusual  bleed- 
ing. In  a  case  under  our  observation  with  the  most  extensive  subcutane- 
ous hemorrhages  we  have  ever  seen,  all  tendency  to  bleed  had  ceased 
before  the  separation  of  the  cord,  although  there  had  previously  been 
bleeding  at  the  navel.  The  bleeding  occurs  with  about  equal  frequency 
in  feeble  and  in  well-nourished  infants.  Syphilis  is  associated  in  but  a 
small  proportion  of  the  cases.  On  the  other  hand  of  132  cases  of 
congenital  syphilis  observed  by  Mracek,  only  14  per  cent  suffered  from 
hemorrhages. 

An  association  with  sepsis  has  sometimes  been  noted.  Of  the  61 
cases  observed  by  Epstein  not  less  than  29,  and  of  the  190  cases  of  Eitter, 
24  were  associated  with  sepsis.  During  one  year  of  our  service  at  the 
ISTursery  and  Child's  Hospital  there  were  8  marked  cases  of  hemorrhage 
in  about  225  deliveries.  While  more  eases  of  sepsis  occurred  among 
the  children  during  that  year  than  usual,  it  was  striking  that  not  one  of 
these  hemorrhagic  cases  gave  any  evidence  of  sepsis,  and  that  none  of  the 
septic  cases  had  bleeding.  Yet  the  circumstances  in  which  these  hemor- 
rhages sometimes  occur  point  strongly  to  an  infectious  origin.  The 
results,  often  remarkable,  following  the  injection  of  human  blood  serum 
indicate  that  the  essential  cause,  in  the  largest  number  of  cases,  is  a  lack 
of  some  substance  in  the  blood  essential  to  coagulation.  Sufficient  studies 
have  not  yet  been  made  to  establish  the  precise  nature  of  these  blood 
changes.  The  results  of  treatment  would  seem  to  show  that  the  cause  of 
these  hemorrhages  is  not  always  the  same. 

Wliile  the  hemorrhages  are  not  traumatic,  bleeding  is  exceedingly 
prone  to  occur  in  the  skin  over  pressure  j)oints  such  as  the  back,  the 
elbows,  the  occiput,  and  the  sacrum.  It  is  also  common  from  the  mucous 
membranes  which  are  the  seat  of  pathological  processes,  especially  from 
the  eyes,  the  nose,  and  the  genitals. 

Lesions.^In  very  many  of  the  cases  the  autopsy  shows  nothing  except 
the  hemorrhages  in  the  various  situations  and  the  blanching  of  the 
organs  due  to  the  loss  of  blood.  The  hemorrhages  of  the  brain  are  usu- 
ally meningeal  and  diffuse.  They  are  considered  more  at  length  in  the 
chapter  upon  Birth  Paralyses.     The  pulmonary  hemorrbages  are  usu- 


SPONTANEOUS  HEMORRHAGES  103 

ally  small  and  unimportant,  and  large  hemorrhages  into  the  pleura  or 
pericardium  are  very  rare.  The  stomach  and  intestines  may  contain 
considerable  blood  variously  disorganized  in  the  different  parts  of  the 
canal,  and  there  may  be  ecchymoses  of  the  mucous  membrane.  In  addi- 
tion, ulcers  may  be  found  in  the  stomach  and  duodenum.  In  twenty- 
four  autopsies  upon  cases  with  hemorrhage  from  the  stomach  and  intes- 
tines collected  by  Dusser,  ulcers  were  found  in  the  stomach  in  nine 
cases,  and  in  the  intestines  in  four.  These  ulcers  are  multiple,  small, 
and  usually  superficial,  but  may  extend  to  the  muscular  coat  and  may 
even  perforate.  The  intestinal  ulcers  are  found  only  in  the  duodenum 
and  resemble  those  of  the  stomach.  The  cause  of  these  ulcers  is  some- 
what obscure;  some  of  them  are  undoubtedly  dependent  upon  inflam- 
matory changes,  probably  of  infectious  origin;  others  have  been  com- 
pared to  the  peptic  ulcers  of  later  life,  and  are  attributed  to  thrombi  in 
the  blood-vessels  of  the  mucous  membrane.  These  ulcers  are  found 
in  but  a  small  proportion  of  the  cases  in  which  bleeding  occurs  from 
the  alimentary  tract,  and  they  may  be  wanting  even  when  it  has  been 
very  profuse.  Small  extravasations  may  be  seen  upon  the  surface  or 
in  the  substance  of  any  of  the  abdominal  organs.  The  changes  found 
in  the  blood  have  not  been  uniform. 

Symptoms. — The  onset  is  most  frequently  in  the  first  week  of  life; 
very  rarely  after  the  twelfth  day.  The  hemorrhages  are  usually  mul- 
tiple. Their  location  in  Eitter's  190  cases  was  as  follows:  Umbilicus, 
138  (umbilicus  alone,  97);  intestines,  39;  mouth,  28;  stomach,  20; 
conjunctivae,  20;  ears,  9.  In  Townsend's  50  cases:  Intestines,  20; 
stomach,  14;  mouth,  14;  nose,  12;  umbilicus,  18  (umbilicus  alone,  3)  ; 
subcutaneous  ecchymoses,  21;  abrasion  of  skin,  1;  meninges,  4;  cephal- 
hematoma, 3 ;  abdomen,  2 ;  pleura,  lungs,  and  thymus,  1  each. 

In  many  cases  nothing  is  noticed  until  the  hemorrhage  begins.  The 
first  bleeding  noticed  may  be  from  the  stomach,  intestines,  or  any  of  the 
mucous  surfaces,  beneath  the  skin,  or  from  the  umbilicus.  The  amount 
of  blood  lost  in  most  cases  is  not  great,  but  there  is  a  continuous  oozing. 
The  total  hemorrhage  may  be  only  a  few  drams  or  it  may  reach  several 
ounces.  The  general  condition  is  one  of  considerable  prostration,  often 
from  the  outset.  In  all  cases  there  is  rapid  loss  of  weight.  The  tem- 
perature may  be  high,  low,  or  subnormal.  A  marked  elevation  of 
temperature  may  depend  not  upon  the  hemorrhage  but  upon  associated 
conditions.    In  a  large  number  of  the  cases  there  is  diarrhea. 

The  duration  of  the  disease  in  cases  which  recover  is  usually  but  one 
or  two  days.  In  fatal  cases  it  is  rarely  more  than  three  days,  and  often 
less  than  one.  Death  may  result  from  the  gradual  failure  of  all  the  vital 
forces  or  from  rapid  loss  of  blood. 

Umbilical  Hemorrhage. — A  slight  oozing  from  the  umbilicus  not  in- 


104  DISEASES  OF  THE  NEWLY  BORN 

frequently  occurs  when  the  ligature  has  been  improperly  applied.  This 
is,  generally  controlled  by  simple  measures.  Spontaneous  hemorrhage 
is  quite  different.  It  occurs  rather  later  than  bleeding  from  the  mucous 
membranes,  usually  occurring  between  the  fourth  and  the  seventh  day. 
There  may  be  bleeding  into  the  cord  as  well  as  from  its  free  extremity. 
A  slight  stain  upon  the  dressing  is  usually  the  first  note  of  warning, 
but  in  exceptional  circumstances  a  gush  of  blood  is  the  first  symptom. 
The  hemorrhage  may  be  temporarily  arrested  by  various  means,  but  it 
shows  a  strong  tendency  to  recur  in  spite  of  everything  which  is  done. 
The  usual  duration  is  two  or  three  days.  It  has  been  known,  howeVer, 
to  persist  for  twelve  or  fourteen  days,  and  it  may  be  fatal  in  less  than 
twenty-four  hours  from  the  time  it  is  noticed. 

Hemorrhage  from  the  Stomach  and  Intestines. — Bleeding  occurs 
much  less  frequently  from  the  stomach  than  from  the  intestines.  The 
latter  is  called  melena.  Gastro-enteric  hemorrhages  begin,  in  the  great 
majority  of  cases,  during  the  first  three  days  of  life.  The  blood  vomited 
is  usually  in  dark-brown  masses,  and  not  very  abundant;  more  rarely 
it  is  bright  red.  The  quantity  varies  from  one  dram  to  half  an  ounce. 
A'omiting  is  liable  to  be  excited  by  nursing.  The  blood  discharged  from 
the  bowels  is  always  dark  colored,  usually  intimately  mixed  with  the 
stool,  very  rarely  in  clots.  If  in  doubt  between  blood  and  meconium, 
one  should  look  for  the  corpuscles  with  the  microscope.  When  this  is 
not  conclusive  on  account  of  the  disorganization  of  the  corpuscles,  a 
chemical  test  for  hemoglobin  should  be  made.  Concealed  hemorrhage 
into  the  stomach  may  take  place,  which  may  even  be  sufficient  to  pro- 
duce death,  no  blood  being  vomited  or  passed  by  the  bowels.  In  such 
cases  the  autopsy  may  reveal  quite  a  large  quantity  of  blood  both  in  the 
stomach  and  intestines. 

Hemorrhage  from  the  Mouth.— The  quantity  of  blood  is  rarely  large; 
but  it  is  here  that  it  is  often  first  seen.  Its  source  may  be  the  mucous 
membrane  of  the  mouth,  pharynx,  esophagus,  stomach,  or  bronchi.  It 
may  be  associated  with  ulceration  of  the  hard  palate,  with  thrush,  or  with 
fissures  of  the  lips. 

Hemorrhages  from  the  nose  are  infrequent,  and  are  more  often  due  to 
syphilis  than  to  other  causes.  These  are  rarely  profuse,  but  are  fre- 
quently repeated. 

Subcutaneous  Hemorrhages.— These  often  appear  in  places  exposed 
to  pressure,  such  as  the  sacrum,  heels,  occiput,  or  back,  but  may  occur 
anywhere.  In  some  cases  these  hemorrhages  are  very  extensive,  as  in 
one  recently  under  observation,  where  nearly  one-third  of  the  thorax  was 
covered.  When  they  occur  alone  or  form  the  principal  lesion,  the  prog- 
nosis is  favorable. 

Hematuria. — The  urine  is  not  only  stained  with  blood,  but  some- 


SPONTANEOUS  HEMORRHAGES  105 

times  contains  clots.  This  hemorrhage  may  have  its  origin  in  the  blad- 
der, urethra,  or  kidney.  Blood  coming  from  the  kidney  is  sometimes 
due  to  the  irritation  of  uric-acid  infarctions,  and  may  have  nothing  to 
do  with  the  general  hemorrhagic  disease. 

Hemorrhage  from  the  Conjunctiva. — The  blood  usually  comes  in 
drops  from  between  the  eyelids,  chiefly  from  the  tarsal  surface.  It  is 
generally  preceded  by  conjunctivitis. 

Hemorrhage  from  the  Female  Genitals. — This  not  infrequently  oc- 
curs without  hemorrhages  elsewhere,  and  under  such  circumstances  is 
rarely  serious.  Cullingsworth  collected  thirty-two  cases  in  children 
under  six  weeks  of  age — no  case  having  resulted  fatally.  These  are  not 
to  be  regarded  as  cases  of  precocious  menstruation. 

Diag^nosis. — This  is  generally  easy,  as  the  hemorrhages  are  usually 
multiple  and  some  of  them  external.  A  slight  hemorrhage  from  the 
intestine  may  be  easily  overlooked.  Large  hemorrhages  into  the  in- 
ternal organs  also  are  obscure  and  not  often  recognized.  Spurious 
hemorrhages  from  the  stomach  may  occur,  blood  being  vomited  which 
has  been  swallowed  during  birth  or  nursing.  The  source  of  bleeding 
may  also  be  the  mouth,  nose,  or  pharynx,  and  sometimes  blood  is  swal- 
lowed in  large  quantities  and  afterward  vomited.  These  cavities  should 
therefore  always  be  examined,  since  local  treatment  may  be  efficacious. 
Syphilis  should  be  suspected  when  the  bleeding  is  chiefly  nasal. 

Prognosis. — Before  the  introduction  of  treatment  with  human  blood 
serum  the  hemorrhagic  disease  in  the  newly  born  had  a  very  bad  prog- 
nosis. Of  709  cases  collected  by  Townsend,  the  mortality  was  79  per 
cent.  No  case  should  be  looked  upon  as  hopeless,  for  perfect  recovery 
has  repeatedly  taken  place  when  it  seemed  impossible. 

Treatment. — Local  measures  may  be  employed  in  all  external  hemor- 
rhages with  some  prospect  of  benefit.  The  bleeding  points  may  be 
touched  with  persulphate  of  iron  or  with  chromic  acid  fused  upon  a 
probe,  or  fresh  human  blood  or  human  serum  may  be  applied  locally. 
These  measures  may  be  employed  alone  or  in  combination  with  pressure. 

Although  recoveries  have  been  reported  following  the  use  of  a  gTeat 
variety  of  remedies,  it  is  by  no  means  established  that  the  result  was 
due  to  the  drugs  employed.  Many  of  the  milder  cases  recover  without 
any  special  treatment.  On  the  whole,  the  medicinal  treatment  is  very 
unsatisfactory.  Epinephrin  is  of  doubtful  benefit.  Gelatin  has  had  many 
advocates.  It  is  used  by  subcutaneous  injection.  A  5-to-lO-per-cent 
solution  which  has  been  twice  sterilized  is  employed,  from  25  to  50  c.  c. 
being  administered  two  or  three  times  daily.  Calcium  lactate  in  some 
instances  appears  to  exert  a  positive  effect.  It  may  be  given  in  frequently 
repeated  doses  up  to  20  or  30  grains  a  day. 

The  most  efficient  treatment  is  transfusion,  first  practiced  by  Carrel. 


106  DISEASES  OF  THE  NEWLY  BORN 

It  should,  if  possible,  be  performed  whenever  the  loss  of  blood  has  been 
great.  From  90  to  150  c.  c.  may  be  given.  This  not  only  replaces  blood 
lost  but,  in  the  vast  majority  of  cases,  stops  further  bleeding  at  once.  Its 
action  seems  specific  and  the  effects  of  transfusion  are  often  truly  mar- 
velous. That  the  subcutaneous  or  intramuscular  injection  of  human  blood 
serum  would  control  these  hemorrhages  was  first  shown  by  J.  E.  Welch. 
Almost  equally  efficacious  is  the  injection  of  human  blood  in  the  same 
manner.  Usually  30  to  40  c.  c.  of  blood  or  blood  serum  is  injected  at  one 
time,  and  this  should  be  repeated  every  few  hours,  if  bleeding  continues. 
For  transfusion,  only  the  blood  of  a  parent  should  be  used  without  pre- 
vious hemolytic  tests ;  for  subcutaneous  use,  blood  from  any  healthy  person 
will  answer  as  well.  The  subcutaneous  injection  of  horse  serum  has  a 
certain  value  in  these  cases  and  should  be  employed  when  it  is  impractical 
to  obtain  human  blood  serum.  It  is,  however,  distinctly  inferior.  In 
some  instances  thrombin,  prepared  according  to  the  metliod  of  Howell, 
has  caused  a  cessation  of  the  hemorrhage.  A  small  proportion  of  patients, 
however,  are  not  improved  by  the  measures  mentioned,  and  in  spite  of 
them  bleeding  may  continue.  These  suggest  a  difi'erent  etiology  of 
which  we  have  as  yet  no  clue.  The  general  treatment  should  have  refer- 
ence to  maintaining  the  nutrition  by  careful  feeding,  judicious  stimula- 
tion, and  attention  to  the  circulation,  the  body  temperature,  and  the 
general  condition  of  the  child. 


CHAPTER   VI 

BIRTH  PARALYSES 

Birth  paralyses  are  chiefly  due  either  to  pressure  upon  the  child  by 
the  parts  of  the  mother,  or  to  artificial  means  employed  in  delivery. 
They  may  be  cerebral,  spinal,  or  peripheral. 

Cerebral  paralyses  are  in  almost  every  instance  due  to  meningeal 
hemorrhage,  and  accompanied  by  a  certain  amount  of  injury  to  the 
brain  substance.  A^ery  infrequently  they  depend  upon  cerebral  hemor- 
rhage, laceration  of  the  brain,  or  pressure  from  a  depressed  fracture. 

Spinal  paralyses  are  extremely  rare,  and  only  a_few  examples  are  on 
record.  They  are  due  to  laceration  of,  or  hemorrhage  into,  the  cord  or 
its  membranes.  These  lesions  produce  paraplegia,  the  exact  distribution 
of  which  depends  upon  the  point  at  which  the  cord  is  injured. 

Peripheral  paralyses  usually  affect  the  face  or  the  upper  extremity. 
Paralysis  of  the  face  is  due  in  most  cases  to  the  application  of  for- 
ceps.   Paralysis  of  the  upper  extremity  is  most  frequently  of  tlie  ^'upper- 


CEREBRAL  PARALYSIS 


107 


arm  type,"  and  is  known  as  the  Duchenne-Erb  paralysis.  It  usually  fol- 
lows extraction  in  breech  presentations.  Peripheral  paralysis  of  the  lower 
extremity  is  almost  unknown. 

CEREBRAL  PARALYSIS 


Cerebral  paralysis  is  often  used  synonymously  with  meningeal  hemor- 
rhage. This  lesion  is  not  infrequent,  and  is  of  great  importance  not 
only  from  its  immediate  effects,  but  because  upon  it  depend  many  of  the 
cerebral  paralyses  seen  in  later  life.  According  to  Cruveilhier,  at  least 
one-third  of  the  deaths  of  infants  which  occur  during  parturition  are 
due  to  this  cause. 

Etiology. — The  same  predisposing  causes  exist  in  the  cases  of  menin- 
geal hemorrhages  as  in  others  occurring  at  this  time.  A  small  number 
of  cases  are  associated 
with  syphilis ;  others 
with  pyogenic  infection. 
In  a  few  cases  there  is  a 
history  of  an  injury — 
usually  a  fall  or  blow 
upon  the  abdomen — dur- 
ing the  last  months  of 
pregnancy.  Meningeal 
hemorrhage  may  occur  as 
one  of  the  lesions  in  the 
hemorrhagic  disease  of 
the  newly  born.  The 
most  important  causes, 
however,  are  connected 
with  parturition.  These 
hemorrhages  are  essen- 
tially mechanical,  and 
are    favored    by    every- 


thing which  increases  or 


Fig.  10. — Meningeal  Hemorrhage  of  the  Newly 
Born.     (Extravasation  above  the  Tentorium.) 

prolongs    pressure    upon 

the  head.  The  conditions  with  which  they  are  associated  are  tedious  labor, 
breech  presentations  with  difficulty  in  extracting  the  head,  instrumental 
deliveries,  and  premature  births.  The  majority  occur  in  first-born  chil- 
dren. In  many  of  the  cases  there  is  also  a  hemorrhage  outside  the  skull. 
Lesions. — The  hemorrhages  may  be  large  or  small.  If  small,  they 
are  frequently  multiple  and  are  found  scattered  over  the  convexity. 
In  such  circumstances  they  are  usually  beneath  the  arachnoid. 
Edema  of  the  brain  is  often  associated  with  them.     It  is  doubtful  if 


108  DISEASES  OF  THE  NEWLY  BORN 

very  small  hemorrhages  that  may  cause  little  more  than  a  discolora- 
tion of  the  meninges  are  sufficient  to  account  for  death.  They  are 
found  so  frequently  when  there  have  been  no  symptoms  referable  to  the 
brain  that  it  is  a  question  if  they  are  not  quite  a  common  sequel  of 
labor.  Larger  hemorrhages  may  be  at  the  base  or  at  the  convexity  and 
either  in  the  anterior  or  posterior  part  of  the  skull.  When  upon  the 
convexity,  the  blood  usually  comes  from  the  veins  ascending  from  the 
middle  cerebral  region  to  the  lateral  aspects  of  the  superior  longi- 
tudinal sinus.  These  are  lacerated  by  the  over-lapping  of  the  parietal 
bones.  Convexity  hemorrhages  are  rarely  limited  to  one  hemisphere, 
although  the  one  side  may  be  much  more  affected.  It  is  usual  for 
the  blood  to  gravitate  toward  the  base  and  become  diffused.  Nearly 
the  entire  surface  of  the  brain  may  be  covered.  Hemorrhages  are  fre- 
quently found  over  the  cerebellum  and  the  occipital  lobes  of  the  cere- 
brum; these  are  usually  due  to  rupture  of  the  tentorium.  While  this 
may  allow  of  some  extravasation  of  blood  above  the  tentorium,  the 
entire  extravasation  is  often  beneath  it.  Eupture  of  the  tentorium 
is  usually  due  to  marked  lateral  compression  of  the  head,  but  may 
occur  when  the  pressure  is  anteroposterior.  It  is  apparent  that  hemor- 
rhages may  result  very  rarely  from  marked  venous  congestion.  In  this 
way  is  explained  the  hemorrhage  which  is  occasionally  found  in  the 
lateral  ventricles  alone.  This  comes  from  rupture  of  the  straight  sinus 
or  of  the  great  vein  of  Galen.  Hemorrhages  between  the  dura  and  the 
skull  may  be  said  never  to  occur  except  when  associated  with  fracture. 
If  the  child  is  still-born,  or,  if  death  has  occurred  on  the  first  or  second 
day,  the  blood  is  partly  fluid  and  partly  coagulated;  later  it  is  entirely 
coagulated  and  may  have  undergone  partial  absorption.  The  amount 
of  extravasated  blood  varies  between  one  dram  and  two  ounces,  the  aver- 
age amount  being  about  one-half  ounce.  The  blood  extends  into  the 
fissures  between  the  convolutions  and  sometimes  into  the  ventricles 
along  the  choroid  plexus,  although  this  is  rare.  In  large  hemorrhages 
the  brain  substance  is  softened  and  in  places  may  be  quite  disintegrated; 
but  with  small  extravasations  these  changes  are  very  slight  and  hard 
to  demonstrate  to  the  naked  eye.  In  cases  which  survive  for  two  or 
three  weeks  there  is  usually  a  certain  amount  of  meningitis.  The  later 
changes — those  of  arrested  development  of  the  cortex  and  cerebral  sclero- 
sis— will  be  considered  in  the  chapter  devoted  to  Cerebral  Paralyses 
in  the  section  on  Diseases  of  the  Nervous  System.  Hemorrhages  into 
the  membranes  of  the  upper  part  of  the  cord  are  .found  in  a  large  pro- 
portion of  the  fatal  cases.  Associated  hemorrhages  of  the  lungs  and 
other  organs  are  not  uncommon. 

Symptoms. — If  the  hemorrhage  is  large,  the  child  is  usually  still- 
born, although  the  fetal  movements  may  have  been  active  up  to  the 


CEREBRAL  PARALYSIS  109 

commencement  of  labor.  When  the  hemorrhage  is  not  so  large  as  to  be 
immediately  fatal,  the  child  may  show  no  symptoms  except  dulness  or 
stupor,  with  feeble  or  irregular  respiration,  death  following  within  the 
first  twenty-four  hours.  A  large  proportion  of  the  infants  are  born 
asphyxiated,  and  frequently  they  are  resuscitated  only  after  consider- 
able effort.  They  nurse  feebly  or  not  at  all.  Convulsions  are  common 
in  cases  which  last  for  four  or  five  days,  and  more  with  hemorrhages 
at  the  convexity  than  with  those  at  the  base.  Opisthotonus  is  often 
present,  also  general  rigidity  of  the  extremities,  clenching  of  the  hands, 
and  increased  knee-jerks.  Earely  there  is  complete  relaxation  of  all 
the  muscles.  Sometimes  there  are  automatic  movements.  The  respira- 
tion is  usually  disturbed;  in  most  cases  it  is  slow  and  irregular.  The 
pulse  is  feeble  and  usually  slow.  The  pupils  are  more  frequently  con- 
tracted than  dilated,  and  there  may  be  oscillation  of  the  eyeballs.  There 
may  be  a  slight  exophthalmus.  In  large  hemorrhages  there  is  marked 
bulging  of  the  fontanel,  and  often  separation  of  the  sutures.  If  the 
hemorrhage  covers  one  hemisphere,  there  is  complete  hemiplegia  of 
the  opposite  side.  Small  localized  cortical  hemorrhages  may  cause 
paralysis  of  the  face,  arm,  or  leg,  according  to  the  position  of  the  lesion, 
or  localized  convulsions.  In  large  hemorrhages  at  the  base  convulsions 
are  rare,  and  death  occurs  early,  usually  in  the  first  two  days.  In 
extensive  cortical  hemorrhages  convulsions  and  rigidity  of  the  extremi- 
ties are  frequent,  and  life  may  be  prolonged  indefinitely.  There  is 
usually  no  fever,  but  exceptionally  the  temperature  may  be  high. 

The  majority  of  the  fatal  cases  die  within  the  first  four  days.  In 
those  lasting  a  longer  time  the  symptoms  are  tonic  spasm  of  the  trunk 
or  of  one  or  more  of  the  extremities,  with  localized  paralysis — mono- 
plegia, diplegia,  or  hemiplegia,  according  to  the  lesion — and  localized 
or  general  convulsions  often  continuing  for  two  or  three  weeks  and 
gradually  subsiding.  In  the  mildest  cases  nothing  abnormal  may  be 
noticed  until  the  child  is  old  enough  to  walk  or  talk.  In  those  more 
severe  there  may  be  gradual  and  continuous  improvement  of  the  early 
symptoms,  and  the  case  may  go  on  to  apparent  recovery,  but  usually 
there  is  some  permanent  damage  to  the  brain. 

The  main  diagnostic  symptoms  in  recent  cases  are :  bulging  fontanel, 
slow  pulse,  stupor,  rigidity,  increased  reflexes,  convulsions,  and  paralysis, 
especially  when  localized,  and  opisthotonus.  These  vary  with  the  extent 
and  situation  of  the  lesion.     Lumbar  puncture  has  very  doubtful  value. 

Prognosis. — A  large  hemorrhage  at  the  base  quickly  causes  death; 
if  it  is  located  at  the  convexity,  although  the  child  may  survive,  there  is 
always  serious  damage  to  the  brain.  Even  from  small  hemorrhages 
some  permanent  injury  usually  results,  though  the  extent  of  this  may 
not  be  evident  for  years. 


110  DISEASES  OF  THE  NEWLY  BORN 

Treatment. — This  is  mainly  prophylactic,  the  chief  indication  being 
to  shorten  tedious  labors  by  the  early  use  of  the  forceps.  When  the 
hemorrhage  has  been  attributed  to  the  forceps,  the  damage  has  prob- 
ably been  the  result  of  the  long-continued  pressure  before  they  were  used. 
Nothing  can  be  done  after  delivery  to  limit  the  amount  of  the  hemor- 
rhage, except  to  keep  the  child  as  quiet  as  possible.  The  removal  of  the 
clot  by  surgical  operation  has  been  successfully  accomplished  by  Gushing 
and  others.  With  more  accurate  diagnosis  there  seems  to  be  no  reason 
why  a  certain  number  may  not  be  saved.  For  the  best  results  opera- 
tion should  be  done  as  soon  as  possible.  One  great  difficulty  is  that 
of  early  and  accurate  diagnosis.  Paralysis  whether  localized  or  general 
is  of  greater  value  in  diagnosis  than  are  convulsions.  The  latter,  how- 
ever, are  especially  important  when  localized  or  continuous  and  threat- 
ening life.  The  operative  risk,  while  considerable,  is  not  to  be  measured 
against  the  permanent  mental  deficiency  usually  resulting  in  most  of 
these  children  when  nothing  is  done.  Cases  with  similar  symptoms 
are  sometimes  seen  in  which  there  is  no  extravasation  of  blood  found 
at  operation,  but  only  intense  congestion  with  an  excessive  serous  ex- 
udate. In  them  also  relief  may  follow  operation.  The  hopeless  outlook 
for  such  cases  when  not  relieved,  justifies  the  taking  of  great  risks. 


FACIAL  PARALYSIS 

The  usual  cause  of  facial  paralysis  is  the  use  of  the  forceps,  but  this 
does  not  explain  all  the  cases.  The  etiology  of  those  in  which  the  for- 
ceps have  not.  been  used  is  still  somewhat  obscure.  In  peripheral  facial 
palsy  the  nerve  is  pressed  upon,  either  near  its  exit  from  the.  stylomas- 
toid foramen,  or  where  it  crosses  the  ramus  of  the  jaw,  at  which  point 
the  parotid  gland  gives  it  but  little  protection  in  the  newly  born.  If  the 
lesion  is  in  front  of  this  point,  any  one  of  the  terminal  branches  may 
be  affected;  most  frequently  it  is  the  temporofacial  branch.  As  only 
one  blade  of  the  forceps  commonly  touches  the  face  in  this  region,  the 
paralysis  is,  as  a  rule,  unilateral. 

Eoulland  has  reported  several  cases  not  due  to  the  forceps.  In  these 
the  pressure  is  believed  to  have  been  produced  by  the  promontory  of  the 
sacrum  at  the  stiperior  strait,  or  by  the  ischium  at  the  inferior  strait,  as 
paralysis  followed  when  the  head  was  long  arrested  at  one  of  these  points. 
It  was  not  seen  with  face  or  breech  presentations.  When  facial  paralysis 
is  of  central  origin  it  depends  generally  upon  a  meningeal  hemorrhage, 
and  the  arm  and  leg  of  the  same  side  as  the  face  are  involved.  It  is, 
however,  possible  for  a  very  small  cortical  hemorrhage  to  produce 
paralysis  of  the  face  only. 


BRACHIAL  BIRTH  PALSY  111 

In  repose,  the  only  symptom  noticed  may  be  that  the  eye  remains 
open  upon  the  affected  side,  owing  to  paralysis  of  the  orbicularis  palpe- 
brarum. When  the  muscles  are  called  into  action,  as  in  crying,  the 
whole  side  of  the  face  is  seen  to  be  affected.  The  paralyzed  side  is 
smooth,  full,  and  often  appears  to  be  somewhat  swollen.  The  mouth 
is  drawn  to  the  side  not  affected.  In  this  paralysis,  the  tongue,  of  course, 
is  not  implicated.  It  is  therefore  rare  that  nursing  is  seriously  in- 
terfered with.^  If  the  paralysis  is  of  central  origin,  only  the  lower  half 
of  the  face  is  involved,  while  in  peripheral  paralysis,  as  the  trunk  of 
the  nerve  is  injured,  the  upper  half  of  the  face,  including  the  orbicularis 
palpebrarum,  is  also  affected. 

The  paralysis  is  generally  noticed  on  the  first  or  second  day  of  life, 
and  does  not  increase  in  severity.  Its  course  and  termination  depend 
upon  the  extent  of  the  injury  done  to  the  nerve.  Some  idea  of  this  may 
often  be  gained  by  the  amount  of  injury  to  the  soft  j)arts,  although  this 
is  not  an  Infallible  guide.  In  cases  not  due  to  tlie  forceps,  the  paralysis 
is  slight  and  disappears  in  a  few  days;  the  great  majority  of  the  forceps 
cases  follow  the  same  favorable  course,  the  paralysis  gradually  disap- 
pearing without  treatment  in  about  two  weeks.  In  more  serious  cases 
it  may  last  for  months,  or  it  may  be  permanent.  The  reaction  of  de- 
generation is  present  in  these  severe  cases,  and  there  may  even  be  per- 
ceptible atrophy  of  the  muscles.  This  symptom  is  fortunately  extremely 
rare. 

Treatment. — Nothing  should  be  done  for  the  first  ten  days  except  to 
IDrotect  the  eye  and  keep  it  clean.  If  improvement  has  begun  by  the  end 
of  this  time,  the  probabilities  are  that  the  case  will  require  no  treatment. 
If  no  improvement  has  taken  place  by  the  end  of  the  third  or  fourth 
week,  electricity  should  be  used  regularly  and  systematically.  If  the 
muscles  respond  to  it,  the  faradic  current  may  be  employed;  if  not, 
galvanism  should  be  used.  The  electrical  treatment  should  be  continued 
for  several  months,  or  until  recovery  has  taken  place. 


BRACHIAL  BIRTH  PALSY 

This,  sometimes  called  "obstetrical  paralysis"  or  "Duchenne-Erb 
paralysis"  is  fortunately  not  a  common  condition.  It  is  almost  always 
unilateral,  though  occasionally  Ijoth  arms  are  involved.  It  may  result 
from  spontaneous  delivery  but  is  vastly  more  frequent  following 
operative  interference  in  difficult  labor.  In  the  majority  of  cases  it 
is  directly  due  to  manipulation,  though  it  may  occur  in  tlie  practice 

^In  this  connection  it  is  to  be  remembered  that  the  principal  part  in  nursing  is 
done  by  the  tongue,  and  not  by  the  lips. 


112 


DISEASES  OF  THE  NEWLY  BORN 


of  the  most  skillful.  Pressure  from  the  application  of  forceps,  while 
a  possibility,  is  an  infrequent  cause,  though  long  regarded  as  the  most 
important  one.  The  injury  may  be  produced  by  any  manipulation  thkt 
forcibly  draws  the  head  and  neck  away  from  the  shoulder.  This  puts 
the  brachial  plexus  upon  the  stretch.  If  the  force  is  slight,  only  stretch- 
ing of  the  nerves  is  caused;  if  more  extreme,  laceration  of  the  nerves 
is  produced  from  above  downward.  The  suprascapular  nerve  is  by 
its  position  the  one  most  exposed  to  injury  and  is  the  one  that  is  first 
and  most  severely  torn.    The  fifth  cervical  next  is  affected,  then  the  sixth, 

the  seventh  and  perhaps  the 
eighth  and  the  first  dorsal. 
While  the  injury  is  almost 
always  to  the  plexus  alone 
it  is  probable  that  in  some 
cases  one  or  more  of  the 
roots  in  the  cervical  region 
may  be  torn  from  the  cord. 
The  amount  of  spontaneous 
improvement  depends  upon 
the  extent  of  the  lesion. 
When  only  overstretching 
has  been  produced,  a  com- 
plete recovery  may  take 
place.  The  same  may  be 
true  when  the  laceration  of 
the  nerves  has  been  slight 
and  the  ends  remain  in  ap- 
position. When  more  ex- 
tensive injury  has  taken  place  complete  recovery  cannot  be  expected. 
Hemorrhage  has  occurred  and  there  has  been  laceration  of  the  fascia 
as  well  as  the  nerves.  The  result  is  usually  the  production  of  a  cica- 
tricial mass  that  interrupts  the  continuity  of  the  nerves  and  prevents 
their  regeneration.     The  nerve  impulses  are  thus  blocked. 

The  paralysis  in  severe  cases  is  noticed  soon  after  birth  owing  to 
the  fact  that  the  infant  cannot  use  his  arm.  In  less  severe  cases  the 
paralysis  may  escape  detection  for  several  weeks. 

The  most  common  form  of  peripheral  paralysis  is  that  known  as 
the  "upper-arm  type.''  The  muscles  paralyzed  are  the  deltoid,  biceps, 
brachialis  anticus,  supinator  longus,  and  sometimes  the  supra-  and  infra- 
spinatus. All  these  muscles  may  be  involved,  or  only  part  of  them,  and 
in  varying  degrees.  The  arm  hangs  lifeless  by  the  side;  it  is  rotated 
inward,  the  forearm  pronated,  the  palm  looking  outward  (Fig.  11).  The 
forearm  and  hand  are  not  affected,  except  in  cases  where  the  whole  plexus 


Fig.  11. — Erb's  Pabalysis,  Left  Arm. 
Infant  two  months  old. 


BRACHIAL  BIRTH  PALSY  113 

has  been  lacerated.  In  severe  cases  there  may  l)e  anesthesia  of  the  outer 
surface  of  the  arm,  in  the  region  supplied  by  the  circumflex  and  external 
cutaneous  nerves.  This  is  rarely  marked,  and  in  its  -slighter  degrees  it 
is  very  difficult  to  determine.  It  is  characteristic  of  this  paralysis  that 
the  triceps  is  not  affected,  so  that  power  to  extend  the  forearm  remains, 
although  it  cannot  be  flexed.  A  nodular  mass  in  the  region  of  the  plexus 
may  be  felt.  This  is  the  result  of  the  hemorrhage  and  the  inflammatory 
reaction.  Atrophy  of  the  paralyzed  muscles  occurs  after  a  few  weeks,  but 
the  muscles  are  so  small  and  so  covered  with  fat  that  it  is  rarely  notice- 
ahle  before  the  second  year.  It  is  most  conspicuous  in  the  deltoid.  In 
all  severe  cases  the  reaction  of  degeneration  is  present.  In  some  of  the 
cases  of  long  standing  there  occurs  a  shortening  of  the  tendon  of  the 
subscapularis  muscle,  often  associated  with  subluxation  of  the  humerus. 
The  paralysis  may  be  complicated  with  fracture  of  the  clavicle,  the  neck 
of  the  scapula,  or  the  shaft  of  the  humerus,  or  with  epiphyseal  separation 
of  its  head.  Injury  confined  to  one  nerve  is  very  uncommon.  We  have 
seen  two  cases  in  which  there  was  temporary  paralysis  of  only  the  muscles 
supplied  by  the  musculo-spinal  nerve.  The  explanation  of  such  cases  is 
obscure. 

The  prognosis  depends  upon  the  severity  of  the  injury.  Some  cases 
recover  spontaneously  in  two  or  three  months,  improvement  being  ob- 
served within  a  few  weeks,  first  in  the  biceps  and  last  in  the  deltoid. 
Recovery  after  many  months  may  take  place  even  in  cases  appar- 
ently severe.  Gradual  improvement  may  continue  to  the  end  of  the  sec- 
ond year.  The  condition  is,  however,  a  very  serious  one.  There  is  usually 
some  permanent  paralysis  left  and  it  may  be  so  marked  as  to  render  the 
arm  almost  useless.  Permanent  paralysis  is  most  frequently  of  the  del- 
toid. 

The  electrical  reactions  are  of  some  value  in  prognosis.  If  the  mus- 
cles respond  to  faradism,  rapid  improvement  can  generally  be  prophesied. 
If  the  reaction  of  degeneration  is  present,  improvement  will  be  slow  and 
the  paralysis  is  likely  to  be  permanent.  . 

The  diagnosis  is  usually  not  difficult,  since  the  great  majority  of  cases 
are  of  the  "upper-arm  type"  with  classical  symptoms.  Peripheral  palsy 
of  the  arm  can  scarcely  be  confounded  with  that  of  cerebral  origin.  If 
the  lesion  is  central  it  is  one  of  the  rarest  occurrences  for  the  arm  alone 
to  be  involved;  either  the  leg  or  face,  or  both,  are  generally  likewise 
affected.  If  the  case  does  not  come  under  observation  until  the  child  is 
a  year  old,  it  may  be  difficult,  or  without  a  good  history  it  may  be  impos- 
sible to  distinguish  peripheral  paralysis  from  that  due  to  poliomyelitis. 
The  particular  group  of  muscles  involved  in  Erb's  paralysis  is  the  chief 
diagnostic  point. 

In  recent  cases  the  disability  resulting  from  the  tenderness  or  pain  of 


114  DISEASES  OP  THE  NEWLY  BORN 

syphilitic  epiphysitis  may  simulate  paralysis^  but  there  is  lacking  the 
characteristic  position  of  the  arm,  and  a  careful  examination  discloses 
the  fact  that  the  paralysis  is  only  apparent.  This  may  affect  both  sides. 
Fracture  of  the  clavicle  or  epiphyseal  separation  of  the  head  of  the 
humerus  may  also  be  nlistaken  for  paralysis.  In  cases  of  long  standing, 
paralysis  of  the  deltoid  may  resemble  dislocation  of  the  humerus.  The 
reaction  of  degeneration  differentiates  paralysis  from  surgical  injuries 
with  similar  deformities. 

Treatment. — As  soon  as  the  paralysis  is  discovered  the  injured  arm 
should  be  put  at  rest  by  means  of  a  sling,  with  the  shoulder  elevated  in 
order  to  bring  the  ends  of  the  nerves  in  apposition.  At  the  end  of  two 
or  three  weeks  gentle  massage  may  be  employed.  ,  In  cases  going  on  to 
permanent  recovery  improvement  is  rapid.  At  the  end  of  two  months^ 
it  is  generally  possible  to  tell  to  what  extent  recovery  will  take  place.  If 
very  little  has  been  gained  by  that  time,  and  if  a  surgeon  expert  in 
nerve  surgery  can  be  consulted,  operation  should  be  considered,  for 
at  this  time  less  nerve  degeneration  will  have  taken  place  than  at  a 
later  date  and  the  regeneration  of  the  nerves  will  require  much  less  time. 
The  operation  consists  in  dissecting  out  and  suturing  the  nerve  trunks 
whose  continuity  has  been  broken  by  the  injury.  A.  S.  Taylor,  New 
York,  from  an  extended  experience,  has  reported  marked  improvement 
in  some  otherwise  hopeless  cases  by  this  operation.  Though  useful  in 
mild  cases,  but  little  is  to  be  expected  from  manipulation  and  electricity 
.in  severe  cases  without  operation. 


CHAPTEE  VII 
TUMORS  OF  THE  UMBILICUS,  MASTITIS,  ETC. 

Granuloma. — This  is  nothing  more  than  a  mass  of  exuberant  granu- 
lations at  the  umbilical  stump.  The  mass  is  generally  about  the  size  of  a 
pea — sometimes  larger — bleeds  readily,  and  has  a  thin,  purulent  dis- 
charge. It  is  promptly  cured  by  the  application  of  any  simple  astringent ; 
powdered  alum  is  probably  the  best.  In  case  this  is  not  successful,  the 
granulations  may  be  touched  with  nitrate  of  silver  or  snipped  off  with 
scissors. 

Adenoma,  Mucous  Polypus,  or  Diverticulum  Tumor — TTmbilical  Fis- 
tula.— The  first  three  terms  are  used  synonymously  to  describe  an  umbil- 
ical tumor  covered  with  a  mucous  membrane  which  is  similar  in  structure 
to  that  of  the  small  intestine.  It  is  usually  associated  with  an  umbilical 
fistula.  This  tumor  is  formed  by  a  prolapse  at  the  navel  of  the  mucous 
membrane  of  Meckel's  diverticulum.     This  diverticulum  is  the  remains 


ADENOMA,  MUCOUS  POLYPUS,  OR  DIVERTICULUM  TUMOR   115 

of  the  omphalomesenteric  duct.  When  it  is  present  in  infants,  it  is  found 
in  various  stages  of  development.  Most  frequently  there  is  a  blind  pouch 
a  few  inches  long  given  off  from  the  lower  part  of  the  ileum.  In  other 
cases  it  may  remain  patent  quite  to  the  umbilicus,  causing  a  fecal  fistula 
(Fig..  12,  A).  As  the  intestine  below  it  is  generally  normal,  this  fistula 
may  persist  for  months  or  even  years,  giving  rise  to  no  symptoms  except 
a  slight  fecal  discharge  from  the  umbilicus.  In  certain  cases  intestinal 
worms  have  been  discharged  through  it.  It  may  close  spontaneously  or 
be  closed  by  operation. 

A  prolapse  of  the  mucous  membrane  lining  the  diverticulum  produces 
an  umbilical  tumor  with  a  fistula  at  its  summit  (Fig.  12,  B).  This  is 
the  most  common  form.    A  cross-section  shows  under  the  microscope  the 


Fig.  12. 


-Umbilical   Fistula   and   Tumors   Produced   by   Prolapse    of    Meckel's 
Diverticulum.     (Barth.) 


structure  of  the  intestinal  mucous  membrane  both  as  an  external  covering 
and  lining  of  the  fistulous  tract.  The  prolapse  may  involve  not  only  the 
mucous  membrane  but  the  entire  intestinal  wall.  There  then  exists  a 
conical  tumor  with  a  fistula  which  has  but  one  external  opening,  but  at  a 
short  distance  from  the  surface  it  bifurcates,  one  branch  leading  upward 
and  one  downward  (Fig.  12,  C).  A  continuation  of  the  prolapse  gives 
a  broad  pedunculated  tumor  (Fig.  12,  D),  which  may  reach  the  size  of 
an  orange.  Its  covering  is  the  same  as  in  the  other  forms.  It  may 
contain  several  coils  of  intestine.  In  this  form  there  are  usually  two 
fistulous  openings  {a,  h)  which  communicate  with  the  intestine. 

In  all  of  these  cases  the  tumor  is  smooth,  irreducible,  of  a  rosy  pink 
color,  and  from  its  surface  there  oozes  a  mucous  discharge.  Microscopical 
examination  shows  the  external  covering  to  be  the  same  in  structure  as 
the  intestinal  mucous  membrane.  These  tumors  are  generally  small, 
varying  in  size  from  a  pea  to  a  small  cherry,  but  they  may  be  very  mucli 
larger.  A  fecal  fistula  usually,  but  not  invariably,  coexists.  In  the  con- 
dition represented  in  Fig.  12,  B,  it  is  easy  to  see  how  an  obliteration  of 
the  fistula  may  occur.     The  small  tumors  are  readily  cured  by  tlie  liga- 


116  DISEASES  OF  THE  NEWLY  BORN 

ture.  The  larger  ones  are  usually  associated  with  other  serious  mal- 
formations of  the  intestines,  which  make  the  outlook  bad  in  almost  every 
instance. 

UMBILICAL  HERNIA 

Hernia  into  the  umbilical  cord  is  a  rare  congenital  condition  of  a 
serious  nature.  It  is  due  to  some  fetal  defect,  and  varies  in  size  from 
a  small  protrusion  to  complete  eventration  in  which  nearly  all  the  abdom- 
inal organs  are  outside  the  body.  Many  cases  in  which  only  intestinal 
coils  are  contained  in  the  sac,  though  the  tumor  is  quite  large,  are  amen- 
able to  surgical  treatment,  which  should  be  instituted  at  once.  In  the 
very  large  ones  the  prognosis  is  bad. 

The  common  umbilical  hernia  is  quite  a  different  condition,  and 
while  a  source  of  much  annoyance  it  is  rarely  serious.  It  is  much  more 
common  in  females  than  in  .males,  and  occurs  especially  in  those  who  are 
poorly  nourished  and  rachitic.  The  tumor  is  usually  from  one-fourth 
to  one-half  an  inch  in  diameter ;  it  may,  however,  be  very  large,  -and  may 
even  become  strangulated,  when  a  surgical  operation  may  become  neces- 
sary. The  ordinary  cases,  however,  require  only  mechanical  treatment. 
The  most  important  thing  is  prevention.  For  this  purpose  it  is  neces- 
sary, after  the  cord  has  separated,  to  place  a  firm  pad  over  the  navel  and 
to  use  a  snug  abdominal  band  for  the  first  two  or  three  months.  After 
this  period  it  is  uncommon  for  hernia  to  develop.  In  cases  coming  under 
observation  after  the  third  or  fourth  month,  the  pad  and  abdominal 
bandage  are  inadequate,  and  other  means  must  be  employed  to  retain 
the  hernia.  The  best  of  these  consists  in  the  use  of  two  adhesive  strips 
applied  obliquely  over  the  abdomen,  crossing  at  the  umbilicus,  the  skin 
along  the  median  line  being  folded  inward  so  as  to  overlap  the  tumor, 
this  forming  the  retention  pad.  A  simple  method  of  retention  is  to  place 
over  the  tumor  a  coin  or  button  covered  with  kid  and  hold  it  in  position 
by  a  strip  of  adhesive  plaster  ten  or  twelve  inches  long.  One  should  be 
cautious  about  using  the  small  conical  pads  frequently  employed,  as  these 
tend  to  dilate  the  opening  rather  than  to  close  it.  If  the  skin  is  made 
absolutely  clean  and  zinc-oxid  plaster  used,  excoriations  are  rare.  The 
dressing  should  be  changed  every  week  or  ten  days  and  worn  for  several 
months.  After  the  first  year  all  mechanical  treatment  is  unsatisfactory. 
For  the  very  small  tumors  it  is  really  unnecessary  to  use  any  form  of 
apparatus,  since  these  cases  ordinarily  show  little  or  no  tendency  to 
increase  in  size,  and  the  retention  apparatus  causes  more  annoyance  than 
the  hernia.  These  small  herniae  sometimes  disappear  spontaneously  dur- 
ing childhood,  and  rarely  need  be  considered  in  children  over  seven  years 
of  age.     Operation  is  seldom  necessary. 


MASTITIS  117 


MASTITIS 


According  to  Guillot,  a  certain  amount  of  secretion  in  the  breasts  of 
the  newly  born  is  physiological.  It  is  certainly  very  common.  It  is  most 
abundant  between  the  eighth  and  fifteenth  days,  but  may  continue  in 
small  quantities  as  late  as  the  third  month.  It  is  seen  with  equal  fre- 
quency in  both  sexes.  The  quantity  of  the  secretion  amounts  in  most 
cases  only  to  a  few  drops;  in  some,  however,  as  much  as  a  dram  has 
been  obtained.  Chemical  analysis  has  shown  this  secretion  to  be  essen- 
tially the  same  as  the  adult  milk — containing  fat,  sugar,  j^rotein,  and 
salts.  In  gross  appearance  it  resembles  colostrum.  The  researches  of 
Sinety  have  shown  that  the  mammary  gland  of  the  newly  born  contains 
cul-de-sacs  lined  with  secreting  cells,  resembling  those  of  the  adult. 
During  the  period  of  secretion  the  gland  is  slightly  reddened,  its  vessels 
turgid,  and  all  the  signs  of  functional  activity  are  present.  This  condi- 
tion in  itself  is  of  no  practical  importance,  and  in  most  cases,  if  left 
alone,  the  secretion  ceases  spontaneously  after  a  week  or  ten  days.  It 
sometimes  happens,  however,  that  the  presence  of  this  secretion  tempts 
the  nurse  or  attendant  to  rub  or  squeeze  the  breast.  Such  manipulation 
occasionally  leads  to  serious  results  by  exciting  a  mastitis  which  may 
terminate  in  abscess.  Mastitis  is  not  a  very  rare  condition,  and  although 
the  inflammation  is  not  usually  severe,  it  may  be  serious  and  even  fatal. 
The  predisposing  cause  is  the  congestion  which  accompanies  functional 
activity,  usually  in  the  second  week.  The  exciting  cause  is  most  often 
some  form  of  traumatism — undue  pressure,  the  squeezing  of  the  breasts, 
or  rough  handling  by  the  nurse.  Through  abrasions  or  fissures  thus  pro- 
duced, microorganisms  find  a  ready  entrance  with  the  same  result  as  in 
the  adult.  It  seems  possible  that  the  germs  may  enter  through  the  lac- 
tiferous ducts  without  any  abrasion  of  the  skin.  Want  of  cleanliness  is 
always  a  favorable  condition  for  such  infection. 

The  symptoms  of  mastitis  usually  begin  during  the  second  week  of 
life.  There  is  redness,  swelling,  and  the  usual  signs  of  inflammation, 
which  may  terminate  in  resolution  or  in  suppuration.  The  process  may 
be  limited  to  the  mammary  region,  or  a  diffuse  phlegmonous  inflamma- 
tion may  be  set  up,  and  the  case  terminate  fatally.  In  the  female  it  is 
possible  for  the  cicatrization  which  follows  such  an  inflammation  to  inter- 
fere with  the  subsequent  development  of  the  gland.  The  general  symp- 
toms are  restlessness,  loss  of  sleep,  disinclination  to  nurse,  and  loss  of 
weight.  In  cases  of  diffuse  phlegmonous  inflammation  the  general  symp- 
toms are  those  of  pyogenic  infection. 

The  parts  should  be  kept  scrupulously  clean,  and  on  no  account 
should  squeezing  of  the  breasts  be  permitted.    They  should  be  protected 


118  DISEASES  OF  THE  NEWLY  BORN 

by  a  cotton  pad.     If  acute  inflammation  develops,  it  should  be  treated 
as  a  suro^ical  affection. 


INTESTINAL  OBSTRUCTION 

The  most  frequent  causes  of  intestinal  obstruction  in  the  newly  born 
are  malformations  of  the  intestine ;  rarely  it  may  be  due  to  pressure  from 
tumors,  or  from  a  persistent  omphalomesenteric  duct  or  artery.  The 
various  pathological  conditions  present  in  intestinal  malformations  are 
considered  in  the  chapter  on  Diseases  of  the  Intestines.  The  most  com- 
mon seat  of  obstruction  is  at  the  anus,  the  bowel  being  normally  formed 
throughout,  lacking  only  the  external  orifice.  The  next  most  frequent 
condition  is  obstruction  in  the  rectum,  which  may  be  due  either  to  a 
membranous  septum  in  the  gut,  or  to  obliteration  of  the  tube  for  some 
distance.  These  rectal  obstructions  are  readily  recognized.  By  the 
examining  finger  or  a  bougie  the  lower  limit  of  tlue  obstruction  can  be 
made  out,  but  there  is  no  means  by  which  the  upper  limit  can  be  deter- 
mined except  by  opening  the  abdomen.  When  the  obstruction  is  above 
the  rectum,  localization  is  more  difficult;  but  the  most  frequent  seat  is 
the  duodenum.  Of  38  cases  collected  by  Gaertner,  the  seat  of  obstruction 
was  the  duodenum  in  19  cases,  the  jejunum  in  3,  the  ileum  in  11,  the 
colon  in  6,  the  ileum  and  colon  in  1.  There  is  often  obstruction  at  more 
than  one  point. 

The  symptoms  vary  with  the  seat  and  the  degree  of  the  obstruction. 
In  atresia  of  the  anus  or  rectum  there  is  at  first  simply  an  absence  of  all 
discharges  from  the  bowel.  Later  there  is  abdominal  distention  from 
dilatation  of  the  sigmoid  flexure  and  colon.  After  several  days  vomiting 
begins.  If  there  is  atresia  of  the  duodenum  or  any  part  of  the  small 
intestine,  vomiting  begins  early — usually  by  the  second  day  of  life — and 
it  is  persistent.  Nothing  is  passed  from  the  bowels  after  the  first  dark 
discharge  of  the  contents  of  the  colon,  which  is  chiefiy  mucus.  There  is 
raj)id  asthenia,  and  death  from  inanition  usually  occurs  in  four  or  five 
days.  The  higher  the  obstruction  the  shorter  the  duration  of  life.  If 
the  condition  is  one  of  stenosis  only,  the  symptoms  are  similar  to  those 
described  but  less  severe,  and  life  may  be  prolonged  for  several  weeks,  or 
even  months.  The  constipation  in  these  cases  is  not  absolute.  When  the 
cause  of  obstruction  is  external  pressure,  the  symptoms  do  not  always 
begin  immediately  after  birth.  We  once  saw  a  child  in  whom  nothing 
abnormal  was  noticed  for  the  first  three  weeks,  but  at  the  end  of  that 
time  there  developed  all  the  signs  of  acute  intestinal  obstruction.  Lapa- 
rotomy revealed  a  loop  of  intestine  constricted  by  a  tiny  cord,  which  was 
probably  the  remains  of  the  omphalomesenteric  duct. 


DIAPHll AC :yr ATTC  TTERXTA 


119 


Cases  of  imperforate  anus  and  membranous  septum  in  tlie  rectum  are 
readily  relieved  by  proper  surgical  treatment.  In  the  other  varieties  of 
obstruction,  whether  in  the  rectum,  in  the  colon,  or  in  the  small  intestine, 
although  life  may  jje  prolonged  by  the  formation  of  an  artificial  anus, 
the  ultimate  result  is  almost  invariably  fatal,  death  usually  occurring 
from  marasmus  during  the  early  weeks  of  life. 

DIAPHRAGMATIC  HERNIA 

This  is  due  to  a  congenital  deficiency  in  the  diaphragm,  which  is 
usually  on  the  left  side.  Of  118  cases  collected  by  Livingston,  83  were 
on  the  left  side,  18  on  the  right,  4  were  central^  2  were  double,  in  1  the 
diaphragm  was  absent.  With  small  openings  only  a  single  coil  of  intes- 
tine, with  large  ones  a  considerable  part  of  the  abdominal  contents,  may 


Fig.  1.3,  A. — Diaphragmatic  Hernia  of 
THE  Right  Side,  Posterior  View. 
Child  sixteen  months  old;  died  of 
pneumonia  at  three  and  a  half  years. 


Fig.  1.3,  B. — The  Same,  Immediately 
after  Administration  of  Bismuth 
in  Suspension.  Stomach  in  the  right 
thoracic  cavity. 


be  found  in  the  thorax.  This  causes  displacement  of  the  heart,  usually 
to  the  right  side,  prevents  the  full  expansion  of  the  left  lung,  and  if  the 
deformity  occurs  early  in  intra-utcrine  life  the  lung  may  remain  rudi- 
mentary. If  a  large  deficiency  exists,  infants  may  live  but  a  few  hours; 
with  smaller  ones,  life  may  be  prolonged  indefinitely. 

The  symptoms  noticed  soon  after  birth  are  usually  cyanosis,  rapid 
respiration,  a  sunken  abdomen,  an  overdistended  chest,  and  dyspnea. 
Children  often  live  but  a  few  hours.    In  those  who  survive  a  longer  time 


120  DISEASES  OF  THE  NEWLY  BORN 

dyspnea  is  generally  the  most  prominent  symptom.  It  may  be  constant, 
it  may  occur  in  severe  paroxysms,  or  there  may  be  attacks  of  cyanosis 
often  of  great  severity,  these  being  produced  by  an  accumulation  of  gas 
in  the  stomach  or  the  thoracic  part  of  the  intestine.  Other  symptoms 
may  at  times  suggest  intestinal  obstruction.  The  physical  signs  vary 
much  from  time  to  time.  Sometimes  those  of  pneumothorax  are  present ; 
at  others  there  is  so  much  dulness  with  the  feeble  respiratory  sounds, 
as  to  suggest  fluid.  The  signs  are  usually  upon  the  left  side,  with  dis- 
placement of  the  heart  to  the  right.  A  positive  diagnosis  can  often  be 
made  by  means  of  the  X-ray  after  the  administration  of  bismuth.  (See 
Figs.  13,  A,  and  13,  B.)     The  condition  is  not  amenable  to  treatment. 


CONGENITAL  STRIDOR 

This  term  has  been  given  to  a  rather  rare  form  of  dyspnea  seen  in 
very  young  infants,  beginning  usually  in  the  first  days  of  life.  Eespira- 
tion  is  noisy  and  inspiration  is  accompanied  by  a  marked  croaking,  or 
crowing  sound,  and  with  recession  of  the  soft  parts  of  the  chest  wall, 
which,  especially  at  times  of  excitement,  may  be  very  great,  yet  there 
is  no  cyanosis  and  no  subjective  distress.  In  spite  of  the  apparent  diffi- 
culty of  respiration  the  child  seems  comfortable.  Expiration  is  usually 
easy  and  voice  and  cry  are  normal.  The  stridor  diminishes  when  the 
child  is  very  quiet  but  usually  does  not  quite  disappear  even  in  sleep. 

The  symptoms  begin  in  most  cases  immediately  after  birth  or  during 
the  first  week  or  ten  days  of  life.  They  may  increase  for  three  or  four 
weeks,  then  remain  about  stationary  until  the  sixth  or  eighth  month; 
after  which  with  the  growth  of  the  larynx  the  dyspnea  and  stridor 
steadily  diminish.  By  the  end  of  the  second  year  it  is  usually  gone  or 
heard  only  on  occasion. 

For  our  knowledge  of  this  affection  we  are  especially  indebted  to  the 
observations  of  Thomson,  of  Edinburgh,  who  believes  that  the  condition 
is  primarily  functional  and  due  to  a  want  of  proper  co-ordination  of 
the  respiratory  muscles.  Secondarily  there  is  produced  a  folding  of  the 
epiglottis  upon  itself  along  the  median  line,  so  that  its  lateral  borders 
approximate  each  other.  In  many  of  the  cases  reported,  however,  the 
change  in  the  larynx  seems  to  be  rather  a  malformation  especially  of  the 
epiglottis,  which  greatly  narrows  the  superior  opening  of  the  larynx. 
Congenital  stridor  is  favored  by  the  soft  collapsible  character  of  the 
structures  of  the  larynx  in  young  infants  and  the  strong  suction  force 
of  inspiration. 

The  prognosis  in  most  of  these  cases  is  good,  the  chief  dangers  being 
from   intercurrent   disease  or   from   bronchopneumonia.      Considerable 


SCLEREMA  121 

deformity  of  the  thorax  may  be  produced  (pigeon  breast)  which  may 
persist  to  later  childhood. 

The  diagnostic  features  of  congenital  stridor  are  the  noisy  respiration 
with  marked  inspiratory  dyspnea  and  crowing,  with  the  absence  of  dis- 
tress or  subjective  symptoms  of  any  kind.  It  seems  to  be  more  frequent 
in  delicate  children.  Conditions  with  which  it  may  be  confounded  are 
papilloma  of  the  larynx,  laryngismus  stridulus,  catarrhal  croup,  and 
laryngeal  spasm  associated  with  adenoids.  The  first  three  of  these  are 
excluded  by  the  history  and  by  the  absence  of  changes  in  the  voice; 
the  last  one  by  the  fact  that  the  child  is  not  a  mouth  breather,  that  the 
dyspnea  is  not  increased  by  closing  the  mouth. 

Congenital  stridor  is  not  amenable  to  special  treatment.  Should  the 
dyspnea  reach  an  alarming  degree  tracheotomy  may  be  performed.  The 
indications  are  to  maintain  the  child's  general  nutrition  and  to  protect 
him,  so  far  as  possible,  from  diseases  of  the  upper  respiratory  tract. 


SCLEREMA 

Sclerema  is  a  condition  characterized  by  hardening  of  the  skin  and 
subcutaneous  tissues.  It  may  occur  in  circumscribed  areas  or  extend  over 
nearly  the  entire  body.  It  affects  infants  who  are  very  feeble  and  usually 
terminates  fatally.  Although  sclerema  is  chiefly  seen  in  the  first  days 
of  life  it  is  not  limited  to  the  newly  born,  but  may  occur  at  any  time 
during  the  first  few  months.  It  is  not  to  be  confounded  with  edema  of 
the  newly  born,  with  which  condition  it  is,  however,  sometimes  associated. 
From  published  reports  it  appears  to  be  of  not  very  infrequent  occur- 
rence in  Europe,  chiefly  in  large  foundling  asylums.  In  America, 
sclerema  is  a  rare  disease.  In  the  newly  born,  sclerema  affects  those 
who  are  premature  or  very  feeble,  sometimes  those  who  are  syphilitic. 
Later  it  may  follow  any  condition  leading  to  extreme  exhaustion,  espe- 
cially the  different  forms  of  diarrheal  disease. 

The  first  thing  to  attract  attention  is  usually  the  induration  of  the 
skin.  It  is  often  seen  first  in  the  calves  or  the  thighs,  sometimes  first 
in  the  cheeks,  but  soon  extends  over  the  greater  part  of  the  body.  It 
is  especially  marked  in  the  cheeks,  buttocks,  and  back,  and  regions 
where  adipose  tissue  is  abundant.  It  may  affect  the  body  uniformly 
or  in  circumscril)ed  areas.  The  skin  may  be  smooth  or  it  may  appear 
somewhat  lobulated.  The  color  is  normal  or  slightly  bluish,  often 
tinged  with  yellow.  The  lips  are  blue,  and  the  capillary  circulation  so 
feeble  that  after  pressure  upon  the  nails  the  blood  returns  slowly  or  not 
at  all.  The  limbs  are  stiff  and  board-like.  The  skin  is  cold  to  the  touch, 
and  often  the  thermometer  in  the  axilla  will  not  rise  above  90°  F.    In 


122  DISEASES  OF  THE  NEWLY  BORN 

one  recorded  case  the  axillary  temperature  was  only  71°  F.  The  general 
feeling  of  the  body  has  been  well  likened  to  that  of  a  half -frozen  cadaver. 
The  tongue  and  the  mucous  membrane  of  the  mouth  are  cold;  no  radial 
pulse  can  be  felt;  the  respiration  is  slow,  irregular,  embarrassed,  and  at 
times  the  movements  of  the  thorax  are  scarcely  perceptible.  The  cry  is 
a  feeble  whine,  scarcely  audible.  The  duration  of  the  disease  is  usually 
from  three  to  four  days.  Death  occurs  slowly  and  quietly.  If  recovery 
takes  place  there  is  gradual  improvement  in  the  circulation  and  nutrition, 
and,  later,  a  disappearance  of  the  areas  of  induration. 

The  causes  of  sclerema  are  general,  the  most  important  factors  being 
loss  of  fluids,  great  feebleness  with  lowering  of  the  body  temperature, 
and,  in  consequence,  hardening  of  the  subcutaneous  fat.  There  are  no 
essential  lesions  in  this  disease.  Atelectasis  is  often  present,  and  may 
have  something  more  than  an  accidental  association,  as  incomplete  aera- 
tion of  the  blood  is  no  doulit  a  factor  in  the  production  of  the  symptoms. 
Microscopical  examination  in  typical  cases  has  shown  the  skin  to  be 
normal. 

The  prognosis  is  very  bad,  because  of  the  grave  conditions  of  which  it 
is  the  expression,  but  it  is  not  invariably  fatal.  In  its  milder  forms, 
where  treatment  is  begun  early,  recovery  may  take  place.  The  diagnosis 
is  to  be  made  from  edema  by  the  fact  that  there  is  no  pitting  upon 
pressure,  by  the  rigidity  of  the  body,  and  by  the  great  reduction  in  the 
temperature.  The  most  important  thing  in  treatment  is  artificial  heat; 
nothing  but  the  incubator  is  efficient.  In  addition  to  this,  care  should 
be  taken  to  promote  the  general  nutrition  by  careful  feeding  and  by  all 
other  means  possible. 

INANITION  FEVER 

The  term  inanition  fever  is  not  altogether  a  satisfactory  one;  but, 
until  these  cases  are  better  understood,  it  is  adopted  because  it  empha- 
sizes the  very  close  connection  which  exists  between  the  rise  of  tempera- 
ture and  the  condition  of  inanition  or  starvation.  Under  this  heading 
are  included  cases  seen  during  the  first  five  days  of  life — generally  from 
the  second  to  the  fourth  day — in  which  there  is  an  elevation  of  tem- 
perature, apparently  due  to  the  fact  that  the  infant  gets  very  little, 
frequently  nothing  at  all,  from  the  breast  at  which  he  is  being  suckled. 
It  is  further  characteristic  of  these  cases  that  the  temperature  falls  when 
the  child  is  put  upon  a  full  breast,  or  when  artificial  feeding  is  begun, 
or  even  when  water  is  administered,  if  freely  given.  Some  have  ascribed 
the  symptoms  to  uric-acid  infarction  of  the  kidneys. 

So  far  as  our  knowledge  goes,  the  first  to  call  attention  to  this  con- 
dition was  McLane  (New  York),  who  in  1890  reported  to  one  of  the 


INANITION  FEVER  123 

medical  societies  an  extraordinary  case  of  hyperpyrexia  in  a  newly-born 
child.  The  infant  was  found  on  the  sixth  day  with  a  temperature  of 
106°  F.,  near  which  point  it  had  remained  for  three  days.  The  child 
was  being  suckled  at  a  breast  which  was  found  to  be  absolutely  dry. 
A  wet-nurse  was  procured,  the  temperature  fell  to  normal  in  a  few  hours, 
and  the  child,  which  when  first  seen  was  apparently  in  a  hopeless  condi- 
tion, was  soon  perfectly  well. 

Since  that  time  very  extensive  observations,  extending  to  upward  of 
three  thousand  cases,  have  been  made  at  the  Sloane  and  the  Nursery  and 
Child's  Hospitals,  which  have  established  the  fact  that  a  rise  of  tempera- 
ture to  102°  or  even  104°  F.  is  quite  common  in  newly-born  infants  dur- 
ing the  first  few  days.  This  fever  is  accompanied  by  no  evidences  of  local 
disease,  and  ceases  in  nursing  infants  with  the  establishment  of  the  free 
secretion  of  milk.  The  fall  in  temperature  is  often  rapid,  dropping  to 
the  normal  in  a  few  hours  after  having  continued  for  tliree  or  four  days, 
and  in  a  large  number  of  cases  it  does  not  rise  again. 

The  following  case  is  a  fairly  typical  one  of  the  moie  severe  form-: 
The  patient  was  the  second  child,  the  first  having  died  at  the  age  of  ten 
days,  from  no  disease,  it  was  said,  but  simply  from  exhaustion.  At  birth 
the  infant,  a  boy,  weighed  eight  and  a  quarter  pounds  and  was  apparently 
vigorous.  During  the  first  forty-eight  hours  his  loss  in  weight  was  five 
and  a  half  ounces  and  his  condition  good.  He  was  seen  on  the  evening 
of  the  third  day.  In  the  preceding  twenty-four  hours  he  had  lost  eight 
ounces  in  weight,  and  the  temperature  had  gradually  risen,  until  at  the 
time  of  our  visit  it  was  102.8°  F.  The  body  was  limp,  the  child  making- 
no  resistance  to  examination.  He  cried  with  a  feeble  whine ;  the  restless- 
ness of  the  early  part  of  the  day  having  given  place  to  complete  apathy. 
The  lips  and  skin  were  very  dry,  the  fontanel  sunken,  the  pulse  weak. 
As  the  father,  a  physician,  expressed  it,  "he  had  been  wilting  through  v^ 
the  day  like  a  flower  in  the  sun."  Although  put  to  the  breast  regularly, 
the  child  had  apparently  obtained  very  little.  It  was,  in  fact,  impossible 
to  express  any  milk  from  the  mother's  breasts.  Water  was  freely  given 
and  a  wet-nurse  secured  in  a  few  hours.  The  first  milk  was  taken  from 
the  wet-nurse  at  11  p.m.,  and  the  temperature,  which  fell  gradually 
during  the  night,  was  normal  the  next  morning  and  did  not  rise  again. 
( See  chart.  Fig.  14. )  During  the  succeeding  four  days  the  child  gained 
eighteen  ounces  in  weight,  and  at  the  end  of  a  week  was  as  well  as  an 
average  infant  of  his  age. 

The  symptoms  are  so  uniform  and  so  characteristic  that  they  make 
for  these  cases  of  fever  a  class  l)y  themselves.  The  frequency  with  which 
this  is.  seen  is  shown  by  the  following  statistics :  Among  200  infants 
taken  successively  at  the  Nursery  and  Child's  Hospital,  20  had  fever 
during  the  first  five  days,  reaching  101°   F.  or  over,  wliich  was  not 


124 


DISEASES  OF  THE  NEWLY  BORN 


103° 


102" 


100 


explained  by  ordinary  causes  and  followed  the  course  above  described.  In 
500  successive  children  born  at  the  Sloane  Hospital,  there  were  135  with 
a  similar  fever.  It  was  seen  in  vigorous  infants  as  well  as  in  those  who 
were  delicate.  The  usual  duration  of  the  fever  was  three  days,  the  tem- 
perature generally  touching  the  highest  point  upon  the  third  or  fourth 
day  of  life.  In  about  two-thirds  of  the  cases  the  temperature  did  not  rise 
above  103°  F.;  in  9  it  was  101°  F.  or  over,  the  highest  recorded  being 
106°  F.     The  fall  was  generally  quite  abrupt,  although  not  always  so. 

Daily  weighings,  which  were  made 
in  these  cases,  showed  that  the  in- 
fants continued  to  lose  weight 
while  the  fever  continued,  and  that 
the  loss  almost  invariably  exceeded 
by  several  ounces  that  of  the  chil- 
dren who  had  no  fever.  The  max- 
imum loss  noted  was  twenty-eight 
ounces.  In  quite  a  large  number 
of  cases  it  exceeded  twenty  ounces. 
As  a  rule  the  infants  began  to  gain 
in  weight  when  the  temperature 
remained  at  the  normal  point,  but 
not  until  then. 

The    symptoms    presented    by 
these  infants  were  a  hot,  dry  skin, 
Fig;  14.-TEMPEBATURE  Chart.   Inanition  marked  restlessness,  dry  lips,  and  a 
Fever.  disposition  to  suck  vigorously  any- 

thing withiil  reach.  With  very 
high  temperature  there  were  considerable  prostration  and  weakened 
pulse.  In  the  less  severe  cases  there  were  only  crying  and  restlessness. 
The  rapidity  with  which  the  symptoms  disappeared  when  the  children 
were  wet-nursed  or  properly  fed,  was  very  striking. 

It  is  important  that  this  fever  should  be  recognized,  because  it  gives 
at  times  the  first  warning  of  a  condition  which  may  prove  fatal.  The 
extra  loss  of  ten  or  fifteen  ounces  in  the  first  week  is  a  serious  handicap 
to  newly-born  infants,  the  effect  of  which  may  last  for  several  weeks. 
The  temperature  of  every  child  should  be  taken  during  the  first  week. 
All  the  usual  local  causes  of  fever  are  first  to  be  excluded  by  a  physical 
examination.  This  fever  can  hardly  be  confounded  with  that  due  to 
pyogenic  infection,  which  rarely  begins  before  the  fifth  or  sixth  day. 

The  treatment  is  simple,  viz.,  to  give  water  regularly  every  two  hours, 
in  quantities  up  to  an  ounce  at  a  time  if  required  by  the  thirst  of  the 
child.  This  should  be  done  in  every  case  where  the  temperature  reaches 
101°  F.    Wlien  the  temperature  does  not  at  once  begin  to  fall,  the  infant 


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INANITION  FEVEK  125 

should  be  put  upon  another  breast  or  artificial  feeding  should  be  begun. 
Examination  of  the  breasts  from  which  the  child  has  been  nursing  will 
usually  reveal  the  fact  that  the  secretion  of  milk  is  very  scanty  and  often 
entirely  absent. 

Such  a  fever  we  have  occasionally  seen  in  older  infants,  usually  in 
those  who  are  nursing  dry  breasts  or  where  fluid  food  and  water  have 
been  withheld  because  of  some  gastric  disturbance.  It  yields  as  promptly 
to  treatment  as  does  the  same  condition  in  the  newly  born. 


# 

; 


SECTION  II 
NUTRITION 

CHAPTER  I 

t 

Nutrition"  in  its  broadest  sense  is  the  most  important  branch  of 
pediatrics.  In  no  other  field  and  at  no  other  time  of  life  does  prophy- 
laxis give  such  results  as  in  the  conditions  of  nutrition  in  infancy.  The 
largest  part  of  the  immense  mortality  of  the  first  year  is  traceable 
directly  to  disorders  of  nutrition.  The  importance  of  correct  ideas 
regarding  this  subject  can  hardly  be  overestimated.  The  problem  is  not 
simply  to  save  life  during  the  perilous  first  year,  but  to  adopt  those 
means  which  shall  tend  to  healthy  growth  and  normal  development. 
The  child  must  be  fed  so  as  to  avoid  not  only  the  immediate  dangers  of 
acute  indigestion,  diarrhea,  and  marasmus,  but  the  more  remote  ones  of 
chronic  indigestion,  rickets,  scurvy,  and  general  malnutrition,  since 
these  conditions  are  the  most  important  predisposing  causes  of  acute 
disease  in  early  life. 

•  One  of  the  difficulties  has  always  been  that  temporary  success  may 
mean  ultimate  failure.  If  the  injurious  effects  of  improper  feeding  were 
immediately  manifest  there  would  be  very  much  less  of  it  than  exists 
at  the  present  time.  Many  things  are  valuable  as  temporary  foods,  which 
when  used  permanently  are  injurious.  No  better  illustration  of  this  is 
seen  than  in  the  too  exclusive  use  of  the  carbohydrate  foods.  Infants 
fed  upon  many  of  the  proprietary  foods  often  grow  very  fat,  and  for  the 
time  appear  to  be  properly  nourished.  The  effect  of  the  absence  from 
the  diet  of  some  of  those  elements  which  are  of  vital  importance  may  not 
be  evident  for  months.  The  physiological  laws  regarding  the  require- 
ments of  the  growing  organism  cannot  be  ignored  without  serious  conse- 
quences, which  will  sooner  or  later  be  evident.  Correct  ideas  of  infant 
feeding  are  based"  upon  a  knowledge  of  these  laws.  An  accurate  under- 
standing of  fundamental  principles  is  essential  to  success  and  the 
vast  majority  of  failures  may  be  ascribed  to  ignorance  or  disregard  of 
them. 

127 


128  NUTEITION 


THE  FOOD  CONSTITUENTS  AND  THE  PURPOSES  THEY  SUBSERVE 

IN  NUTRITION 

In  infancy  and  childhood,  as  in  adult  life,  the  elements  of  the  food 
are  five  in  number :  protein,  fat,  carbohydrates,  mineral  salts  and  water. ^ 
The  forms  in  which  they  must  be  furnished  to  the  child,  and  the  relative 
quantities  in  which  they  are  demanded,  are  different  from  those  required 
by  the  adult.  One  reason  for  this  difference  is  the  delicate  structure  of 
the  organs  of  digestion  in  infancy,  and  their  inability  to  assimilate  cer- 
tain forms  of  food.  Again,  provision  must  be  made  not  only  for  the 
natural  waste  of  the  body,  but  for  its  rapid  growth,  nearly  trebling  in 
size,  as  it  does,  during  the  first  twelve  months. 

-y  Amount  of  Food  Required. — The  attempt  has  been  made  to  deter- 
mine accurately  the  amount  of  food  which  an  infant  should  receive  dur- 
ing the  first  year.  The  food  of  infants  who  were  thriving  satisfactorily 
has  been  measured,  and  many  metabolism  experiments  have  been  carried 
out  for  the  purpose  of  definitely  settling  this  question.  While  all  these 
observations  have  shed  much  light  upon  the  subject  we  are  not  yet  able 
to  reduce  to  a  mathematical  formula  the  amount  of  food  which  shall  be 
given  to  keep  an  infant  in  health  and  enable  him  to  develop  normally. 
As  yet,  the  results  of  intelligent  clinical  observation  of  infants  form  our 
best  guide  as  to  food  requirements.  Individual  infants,  though  they  may 
all  be  equally  healthy,  differ  very  much  in  this  respect,  depending  upon 
their  weight,  their  size  and  also  much  upon  their  physical  activity.  One 
that  is  particularly  active  or  restless  requires  more  food  than  does  one 
who  is  very  quiet  and  lethargic.  The  size  of  the  body,  or  the  surface  area, 
is  doubtless  of  much  more  importance  in  estimating  food  requirements 
than  the  weight,  but  the  latter  is  so  much  more  easily  determined  that  it 
has  come  into  general  use  in  estimating  the  amount  of  food  to  be  given 
per  diem.  It  is  a  matter  of  general  agreement  that  the  requirements  of 
the  infant,  relatively  to  the  weight,  are  greatest  during  the  first  months  of 
life  and  become  gradually  less,  so  that  by  the  end  of  the  first  year  they 
are  only  about  three-fourths  as  great  as  during  the  first  mouth.  Heubner 
placed  the  child's  needs  at  100  calories  per  kilo  (45  per  pound)  during 
the  first  quarter  year  and  at  70  per  kilo  (30  per  pound)  during  the  last 
quarter  year.  These  figures  have  been  much  used  as  an  arbitrary  stand- 
ard, and  indeed  they  do  furuish  an  excellent  starting  point  for  the  feed- 
ing of  an  individual  child,  but  they  can  hardly  do  more.  The  subsequent 
variations  in  the  amount  of  food  must  be  decided  by  the  child's  demon- 

^  There  are  other  substances  whose  presence  in  the  food  is  vitally  necessary 
for  life,  such,  for  instance,  as  the  vitamins.  They  exist  in  most  of  the  common 
articles  of  food.  Their  chemical  composition  is  uncertain.  Their  absence  pro- 
duces definite  symptoms. 


THE  FOOD  CONSTITUENTS  129 

strated  needs  and  his  digestive  capacity;  but  wide  variations  from  these 
averages,  whether  above  or  below  them,  are  usually  found  to  be  either 
inadequate  or  disturbing.  Again,  these  amounts  are  designed  for  healthy 
infants  with  good  digestion.  Sick  children,  or  those  suffering  from 
digestive  disturbances,  must  be  fed  according  to  the  capacity  of  their 
digestion.  The  expression  in  calories  of  the  energy  value  of  the  food  does 
]iot  imply  that  this  is  to  be  regarded  as  a  method  of  feeding.  It  is  only 
a  method  of  stating  the  amount  of  food  which  a  child  is  receiving,  in  a 
more  accurate  and  scientific  way  than  others  that  have  been  employed, 
e.g.,  the  number  of  ounces  given  daily,  which  really  represents  only  the 
volume  of  the  food,  or  tells  rather  the  amount  of  water  in  which  the  food 
is  given. 

The -calculation  of  the  total  food  in  terms  of  energy  units  is  chiefly  of 
assistance  in  enabling  one  to  recognize  readily  whether  an  infant  is 
receiving  too  much  or  too  little  food. 

In  determining  the  calories  of  the  food  it  is  calculated  that: 

1  gram  of  fat  yields    9.3  calories 

1      "      "    carbohydrate       "        4.1       " 
1      "      "    protein  "        4.1       " 

Protein. — Protein  is  essential  to  life,  since  it  is  the  only  kind  of  food 
which  is  capable  of  replacing  the  continuous  nitrogenous  waste  of  the 
cells  of  the  body  upon  which  health  depends.  Protein  is  also  indis- 
pensable for  growth.  In  the  adult  only  the  requirements  of  repair  are 
to  be  supplied.  In  the  child  a  much  larger  amount  is  demanded  to 
provide  for  growtli.  Without  the  aid  either  of  the  fats  or  the  carbo- 
hydrates, protein  may  sustain  life  for  a  considerable  time;  but  in  so 
doing  a  great  excess  of  such  food  is  required.  When  fats  and  carbo- 
hydrates are  added  to  the  food  much  less  protein  is  required  to  replace 
the  nitrogenous  waste. 

Of  all  the  forms  in  which  protein  food  may  be  furnished  to  the  body, 
in  proportion  to  its  nitrogen  content,  milk  taxes  the  digestive  organs 
least.  Purthermore,  there  is  no  other  form  of  protein  in  which  those 
amino-acids  which  have  been  shown  to  be  essential  for  growth  are  so 
abundantly  supplied  as  in  milk.  These  facts  are  of  great  importance  and 
indicate  the  superiority  of  milk  as  a  food  for  infants,  particularly  during 
the  first  year.  The  protein  of  woman's  milk  is  very  readily  digested. 
Regarding  the  protein  of  cow's  milk  there  is  no  doubt  that  the  view 
formerly  held  that  it  was  difficult  of  digestion  was  erroneous.  On  the 
contrary,  under  most  conditions  it  is  digested  and  absorbed  with  facility. 
During  most  of  the  first  year,  milk  furnishes  all  the  protein  that  is 
needed  for  proper  nutrition.  But  as  cow's  milk  protein  is  low  in  certain 
important  amiuo-acids,  a  larger  amount  of  it  must  be  given  than  the 


130  NUTRITION 

protein  contained  in  woman's  milk,  or  growth  will  suffer.  During  the 
second  year  meat,  eggs,  etc.,  may  add  to  the  protein  of  the  diet. 

The  digestion  of  protein  is  heguu  in  the  stomach  but  is  principally 
carried  on  in  the  intestines.  The  albumoses  and  peptones  produced  by 
gastric  and  pancreatic  digestion  are  broken  up  as  the  result  of  the  action 
of  the  erepsin  of  the  intestinal  juice  into  polypeptids  and  finally  into 
amino-acids.  It  is  as  amino-acids  that  nearly  all  of  the  nitrogen  is 
absorbed.  In  almost  all  circumstances,  the  nitrogen  of  the  protein  is 
well  absorbed.  The  tendency  to  retain  nitrogen  is  one  of  the  striking 
attributes  of  the  infant.  He  retains  this  if  it  is  in  any  way  possible  and 
may  continue  to  do  so  even  when  losing  greatly  in  weight.  This  may  be 
taken  as  an  indication  of  the  great  efforts  that  the  body  makes  to 
further  growth. 

The  nitrogen  which  is  not  retained  is  largely  excreted  by  the  urine. 
The  nitrogen  of  the  feces  is  relatively  small  in  amount,  is  influenced 
somewhat  by  the  kind  of  food  and  is  in  considerable  part  derived  from 
the  intestinal  secretions  which  themselves  contain  a  certain  amount  of 
protein. 

In  artificial  feeding  it  has  been  maintained  that  a  large  excess  of 
nitrogenous  products  must  be  disposed  of  by  digestion  and  elimination 
and  that  this  taxes  the  organs  of  digestion  and  excretion.  It  may  be  said 
that  there  is  at  the  present  time  no  proof  that  milk  protein  even  in  con- 
siderable excess  is  dangerous  to  the  welfare  of  the  infant. 

The  prolonged  use  of  a  diet  in  Avhich  the  protein  is  insufficient  in 
amount  or  defective  in  character  produces  a  certain  definite  group  of 
symptoms  which  are  not  always  referred  to  their  proper  cause.  In  infants 
the  most  striking  are  slower  growth,  anemia,  poor  circulation,  feeble  mus- 
cular power,  disinclination  to  exertion,  and  various  functional  nervous 
disturbances.  Such  children  are  often  very  fat.  Vegetable  proteins  do 
not  seem  able  permanently  to  take  the  place  of  animal  proteins  in  the 
food  of  young  infants  for  the  reason  that  most  of  them  are  defi,cient  in 
some  of  the  essential  amino-acids.  Since  in  milk  and  in  fact  in  almost 
all  the  foods  of  the  infant  a  very  constant  relation  exists  between  the 
protein  and  the  salts,  it  is  somewhat  difficult  to  separate  symptoms  due 
to  low  protein  from  those  due  to  low  salts ;  the  two  are  often  combined. 

The  ingestion  of  casein  in  large  amount  produces  in  infants,  large, 
dry,  light  colored  stools,  often  of  an  alkaline  reaction.  They  also  con- 
tain a  high  proportion  of  mineral  salts.  With  these  stools  there  is  usually 
constipation.  While  this  effect  in  health  is  one  not  to  be  desired,  it  is 
decidedly  advantageous  in  diarrhea  to  combat  the  fermentation  produced 
by  carbohydrates  and  fats.  For  this  reason,  as  will  be  seen  later,  protein 
in  large  amoimt  is  a  valuable  therapeutic  remedy  for  many  intestinal 
conditions  during  infancy  and  childliood. 


THE  FOOD  CONSTITUENTS  131 

Fats.— Fats  are  a  most  important  source  of  energy  to  the  body,  their 
caloric  vahie  being  a  little  more  than  twice  as  great  as  that  of  either  the 
carbohydrates  or  the  protein.  They  save  nitrogenous  waste  and  increase 
the  body  weight.  The  large  amount  of  fat  stored  up  in  the  subcutaneous 
tissues  in  infancy  is  one  of  the  best  evidences  of  health. 

The  amount  of  fat  received  by  a  breast-fed  infant  is  relatively  much 
greater  than  that  given  to  adults  in  a  normal  diet.  A  well-nourished, 
nursing  infant  weighing  fifteen  pounds  actually  receives  about  one-half 
as  much  fat  as  is  allowed  in  a  ration  for  an  adult  doing  moderate  work, 
who  weighs  ten  times  as  much.  There  can  be  no  doubt  that  fat  is  bene- 
ficial for  infants  and  that  those  who  can  take  a  reasonable  amount  of  fat 
thrive  better  than  those  who  can  not.  It  is  also  plain  that  the  one  of  the 
ingredients  of  cow's  milk  most  difficult  for  the  infant  to  digest  is  the  fat. 

Fats  may,  for  a  considerable  time,  be  largely  replaced  by  the  carbo- 
hydrates; but  nutrition  suffers  if  this  substitution  is  complete  or  long 
continued.  Fats  are  acted  upon  very  slightly  in  the  stomach,  although 
they  greatly  retard  the  emptying  of  the  stomach.  Their  digestion  in  the 
intestine  is,  under  normal  conditions,  very  complete,  and  only  a  small 
percentage  of  the  fat  passes  through  the  intestine  unchanged.  Under 
normal  conditions,  from  80  to  90  per  cent  of  the  fat  ingested  is  absorbed 
either  as  fatty  acids  or  as  soaps.    Ko  neutral  fat  can  be  absorbed. 

When  the  diet  contains  fat  and  protein  in  considerable  quantity  and 
is  low  in  carbohydrate,  stools  are  formed  consisting  largely  of  calcium 
and  magnesium  soaps,  and  the  loss  of  these  substances  may  even  be  so 
great  that  a  negative  balance  of  these  minerals  results.  In  certain 
circumstances,  fats  in  the  intestine  may  be  decomposed  and  acids  formed, 
but  this  rarely  occurs  unless  carbohydrates  in  excess  are  also  given.  As 
a  result  of  this  fermentation,  irritating  products — chiefly  the  lower  fatty 
acids — are  formed,  and  these  readily  provoke  diarrhea.  In  the  diarrheal 
stools  there  may  be  sufficient  potassium  and  sodium  loss  to  bring  about 
a  negative  balance  of  these  minerals.  The  influence  of  the  fat,  therefore, 
upon  the  mineral  balance  is  an  important  one. 

Carbohydrates. — Although,  like  the  fats,  these  can  not  replace  the 
nitrogenous  waste  of  the  body,  they  are  important  aids  in  sparing  the 
protein,  and  in  this  respect  they  are  even  more  valuable  than  the  fats. 
The  carbohydrates  are  partly  converted  into  fat,  and  may  thus  increase 
the  body  weight.    They  are  capable  of  replacing  the  fat-waste  of  the  body. 

Carbohydrates  are  the  most  abundant  of  the  solid  elements  of  the 
food,  although  they  form  a  smaller  percentage  of  the  entire  quantity  of 
food  in  infancy  than  in  adult  life.  The  soluble  carbohydrates  which  are 
used  as  foods  for  infants  are:  milk  sugar,  cane  sugar  and  mixtures  of 
maltose  and  dextrin.  Maltose  in  a  pure  form  is  not  used  on  account  of 
its  cost  and  because  it  has  no  advantages.     Mixtures  containing  maltose 


132  NUTRITION 

have  distinct  advantages  in  some  circumstances.  Since  all  sugars  are 
finally  converted  into  glucose,  they  are,  to  a  certain  extent,  inter- 
changeable. Milk  sugar  has  an  advantage  in  not  fermenting  with  the 
common  varieties  of  yeast  present  in  the  stomach  as  do  both  maltose  and 
cane  sugar.  Except  for  this,  there  is  not  much  to  choose  between  milk 
sugar  and  cane  sugar.  Gain  in  weight  is  satisfactory  with  either,  and 
they  are  equally  safe.  They  have  the  same  disadvantages  and  dangers  in 
that  they  readily  undergo  fermentation  in  the  intestine  by  the  action  of 
bacteria.  As  a  result  of  this  fermentation,  lower  fatty  acids  are  formed 
not  only  from  the  sugar  but  also  from  the  fats  which  are  present  in  the 
food,  with  the  result  which  has  been  described  above  under  the  fermen- 
tation due  to  excessive  quantities  of  fat. 

The  ability  of  the  young  infant  to  digest  starches  is  relatively  feeble, 
although  this  power  does  exist  to  some  degree  from  birth ;  but  the  greater 
part  of  the  carbohydrates  required  should  be  furnished  in  the  form  of 
sugar.  To  infants  of  four  months  and  over,  starches  may  at  times  ad- 
vantageously be  added  to  the  diet,  and  after  seven  or  eight  months  the 
quantity  may  be  considerably  increased.  But  in  whatever  form  or  quan- 
tity used  thorough  cooking  is  necessary. 

The  advantages  of  the  carbohydrates  as  foods  depend  upon  the  ease 
with  which  they  are  digested  and  absorbed.  They  are  at  a  great  dis- 
advantage on  account  of  the  readiness  with  which  all  of  them,  and  espe- 
cially the  sugars,  undergo  fermentation  in  different  parts  of  the  ali- 
mentary tract.  The  mixtures  of  maltose  and  dextrin,  for  some  unex- 
plained reason,  are  often  safer  to  give  to  children  who  have  suffered  from 
diarrhea.  While  they  themselves  have  a  tendency  to  cause  rather  loose, 
brownish  stools,  they  do  not  so  readily  undergo  excessive  fermentation 
and  may  sometimes  be  given  with  safety  when  other  sugars,  especially 
lactose,  would  cause  serious  disturbances. 

A  diet  consisting  too  exclusively  of  carbohydrates  often  leads  to  a 
rapid  increase  in  weight,  but  it  is  not  accompanied  by  a  proportionate 
increase  in  strength.  Infants  so  fed  have  but  little  resistance,  and  many 
of  them  become  rachitic.  The  easy  digestion  of  foods  consisting  chiefly 
of  soluble  carbohydrates,  such  as  sweetened  condensed  milk  and  the  pro- 
prietary infant  foods,  and  the  rapidity  with  which  children  so  fed  gain 
in  weight,  lead  to  a  great  misapprehension  in  regard  to  their  value  as 
foods.  The  ultimate  results  of  such  one-sided  feeding,  if  long  continued, 
are  almost  invariably  disastrous. 

In  building  up  the  cells  of  the  body  the  protein  is  first  in  importance, 
but  in  the  production  of  energy  the  fats  and  the  carbohydrates  have  a 
greater  value.    In  a  proper  diet  all  of  these  elements  are  represented. 

Mineral  Salts. — The  great  importance  of  the  mineral  salts  in  the 
nutrition  of  infants  and  children  has  only  recently  been  appreciated. 


THE  FOOD  CONSTITUENTS  133 

These  salts  are  important  not  only  for  growth,  but  for  all  the  physical 
and  chemical  processes  which  are  carried  on  in  the  body.  If  they  are 
not  furnished  in  sufficient  amount  in  the  food,  or  if  conditions  exist  in 
which  their  absorption,  retention  and  utilization  are  interfered  with,  all 
the  functions  of  the  body  are  disturbed  and  life  may  be  jeopardized. 
Except  in  the  case  of  infants  fed  upon  the  proprietary  foods,  salts  are 
very  seldom  lacking  in  the  food.  Those  who  receive  woman's  milk  usually 
receive  an  adequate  supply ;  and  those  who  are  fed  on  cow's  milk  receive 
not  only  the  salts  required,  but  a  very  considerable  excess  of  them,  often 
two  or  three  times  the  requirements  of  the  child.  This  excess  apparently 
does  no  harm,  as  it  is  either  not  absorbed  or  is  excreted  by  the  intestines 
or  kidneys.  The  mineral  salts  form  from  10  to  35  per  cent  of  the  dried 
matter  of  the  normal  stool.  For  perfect  nutrition  not  only  must  all  the 
mineral  salts  be  furnished  in  the  food  but  the  other  elements  of  the  food 
must  not  have  an  injurious  effect  upon  their  retention.  The  chief  dan- 
gers to  the  retention  of  sodium  and  potassium  arise  from  fermentation 
of  carbohydrates  and  fats  in  the  intestine.  Disturbances  in  the  metab- 
olism of  the  salts  are  very  frequent  and  are  no  doubt  at  the  basis  of  many 
common  nutritional  disturbances  of  infancy. 

Water. — The  food  of  all  young  mammals  consists  of  from  eighty  to 
ninety  per  cent  of  water.  This  is  needed  for  the  solution  of  certain  parts 
of  the  food,  such  as  the  sugar,  the  salts,  and  some  of  the  protein,  and  for 
the  suspension  of  other  protein  and  the  emulsified  fat.  All  the  food  is 
thus  dissolved  or  very  finely  divided  so  as  to  be  more  readily  acted  upon 
by  the  delicate  digestive  organs  of  the  infant.  Water  is  needed  also  in 
large  quantities  for  the  rapid  elimination  of  the  waste  of  the  body. 

The  amount  of  fluid  required  by  the  infant,  in  proportion  to  his  size 
and  weight,  is  much  greater  than  that  required  by  the  adult.  During 
early  infancy  an  infant  should  receive  daily  an  amount  of  fluid  equal  to 
about  one-fifth  his  body  weight.  As  it  is  practically  impossible  to  give 
to  a  young  infant  any  considerable  part  of  this  as  water,  this  figure  gives 
us  an  important  guide  as  to  the  volume  of  the  food  to  be  given  daily  to 
an  artificially-fed  infant.  The  passage  of  a  large  amount  of  urine  of 
low  specific  gravity  is  one  of  the  physiological  conditions  of  infancy  and 
sufficient  water  must  be  furnished  to  the  infant  to  make  this  possible. 
It  is  not  therefore  a  matter  of  indifference  whether  we  give  the  daily 
amount  of  food  with  twenty  or  with  thirty-five  ounces  of  water.  After 
six  months  fluids  can  be  given  in  the  form  of  fruit  juices,  broth,  etc.,  and, 
besides,  the  older  infant  will  usually  take  water  in  proper  amount  without 
difficulty,  so  that  the  same  relation  of  the  volume  of  food  to  the  body 
weight  need  not  be  maintained.  Of  the  water  received  it  is  estimated 
that  59  per  cent  is  eliminated  by  the  kidneys;  133  per  cent  by  the  lungs, 
6  per  cent  by  the  intestines,  and  that  from  1  to  3  per  cent  is  retained.     . 


134  NUTRITION 

V  CHAPTER  II 

THE  INFANT'S  DIETARY 

WOMAN'S  MILK 

Wo]\ian's  milk  is  the  ideal  infant-food.  A  knowledge  of  its  character, 
composition;,  and  variations  is  indispensable,  for  upon  this  knowledge  are 
based  all  our  substitutes  for  woman's  milk  when  this  can  not  be  obtained. 

Woman's  milk  is  a  secretion  of  the  mammary  glands  and  not  a  mere 
transudation  from  the  blood-vessels ;  although  under  abnormal  conditions 
it  may  partake  more  of  the  character  of  a  transudation  than  a  secretion. 
A  few  drops  may  be  squeezed  from  the  breasts  before  parturition;  gen- 
erally speaking,  however,  it  is  only  present  after  delivery.  During  the 
first  two  days  the  secretion  is  scanty.  Usually  upon  the  third  or  fourth 
day  it  becomes  well  established,  although  it  may  be  delayed  many  days 
longer  and  yet  become  abundant.  During  the  period  of  lactation,  milk 
is  constantly  formed  in  the  mammary  glands,  but  the  process  is  more 
active  while  the  child  is  at  the  breast. 

Physical  Charactera. — Woman's  milk  is  of  a  bluish-white  color  and 
quite  sweet  to  the  taste.  When  freshly  drawn  its  reaction  is  amphoteric- 
to  litmus,  or  slightly  acid  to  phenolphthalein.  The  specific  gravity  varies 
between  1.026  and  1.036,  the  average  being  1.031  at  60°  F.  On  the 
addition  of  acetic  acid  only  a  slight  coagulation  is  seen,  this  being  in 
the  form  of  small  flocculi,  and  never  in  large  masses  as  is  the  case 
in  cow's  milk.  Microscopically,  there  are  seen  great  numbers  of 
fat-globules  nearly  uniform  in  size  and  some  granular  matter.  Oc- 
casionally there  are  present  epithelial  cells  from  the  milk-ducts  or  from 
the  nipple. 

Early  Milk. — The  secretion  of  the  early  days  of  lactation  to  which 
the  term  "colostrum"  has  been  given,  differs  quite  markedly  from  the 
later  milk.  It  is  of  a  deep-yellow  color,  which  is  chiefly  due  to  the  colos- 
trum-corpuscles. It  has  a  specific  gravity  of  1.030  to  1.035,  a  strongly 
alkaline  reaction,  and  is  coagulated  into  solid  masses  by  heat,  and  some- 
times the  milk  of  the  first  days  coagulates  spontaneously.  It  is  very  rich 
in  protein  and  in  salts.  Microscopically  the  fat-globules  are  of  unequal 
size,  and  there  are  present  large  numbers  of  granular  bodies  known  as 
colostrum-corpuscles.  These  are  four  or  five  times  the  size  of  the  milk- 
globules,  and  they  are  probably  leucocytes  in  which  are  contained  numer- 
ous fat  granules.  They  are  much  larger  than  ordinary  leucocytes  and 
are  nucleated. 
•     The  colostrum-corpuscles  are  very  abundant  during  the  first  few  days. 


WOMAN'S  MILK  135 

but  under  normal  conditions  they  are  not  found  after  the  tenth  or  twelfth 
day. 

Composition  of  Colostrum 

First  and  Two  to 

second  days  ten  days 

Fat 2.38  3.00 

Sugar 3.38  7.50 

Protein   SjBQ.  2.25 

Ash  0.37  0.30 

Water   85.27  86.95 


100.00  100.00 

The  characteristic  features  of  colostrum  milk  continue  for  a  period 
^■arying  from  five  to  ten  days;  but  it  is  not  until  about  the  end  of  the 
lirst  month  that  the  milk  assumes  its  stable  or  "mature'^  character.  The 
milk  of  the  intermediate  period  is  sometimes  spoken  of  as  "transition 
milk."  It  shows  a  marked  but  gradual  fall  in  the  protein  and  ash,  and 
a  moderate  rise  in  the  fat  and  sugar  until  the  composition  of  mature  milk 
is  reached ;  after  this  time  no  constant-or  regular  changes  are  seen  in  the 
proportion  of  the  different  constituents  until  near  the  close  of  lactation. 

Daily  Quantity. — Exact  information  upon  this  point  is  difficult  to 
obtain.  There  are  recorded,  however,  extended  observations  made  with 
great  care  upon  a  number  of  cases.     The  eight  cases  quoted  below  ^  were 

^Haehner's  cases  (Jahrb.  f.  Kinderh.,  xv,  23;  xxi,  314).  Case  I.  Female; 
birth-weight,  7  pounds  14  ounces  (3,100  grams).  First  week,  lost  li  ounce  (45 
grams);  after  this  gained  steadily  during  the  twenty-three  weeks  of  observation; 
from  second  to  ninth  week,  average  weekly  gain  8  ounces  (241  grams) ;  from 
tenth  to  eighteenth  week,  average  gain  4J  ounces  (138  grams);  from  nineteenth 
to  twenty-third  week,  average  gain  4  ounces  (130  gi-ams) ;  weight  at  the  end  of 
twenty-third  week,  14  pounds  (6,690  grams). 

Case  II.  Male;  birth-weight  61  pounds  (2,950  grams).  Loss,  first  week,  3 
ounces  (90  grams) ;  after  this  gained  steadily  during  the  eleven  weeks  of  obser- 
vation; from  second  to  eleventh  week,  average  weekly  gain  7^  ounces  (214 
grams);  weight  at  end  of  eleventh  week,  11  pounds  2  ounces  (5,045  grams). 

Case  III.  Female;  birth-weight  3  pounds  9  ounces  (1,620  grams).  Gain, 
first  week,  1^  ounce  (45  grams);  during  the  succeeding  twenty-one  weeks  of 
observation,  average  weekly  gain  5  ounces  (141  grams);  weight  at  the  end  of 
twenty-second  week,  10  pounds  3  ounces  (4,620  grams). 

Laure's  case  (These,  Paris,  1889).  Female;  birth-weight  8  pounds  13  ounces 
(4,000  grams) ;  loss,  first  week,  8  ounces  (225  grams) ;  after  this  gained  steadily 
during  the  nine  weeks  of  obswvation,  on  an  average  9 J  ounces  (268  grams) 
weekly;  at  the  end  of  ninth  week,  weight  13  pounds  32  ounces   (6.000  grams). 

Ahlfeld's  case*(Deutsch.  Ztschr.  f.  Prakt.  Med.,  1878).  Birth-weight  7  pounds 
14  ounces  (3,100  grams).  Observations  continued  from  fourth  to  thirtieth  week. 
During  first  ten  weeks,  average  weekly  gain  51  ounces  (161  grams);  from 
eleventh  to  twentieth  week,  7i  ounces  (214  grams) ;  from  twenty-first  to  thirtieth 


136 


NUTKITION 


all  healthy  infants,  nursing  exclusively  and  gaining  steadily  in  weight. 
From  these  observations,  and  others  less  extended,  the  average  daily 
quantity  of  milk  secreted  under  normal  conditions  of  health  may  be 
assumed  to  be  pretty  nearly  as  follows : 

Approximately. 

At  the  end  of  the  first  week 10  to  16  oz.  (300  to     500  c.cm.) 

During  the  second  week 13  to  18  oz.  (400  to     550  c.cm.) 

During  the  third  week 14  to  24  oz.  (430  to     720  c.cm.) 

During  the  fourth  week 16  to  26  oz.  (500  to     800  c.cm.) 

From  the  fifth  to  the  thirteenth  week..  '20  to  34  oz.  (600  to  1,030  c.cm.) 

From  the  fourth  to  the  sixth  month. .  .   24  to  38  oz.  (720  to  1,150  c.cm.) 

From  the  sixth  to  the  ninth  month 30  to  40  oz.  (900  to  1,220  c.cm.) 

It  will  be  noted  that  the  amount  increases  very  rapidly  up  to  about 
the  eighth  week,  and  after  this  much  more  slowly.  The  amount  of  milk 
varies  also  with  the  demands  of  the  child  in  a  very  striking  way.^    The 

week,  6  ounces  (168  grams) ;  at  the  end  of  the  thirtieth  week,  weight  18  pounds 
9 J  ounces  (8,435  grams) . 

Feer  (Jahrb.  f.  Kinderh.,  xlii,  195).     Three  cases. 

In  all  these  cases  the  amount  of  milk  was  determined  by  weighing  the  infant 
both  before  and  after  every  nursing  during  the  entire  period  of  observation. 
The  following  table  gives  in  a  condensed  form  the  daily  quantity  of  milk  in 
these  cases: 


Time. 


Haehner's 

Haehner's 

Haehner's 

Laure's 

Ahlfeld's 

1st  Case. 

2d  Case. 

3d  Case. 

Case. 

Case. 

Grams. 

Grams. 

Grams. 

Grams. 

Grams. 

20 

75 

20 

176 

135 

45 

265 

325 

70 

125 

420 

295 

99 

222 

360 

290 

124 

400 

374 

340 

136 

475 

423 

350 

156 

500 

497 

423 

229 

556 

550 

468 

314 

730 

594 

531 

379 

810 

576 

663 

561 

447 

944 

655 

740 

661 

472 

978 

791 

880 

681 

525 

1,038 

811 

835 

730 

568 

1,024 

845 

766 

665 

584 

1,085 

810 

796 

600 

869 

807 

673 

983 

870 

709 

1,029 

1,14^ 

Feer's 
3  Cases. 
Average. 


1st  day 

2d  day 

3d  day 

4th  day 

5th  day . 

6th  day 

7th  day 

Average  2d  week .... 
Average  3d  week .... 
Average  4th  week .  .  . 
Average  5th  week .  .  . 
Average  6th  week .  .  . 
Average  7th  week .  .  . 
Average  Sth  week .  .  . 
Average  9th  week .  .  . 
Average  10th  to  13th  week 
Average  14th  to  17th  week 
Average  18th  to  23d  week 
Average  24th  to  30th  week 


Grams. 


256 

(average 
1st  week) 


610 
667 
753 
802 
815 
820 
795 
845 
919 
1,002 


^  There  are  a  number  of  recorded  instances  in  which  the  amount  of  milk  se- 
creted has  been  quite  extraordinary — in  some  casle  as  much  as  four  quarts  daily. 
Lactation  in  exceptional  instances  also  is  unduly  prolonged.  We  know  of  one 
well  authenticated  American  case  in  which  it  continued  for  seven  years.  Among 
the  Japanese  it  is  frequent  for  it  to  continue  up  to  three  or  four  years. 
Among  the  Hottentots  and  other  savage  races  lactation  may  be  prolonged  until 
the  sixth  or  seventh  year. 


■( 


\ 


WOMAN'S  MILK  137 

quantities  mentioned  can  not  be  taken  as  an  absolute  guide  to  the 
amount  of  food  to  be  given  to  bottle-fed  infants.  Breast  milk  contains 
an  average  of  twelve  per  cent  solids ;  while  the  modification  of  cow's  milk 
best  suited  to  the  early  months  seldom  has  more  than  from  nine  to 
eleven  per  cent  solids.  For  this  period,  therefore,  somewhat  larger  quan- 
tities are  needed  than  of  breast  milk. 

A  comparison  of  the  daily  amount  of  milk  taken  with  the  weight  of 
fR'e  child  at  the  different  periods,  showed  that  both  during  the  early  and 
the  later  periods  the  larger  children  took  not  only  more  milk,  but  con- 
siderably more  in  proportion  to  their  body  weight  than  did  the  smaller 
ones.  This  harmonizes  with  the  common  observation  that  small  children 
are  much  more  likely  to  be  overfed  than  large  ones. 

The  average  quantity  taken  at  one  nursing  by  five  of  the  children 
previously  mentioned  was  as  follows : 

Approximately. 

During  the  first  week f    to  1|  oz.     (18  to    45  c.cm.) 

During  the  second  week 1    to  3    oz.     (30  to    90  c.cm.) 

During  the  third  week 1|  to  4    oz.     (45  to  120  c.cm.) 

During  the  fourth  week 1|  to  4^  oz.     (45  to  140  c.cm.) 

From  the  fifth  to  the  seventh  week 2    to  5    oz.     (60  to  150  c.cm.) 

From  the  eighth  to  the  eleventh  week.,. .  2^  to  5|  oz.    (75  to  160  c.cm.) 

During  the  fourth  month 3    to  6    oz.     (90  to  180  c.cm.) 

During  the  fifth  month 3J  to  6J  oz.  (110  to  200  c.cm.) 

During  the  sixth  month 4    to  7    oz.  (120  to  220  c.cm.) 

Between  the  limits  mentioned  the  greater  number  of  cases  will  un- 
doubtedly fall.  The  amount  taken  at  one  time  is,  however,  modified  by 
the  frequency  of  nursing,  and  is  therefore  not  so  good  a  guide  to  the 
amount  of  food  required,  as  is  the  quantity  taken  in  twenty-four  hours. 

Composition. — According  to  the  analyses  of  Pfeiffer,  Koenig,  Leeds^ 
Harrington,  Adriance,  Courtney  and  Fales  and  others,  the  composition 
of  human  milk  is  as  follows : 


Normal  Average 
(Mature  Milk) 

Common  Healthy 
Variations. 

Fat 

Per  cent 

3.50 
7.50 
1.25 
0.20 

87.55 

Per  cent 

3.00  to       5.00 

Sugar 

6.50    "       8.00 

Protein  

1.00    "        2.00 

Ash 

0.18    "        0.25 

Water 

89.32    "     84.75 

100.00 

100.00        100.00 

In  the  older  analyses  the  percentage  of  protein  was  almost  invariably 
made  too  high  and  the  sugar  too  low.  After  the  first  month  there  are 
no  regular  changes  in  composition  until  near  the  end  of  lactation.  This 
is  a  point  to  be  borne  in  mind  in  the  selection  of  wet-nurses. 


138  NUTEITTON 

Milk  also  contains  certain  natural  ferments  which;,  though  little 
understood,  are  believed  to  have  a  function  in  digestion. 

Protein. — The  important  forms  of  protein  are  casein  and  lactalbu- 
min;  several  others,  laetogiobulin,  lactoj^rotein  and  nuclein  are  also  de- 
scribed. The  casein  is  in  suspension  by  virtue  of  the  presence  of  calcium 
phosphate  in  the  milk,  with  which  it  is  probably  in  combination.  It 
coagulates  only  slightly  with  rennet,  while  acetic  acid  produces  a  loose 
flocculent  precipitate.  The  lactalbumin  resembles  the  serum-albumin  <wf 
the  blood.  In  Avoman's  milk  it  is  nearly  twice  as  abundant  as  casein. 
Its  proportion  to  casein  is  nearly  twelve  times  as  great  as  in  cow's 
milk. 

The  total  protein  of  normal  mature  milk  is  usually  l^etween  1.0  and 
1.5  per  cent.  In  abnormal  sj^ecimens  the  variations  are  from  0.7  to  3.5 
j)er  cent.  The  total  protein  is  highest  in  the  colostrum  period;  it  falls 
steadily  to  the  latter  part  of  the  first  month.  After  this  time,  during 
the  mature  period,  the  variations  are  slight,  but  it  tends  to  fall  slowly. 
Toward  the  end  of  lactation  the  proportion  of  protein  falls  quite  rapidly. 

Fai. — This  exists  in  the  form  of  minute  globules,  which  are  held  in  a 
state  of  permanent  emulsion  by  the  albuminous  solution  in  which  they  are 
suspended.  The  fat  of  woman's  milk  is  chiefly  made  up  of  the  neutral 
fats — palmitin,  myristin,  stearin  and  olein;  the  last  mentioned  predom- 
inating. There  are  also  small  quantities  of  free  fatty  acids,  but  these 
are  much  less  in  amount  than  in  cow's  milk.  The  fat  of  woman's  milk 
is  relatively  low  in  volatile  fatty  acids,  compared  with  that  of  cow's  milk. 
The  proportion  of  fat  is  suljject  to  even  wider  variations  than  is  that  of 
the  protein,  3.5  per  cent  being  taken  as  the  normal  average.  In  a  series 
of  thirty-four  analyses  the  fat  varied  between  1.13  and  6.G6  per  cent.  The 
highest  percentage  we  have  known  was  10.91.  In  forty-three  analyses 
by  Leeds,  the  variations  were  between  2.11  and  6.89  per  cent.  The  pro- 
portion is  very  little  alfected  by  the  period  of  lactation. 

Sugar. — The  sugar  is  in  solution.  Its  proportion  is  more  nearly  con- 
stant under  all  conditions  than  any  other  constituent  of  milk.  The 
ordinary  variations  are  usually  within  the  limits  of  6.5  and  8  per  cent. 

Asli. — The  average  proportion  of  inorganic  salts  is  0.20  per  cent,  or 
a  little  more  than  one-fourth  that  of  cow's  milk.  The  percentage  com- 
position of  the  ash  as  compared  with  that  of  cow's  milk  is  given  in  a 
subsequent  chapter. 

With  the  exception  of  calcium  phosphate  nearly  all  the  salts  are  in 
solution.  The  milk  of  the  first  few  days  is  very  rich  in  salts,  chiefly  owing 
to  the  large  proportion  of  sodium  and  potassium  chlorid;  after  the  first 
month  the  normal  variations  ^  are  slight  and  inconstant. 

^  From  thirty-eight  analyses  h\  Courtney  and  Fales  at  the  Babies'  Hos- 
fjital,  the  following  average  figures  were   obtained  of  the  composition   of  the 


WOMAN'S  MILK 


139 


1,010 


1,010 


\ 


Cjt 


The  Examination  of  Milk. — The  exact  composition  of  human  milk  is 
to  be  determined  only  l)y  a  complete  chemical  analysis.  Many  variations 
in  composition  the  physician  may  readily  ascertain  for  himself  l^y  simple 
methods. 

The  quantity  of  milk  secreted  by 
the  breasts  may  be  estimated  l)y  the 
quantity  which  may  be  drawn  by  a 
l)reast-pump,  although  this  is  not  a 
very  reliable  test.  If  the  child 
nurses  habitually  thirty  or  forty 
minutes,  the  probal^ilities  are  very 
strong  that  the  milk  is  scanty.  If 
the  breasts  at  nursing  time  are  full, 
hard,  and  tense,  the  supply  is  prob- 
ably abundant.  If  the  breasts  are 
soft  and  flabby,  and  appear  to  fill 
only  while  the  child  is  nursing,  it  is 
almost  certain  that  the  quantity  is 
small.  The  only  really  reliable  test 
is  weighing  the  infant  just  before 
and  after  nursing,  upon  an  accurate 
pair  of  scales  sufficiently  sensitive  to 
indicate  half-ounces.  This  should 
be  repeated  several  times  in  the  day. 

The  reaction  of  woman's  milk 
even  when  freshly  drawn  is  jarely 
alkaline,  being  amphoteric  to  litmus, 
or  slightly  acid  to  phenolphthalein. 

The  specific  gravity  may  be  taken 
with  any  small  hydrometer  graduated  from  1.010  to  1.010  (Fig.  15,  A). 
The  specific  gravity  is  lowered  by  the  fat,  but  increased  by  the  other 
solids.     An  ordinary  urinometer  will  answer   every  purpose,  the  only 


A  B 

Fig.  15. — ^Apparattts  for  Examination 
OF  Woman's  Milk.  The  authors' 
lactometer  and  cream-gauge.^ 


ash  of  woman's  milk  at  the  different  periods  of  lactation, 
of  Children,  Oct.,   1915.) 


(Amer.  Jour.  Diseases 


Period 

No.  of 
Analyses 

Total 
Ash 

CaO 

MgO 

P2O5 

NasO 

K2O 

CI 

5 
6 
9 

8 
10 

.3077 
.2407 
.20.56 
.2069 
.1978 

.0446 
.0409 
.0486 
.0458 
.0390 

.0101 
.00.57 
.0082 
.0074 
.0070 

.0410 
.0404 
.0342 
.0345 
.0304 

.0453 
.0255 
.01.54 
.0132 
.0145 

.09.38 
.0709 
.0.539 
.0609 
.0575 

.0568 

Transition  (12-.30  days) 

Early  mature  (1-4  months) 

Middle  mature  (4-9  months)  .... 
Late  milk  (10-20  months) 

.0.580 
.0351 
.0358 
.0442 

^  The  authors'  apparatus  may  be  obtained  from  Eimer  &  Amend,  Eighteenth 
Street  and  Third  Avenue,  New  York. 


140 


NUTEITION 


difficulty  being  the  quantity  which  is  required  to  float  the  instrument. 
Microscopical  Examinaiion. — The  microscope  may  reveal  the  pres- 
ence of  fat  globules,  colostrum  corpuscles,  blood,  pus,  epithelium,  and 
granular  matter.  Colostrum  corpuscles  are  abnormal  after  the  twelfth 
day;  pus  and  blood  are  always  abnormal.  The  presence  of  any  of  these 
elements  necessitates  the  suspension  of  nursing,  at  least  temporarily. 
But  little  importance  can  be  attached  to  the  size  and  appearance  of  the 
fat  globules  as  affecting  the  nutritive  properties  of  the  milk. 

The  Determination  of  Fat. — The  simplest  method  is  by  the  cream- 
gauge  (Fig.  15,  B).    Its  results  are  only  approximate,  but  in  most  cases 

sufficiently  accurate  for  clinical  purposes. 
The  tube  is  filled  to  the  zero  mark  with 
fresh  milk,  which  stands,  corked,  at  room 
temperature  for  twenty-four  hours,  when 
the  percentage  of  cream  is  read  off.  The 
ratio  of  this  to  the  fat  is  approximately 
five  to  three;  thus  5  per  cent  cream  indi- 
cates 3  per  cent  fat,  etc. 

For  an  accurate  determination  the  best 
ready  method  is  the  Babcock  test,  which 
requires  20  c.c.  of  milk,  or  the  modifica- 
tion by  Lewi  ^  of  the  Leffman  and  Beam 
test  for  cow's  milk.  This  requires  special 
tubes. 

Sugar. — The  projoortion  of  sugar 
varies  so  little  that  it  may  be  ignored  in 

Fig.  16.-TUBES  for  Determin-  Conical   examinations. 

iNG  THE  Fat  in  Milk.    A,         Protein. — Clinical  methods  for  the  es- 

Babcock's  tube  for  cow's  milk;    i-         i-  j?    ii  j.    •  ,  ,- 

B,    Lewi's    modification    for  timation  of  the  protem  are  not  very  satis- 
woman's  milk.  factory.^     We  may  also  form  some  idea  of 

the  protein  from  a  knowledge  of  the  spe- 

^ Lewi's  method  is   as   follows: 

(1)  Place  in  the  milk  flask  2.92  c.c.  of  woman's  milk  measured  in  a  special 
graduated  pipette;  (2)  carefully  rinse  the  pipette  and  add  the  same  quantity 
of  sulphuric  acid  C.  P.  of  specific  gravity  1.830.  The  acid  should  be  added 
slowly,  and  mixed  with  the  milk  by  gently  rotating  the  flask.  The  color  turns 
to  a  very  dark  brown  from  the  oxidation  of  the  sugar  and  protein;  (3)  now 
add  0.6  c.c.  of  a  mixture  of  equal  parts  of  fusel  oil  and  strong  hydrochloric  acid; 
(4)  add  sufiicient  of  a  mixture  of  the  same  sulphuric  acid  and  water,  equal 
parts,  to  bring  the  level  of  the  fluid  well  up  into  the  neck  of  the  flask;  (5) 
centrifuge  for  three  or  fovu"  minutes.  The  percentage  of  fat  is  now  read  off, 
each  one-tenth  gradation  in  the  neck  of  the  flask  representing  0.3  per  cent 
of  fat  in  the  specimen  of  milk. 

^The  one  giving  the  best  results  is  that  in  which  the  protein  is  precipitated 
by  a  solution  of  phosphotungstic  and  hydrochloric  acids  in  the  Esbach  tube,  the 


^ 


WOMAN'S  MILK 


141 


cific  gravity  and  the  percentage  of  fat,  if  we  regard  the  sugar  and  salts 
as  constant,  or  so  nearly  so  as  not  to  affect  the  specific  gravity.  We  may 
thus  determine  whether  it  is  greatly  in  excess  or  very  low,  which,  after 
all,  is  the  important  thing.  The  specific  gravity  will  then  vary  directly 
with  the  proportion  of  protein,  and  inversely  with  the  proportion  of  fat, 
i.  e.,  high  protein,  high  specific  gravity;  high  fat,  low  specific  gravity. 
The  application  of  this  principle  will  be  seen  by  reference  to  the  accom- 
panying table. 

Woman's  Milk 


Specific  gravity^-70°  F, 


Cream — 24  hours. 


Protein  (estimated). 


A.verage ...... 

Normal  variations 
Normal  variations 
Abn'l  variations  . 
Abn'l  variations . 
Abn'l  variations  . 
Abn'l  variations . 


1.031 
1.028-1.029 

1.032 
Low  (below  1.028) 
Low  (below  1 .  028) 
High  (above  1 .  032) 
High  (above  1.032) 


7% 

8%-12% 

5%-6% 

High  (above  10%) 

Low  (below  5%) 

High 

Low 


1.2.5% 

Normal  (rich  milk) 

Normal  (fair  milk) 

Normal  or  sUghtly  below 

Very  low  (very  poor  milk) 

Very  high  (very  rich  milk) 

Normal  (or  nearly  so) 


A  sj)ecinien  taken  for  examination  should  be  either  the  middle  portion 
of  the  milk — i.  e.,  after  nursing  two  or  three  minutes — or,  better,  the 
entire  quantity  from  one  breast.  The  first  milk  is  slightly  richer  in 
protein  and  much  poorer  in  fat.  The  last  drawn  from  the  breasts  is  lower 
in  protein  and  much  higher  in  fat.  The  following  analyses  from  Forster 
illustrate  these  differences : 


First  Portion. 

Second  Portion. 

Third  Portion. 

Fat 

Per  cent 

1.71 
1.13 

Per  cent 

2.77 
0.94 

Per  cent 
5.51 

Protein 

0.71 

Conditions  Affecting  the  Composition  of  Woman's  Milk. — The  Age  of 

the  Nurse. — This  has  no  constant  influence.  Other  things  being  equal, 
the  milk  of  very  young  women,  and  also  of  those  over  thirty-five  years 
of  age,  is  likely  to  be  lower  in  fat  than  that  of  women  between  twenty 
and  thirty-five  years. 

Number  of  Pregnancies. — Adriance  found  that  the  average  milk  of 
23  primiparae  and  23  multiparae,  both  taken  at  the  third  month,  showed 
the  following  differences:  The  milk  of  the  primiparae  averaged  higher 
in  fat  and  in  protein,  but  a  little  lower  in  sugar. 

Acute  Illness.— In  the  majority  of  cases  of  acute  illness  of  a  minor 
character  and  of  short  duration  there  is  no  perceptible  effect  upon  the 


percentages  being  read  off  after  standing  twenty-four  hours.    For  description  see 
Boggs,  Johns  Hopkins'  Hospital  Bulletin,  No.  187,  October,  1906. 


142  NUTRITION 

milk.  In  the  acute  febrile  diseases  of  a  severe  type  the  quantity  of  milk 
is  reduced,  the  fat  is  low,  and  the  protein  is  apt  to  be  high.  In  septic 
conditions  bacteria  may  appear  in  the  milk. 

Menstruation. — The  effect  of  this  is  exceedingly  variable,  dejaending 
much  upon  the  individual  and  the  ease  of  menstruation.  The  most 
frequent  changes  noted  are  diminution  in  the  quantity  and  a  lower  fat 
with  the  protein  sometimes  increased. 

From  observations  upon  685  cases,  Meyer  noted  disturbances  in  the 
child  in  over  one-half  the  number.  Our  own  experience  accords  rather 
with  that  of  Pfeiffer  and  Schlichter,  who  consider  it  quite  exceptional 
for  the  child  to  be  visibly  affected.  Schlichter  made  observations  upon 
infants  during  233  menstrual  days,  noting  the  condition  of  the  stools 
and  digestion  both  before  and  after  menstruation.  In  ninety  per  cent  of 
the  cases  there  was  no  perceptible  influence.  In  only  eight  per  cent  were 
the  stools  bad,  and  in  only  three  per  cent  was  there  disturbance  of  the 
stomach  with  vomiting.  It  is  safe  to  say  that  the  changes  in  milk  accom- 
panying menstruation  are  not  uniform,  and  that  in  very  many  cases  none 
of  importance  are  produced. 

Diet. — The  composition  of  the  milk  is  not  so  much  influenced  by  diet 
as  was  formerly  believed  to  be  the  case.  The  milk  of  an  under-nourished 
woman  is  likely  to  be  poor  both  in  fat  and  protein.  Sufficient  food  causes 
an  increase  in  these  substances.  It  is  doubtful  if  the  amount  of  fat  can 
be  further  influenced  by  feeding  either  fat  or  carbohydrate,  though  by 
some  authors  it  has  been  claimed  that  this  could  be  done.  Diet  has  a 
similar  influence  upon  the  quantity  of  protein.  The  aAnount  of  sugar  is 
nearly  constant  under  almost  all  circumstances.  It  is  probably  true  that 
when  the  quantity  of  protein  and  fat  are  high  they  may  be  somewhat 
reduced  by  exercise  and  taking  less  food,  but  not  to  a  marked  extent 
unless  under-nourishment  had  been  present.  All  fluids  tend  to  increase 
the  quantity  of  milk. 

The  nursing  woman  should  have  a  generous  diet  of  simple  food,  and 
should  drink  largely  of  milk  or  gruels  made  with  milk.  The  diet  should 
be  a  varied  one,  not  excessive  in  nitrogenous  food  nor  in  vegetables. 
Salads  and  highly  seasoned  dishes  should  be  avoided,  not  so  much  be- 
cause they  upset  the  child,  although  this  may  happen,  as  because  they 
are  likely  to  disturb  the  digestion  of  the  nurse.  Nearly  all  the  common 
vegetables  and  sweet  fruits  in  season  may  be  allowed  in  moderation. 
Strong  tea  and  coffee  should  be  prohibited,  although  weak  tea  or  coffee 
may  be  allowed,  each  but  once  a  day.  Cocoa  is  not  objectionable.  In 
addition  to  her  regrdar  meals  the  nurse  should  have  milk  or  gruel  at 
bedtime.  The  diet  should  in  all  cases  be  adapted  to  her  digestion.  The 
bowels  should  move  daily,  1)y  the  use  of  laxatives  if  necessary.  Great 
harm  often  results  from  overfeeding  with  its  consequent  indigestion. 


WOMAN'S  MILK  143 

Alcoliolic  Beverages. — With  many  women  the  use  of  malted  liquors — 
ale,  beer,  etc. — increases  the  quantity  of  milk  and  the  proportion  of  fat; 
l)ut  with  many  others  their  only  effect  is  to  fatten  the  nurse,  often  to  a 
striking  degree.  The  effect  of  spirits  upon  the  quantity  and  composition 
of  the  milk  is  less  marked,  but  along  similar  lines.  Unless  taken  in  large 
amounts  by  the  mother,  alcohol  does  not  appear  in  her  milk,  and  there  is 
no  sufficient  evidence  that  in  usual  amounts  it  has  any  deleterious  effect 
upon  the  milk;  but  the  general  use  by  nursing  women  of  alcoholic  bever- 
ages in  any  form  is  to  be  condemned.  There  are  in  most  cases  much  bet- 
ter means  of  improving  the  milk  than  by  ale,  beer  or  whisky;  they  should 
be  recommended  by  the  physician  to  nursing  women  with  the  greatest  dis- 
.  crimination.  The  danger  of  the  formation  of  the  alcoholic  habit  is  too 
great  to  be  passed  over  lightly. 

Drugs. — The  elimination  of  drugs  Ibrougli  the  milk  is  somewhat  un- 
certain and  variable;  few  of  those  popularly  sujjposed  to  affect  the  child 
through  the  milk  really  do  so.  Given  in  full  doses,  belladonna  regularly 
appears  in  the  milk.  Opium  does  not  do  so  constantly;  but  when  the 
milk  is  poor,  enough  may  be  excreted  to  produce  serious  symptoms.  The 
iodids  and  bromids  when  long  administered  may  be  eliminated  in  suf- 
ficient quantity  to  produce  their  constitutional  effects  in  the  child.  Mer- 
cury does  not  appear  regularly,  but  only  after  prolonged  use,  and  then 
in  variable  quantity.  Most  of  the  saline  cathartics,  arsenic,  and  the 
salicylates  are  occasionally  found  in  the  milk  sometimes  in  quantities 
sufficient  to  produce  symptoms  in  the  nursing  child. 

Pregnancy. ^The  milk  of  a  nursing  woman  who  has  become  preg- 
nant is  generally  scanty  and  poor  in  quality,  especially  in  fat.  The 
milk  of  a  woman  suffering  from  the  toxemia  of  pregnancy  is  toxic 
to  her  infant.  Fatal  consequences  have  not  infrequently  followed  put- 
ting an  infant  to  the  breast  shortly  after  eclamptic  attacks  in  the 
mother. 

Bacteria. — Under  normal  conditions  woman's  milk  may  contain  a 
few  bacteria.  They  are  chiefly  cocci  derived  from  the  external  milk  ducts 
and  are  of  no  importance.  In  suppurative  inflammation  of  the  mam- 
mary gland,  numerous  bacteria  may  be  found  in  the  milk ;  also  in  some 
cases  of  puerperal  sepsis.  Tubercle  bacilli  have'  been  demonstrated  by 
Roger  and  Garnier  in  the  milk  of  a  woman  with  advanced  tuberculosis, 
but  ordinarily  they  are  not  present  unless  the  gland  is  the  seat  of  the 
disease. 

The  Elimination  of  Antitoxin  and  Other  Protective  Substances  by  the 
Milk. — The  immunity  of  nursing  infants  to  most  of  the  contagious  dis- 
eases has  long  been  noted,  but  until  recently  little  understood.  Animal 
experiments  have  demonstrated  the  constant  presence  of  diphtheria  an- 
titoxin in  the  milk  of  immunized  animals.    The  Widal  reaction  has  been 


144  NUTRITION 

obtained  with  the  milk  of  mothers  suffering  from  typhoid  and  with  the 
blood  of  their  healthy  nursing  infants. 

Nervous  Impressions. — The  effect  of  the  nervous  condition  of  a 
woman  upon  her  milk  secretion  is  very  striking,  and  much  more  im- 
portant than  the  diet.  Both  the  quantity  and  the  composition  of  the 
milk  are  markedly  changed  by  many  different  nervous  impressions. 
Fright,  grief,  passion,  excessive  sexual  indulgence,  or  any  great  excite- 
ment may  entirely  arrest  the  secretion,  or  if  not  arrested  the  milk  may 
be  so  altered  in  composition  as  to  make  the  child  acutely  ill.  Worry, 
anxiety,  fatigue,  intense  or  prolonged  nervous  strain  may  so  alter  the 
milk  as  to  cause  it  to  disagree  with  a  child  who  had  previously  thrived 
well  upon  it,  or  they  may  greatly  diminish  and  sometimes  even  arrest 
the  secretion.  It  is  the  nervous  condition  of  the  mother  more  than 
anything  else  which  determines  her  success  or  failure  as  a  nurse.  If 
a  mother  would  nurse  successfully,  she  must  have  plenty  of  rest  and 
sleep,  moderate  exercise,  keep  her  mind  free  from  imnecessary  worries, 
avoid  social  engagements,  and  lead  a  simple,  regular,  natural  life.  Unless 
she  can  and  will  do  this  successful  nursing  can  hardly  be  expected. 

The  nature  of  the  changes  produced  in  milk  by  nervous  disturbances 
in  the  mother  are  as  5'et  little  understood.  Some  infants  are  so  pro- 
foundly affected  as  to  suggest  the  development  of  toxic  substances  in  the 
milk.  The  milk  of  the  tired  and  worried  mother  is  nearly  always  low 
in  fat,  while  the  protein  is  usually  high,  and  possibly  there  are  other 
changes  as  yet  unknown. 

COW'S  MILK 

Cow's  milk  being  our  main  reliance  in  the  artificial  feeding  of  infants 
and  the  staple  food  of  nearly  all  young  children,  it  follows  that  every- 
thing relating  to  its  production  and  handling  is  important.  For  fuller 
information  than  it  is  possible  to  give  here  the  reader  is  referred  to 
special  works  upon  the  subject.^ 

The  essential  conditions  to  be  fulfilled  in  cow's  milk  which  is  to 
be  used  as  a  food  for  infants  and  young  children  are:  (1)  Freshness; 
(2)  it  should  contain  no  preservatives;  (3)  it  should  be  from  healthy- 
animals,  free  from  tuberculous  or  other  taint;  (4)  it  should  be  clean; 
(5)  it  should  not  be  skimmed  or  otherwise  falsified;  (6)  it  should  con- 

^  Convenient  works  for  a  physician's  use  are  Richmond's  Dairy  Chemistry ; 
Aikman's  Milk,  Its  Nature  and  Composition,  Block,  London;  Russell's  Outlines 
of  Dairy  Bacteriology;  Belcher's  Clean  Milk,  Hardy  Publishing  Co.,  New  York; 
Pearsons'  Jensen's  Milk  Hygiene;  Milk  and  Its  Relation  to  Public  Health, 
Bulletin  56,  U.  S.  Public  Health  and  Marine-Hospital  Service;  The  Milk 
Question,  M.  J.  Rosenau. 


COW'S  MILK  145 

tain  no  pathogenic  organisms;  (7)  the  nnmher  of  other  organisms  should 
not  be  excessive.  It  is  also  desirable  for  purposes  of  infant  feeding  that 
the  composition  of  the  milk,  particTilarly  the  percentage  of  fat,  should 
be  known,  and  that  the  milk  should  be  as  nearly  uniform  as  possible  from 
day  to  day  and  at  different  seasons  of  the  year.  Mixed  or  herd  milk  is 
therefore  to  be  preferred  to  that  from  a  single  animal,  since  it  is  subject 
to  fewer  variations.  The  common  varieties  or  "grade  cows"  should  be 
chosen  rather  than  highly  bred  animals,  if  for  no  other  reason,  because 
they  are  more  hardy,  less  subject  to  disease,  and  less  susceptible  to  other 
influences  which  might  affect  the  milk. 

As  ordinarily  handled,  milk  should  if  possible  be  used  before  it  is 
twenty-four  hours  old;  after  this  time  changes  occur  very  rapidly,  and 
such  milk  can  not  in  summer  be  used  with  safety  for  infants.  Milk 
may  be  safe  for  a  longer  time  provided  special  precautions  are  taken 
in  producing  and  handling  it,  and  special  care  in  keeping  it  constantly 
at  a  temperature  below  50°  F. 

Preservatives  are  sometimes  added,  particularly  in  hot  weather,  by 
unscrupulous  dealers  to  retard  the  souring  of  milk,  in  order  thereby  to 
avoid  the  necessity  and  expense  of  proper  icing.  Formerly  boric  or  sali- 
cylic acid  was,  and  recently  formaldehyd  has  been  largely  employed  for 
this  purpose. 

Microorganisms  in  Milk. — Most  of  the  common  bacteria  grow  readily 
in  milk,  and  the  conditions  under  which  it  is  produced  and  handled 
render  it  liable  to  contamination  in  many  ways. 

1.  Disease  in  the  Coiv. — From  disease  of  the  udder  streptococci  or 
other  pyogenic  germs  may  enter  the  milk  in  such  numbers  as  to  excite 
acute  gastro-enteritis  in  a  child,  but  the  particular  danger  under  such 
circumstances  is  "septic  sore  throat."  Within  the  last  few  years  several 
severe  epidemics  of  this  dangerous  disease  have  been  reported.  A  number 
of  these  have  been  traced  to  herds  that  have  included  one  or  more  animals 
with  septic  infection  of  the  ndder.  Other  diseases  Avhich  may  be  com- 
municated from  the  cow  are  tuberculosis,  anthrax;,  and  the  foot-and- 
mouth  disease.  Veterinarians  differ  much  in  their  estimates  of  the 
amount  of  tuberculosis  among  cattle,  the  estimates  range  from  3  to  25  per 
cent.  It  is  the  general  opinion  that  it  is  on  the  increase,  though  this  may 
only  mean  that  th^,^lisease  is  now  more  often  recognized.  Of  the  cattle 
slaughtered  in  London,  25  per  cent  are  stated  to  be  tuberculous.  Unless 
the  process  is  advanced  or  the  udder  is  the  seat  of  disease,  tubercle  bacilli 
are  usually  absent  from  the  milk.  Kevertheless  tubercle  bacilli  are  fre- 
quently found  in  small  numbers  in  ordinary  market  milk.  In  107  unse- 
lected  specimens  of  milk  sold  from  cans  in  New  York  City,  Hess  found 
tubercle  bacilli  in  17,  or  1()  per  cent.  Rabinowitch  and  Kempncr  in  25 
similar  examinations  in  Berlin  found  tubercle  bacilli  iu  7,  or  28  per 


146  NUTRITION 

cent.  Macfadyen  in  London  found,  in  77  samples  of  milk,  tubercle 
bacilli  present  in  17,  or  23  per  cent.  These  figures  may  probably  be 
taken  to  represent  average  conditions  in  large  cities.  But  the  dangers 
from  milk  are  not  quite  so  great  as  would  appear  from  these  findings, 
for  in  many  of  the  cases  the  number  of  bacilli  is  very  small  and  only 
discovered  by  animal  inoculations. 

For  reasons  given  elsewhere  (vide  Tuberculosis),  we  can  not  believe 
the  danger  of  acquiring  tuberculosis  through  milk  as  great  as  many 
have  represented;  yet  milk  must  be  regarded  as  one  of  the  sources  of 
tuberculous  infection.  The  sale  of  milk  from  cows  showing  evidence 
of  tuberculosis  upon  physical  examination,  and  from  those  having  tuber- 
culosis of  the  udder  should  not  be  permitted;  also  the  milk  of  every 
cow  which  reacts  to  the  tuberculin  test  unless  pasteurized. 

2.  Specific  Pathogenic  Organisms  Accidentally  Gaining  Access  to 
Milk. — The  role  of  milk  in  the  spread  of  infectious  disease  may  be  ap- 
preciated by  the  fact  that  in  1900  Kober  was  able  to  find  records  of  330 
outbreaks  which  were  traced  to  it.  The  disease  most  frequently  com- 
municated in  this  way  is  typhoid  fever.  In  the  reports  of  195  epidemics 
collected,  typhoid  existed  at  the  dairy  in  148  instances;  in  24  cases  the 
employees  acted  as  nurses  to  typhoid  patients,  and  in  10  they  continued 
at  work,  although  themselves  suffering  from  the  disease. 

Next  to  typhoid  the  disease  most  often  spread  through  milk  is  scar- 
let fever.  The  sudden  and  simultaneous  development  of  a  considerable 
nimiber  of  cases  in  a  community  should  lead  one  to  consider  the  milk 
supply  as  a  possible  cause.  Of  99  epidemics  of  scarlet  fever,  there  was 
disease  at  the  farm  or  dairy  in  68;  in  17,  employees  were  themselves 
affected,  and  in  10  they  acted  as  nurses. 

During  1911  and  1912  extensive  epidemics  of  septic  sore  throat  oc- 
curred in  Boston,  Chicago  and  Baltimore  which  were  traced  to  strepto- 
cocci spread  through  milk. 

Besides  the  diseases  mentioned,  diphtheria,  cholera,  dysentery,  and 
certain  forms  of  diarrheal  diseases  may  be-  spread  by  milk. 

3.  Other  Bacteria  Found  in  Milk. — These  are  chiefly  derived  from 
the  dust  of  the  stable,  the  hands  and  clothing  of  the  milker,  and  from  the 
dirt  which-  falls  from  the  udder  and  belly  of  the  cow  into  the  pail  during 
milking;  very  many  come  from  the  cow's  excreta.  Freeman  exposed 
a  Petri  gelatin-plate  beneath  a  cow's  udder  for  one  mimite  during 
milking  and  obtained  4,450  colonies.  The  varieties  of  bacteria  found 
in  fresh  milk  are  many  and  vary  with  locality.  Toward  the  souring 
point  the  great  majority  are  of  two  or  three  varieties  only;  fully  95 
per  cent  at  that  time  belong  to  the  lactic-acid-producing  group.  They 
cause  the  ordinary  souring  of  milk  by  acting  upon  the  milk  sugar.  Colon 
bacilli  are  very  common.     Other  bacteria  act  upon  the  milk  protein. 


COW'S  MILK  147 

inducing  various  putrefactive  changes ;  and  still  others  have  a  peptonizing 
power. 

Many  of  the  bacteria  are  harmless.  Others,  while  not  strictly  patho- 
genic, yet  when  present  in  large  numbers  induce  changes  in  milk  that  in 
susceptible  infants  may  cause  serious  illness.  The  relation  of  bacterial 
contamination  of  milk  to  infantile  diarrheas  is  considered  in  the  intro- 
ductory chapter  upon  Diarrheal  Diseases. 

The  Number  of  Bacteria  in  Milk. — This  depends  upon  three  condi- 
tions: (1)  Cleanliness  in  handling;  (2)  temperature;  (3)  age  of  the 
milk.  Hence  the  bacterial  count  becomes  of  value  in  furnishing  in- 
formation as  to  these  matters,  although  of  less  importance  in  regard 
to  the  production  of  disease  than  the  nature  of  the  organisms  present. 
The  influence  of  temperature  alone  upon  the  multiplication  of  bacteria 
in  milk  is  well  shown  by  the  following  experiment:  Four  samples  of 
the  same  milk  were  kept  at  different  temperatures  for  twenty-four  hours 
and  equal  quantities  were  then  plated;  No.  I  was  kept  at  60°  F.  and 
showed  134,340  colonies;  Ko.  II  was  kept  at  55°  F.  and  showed  67,170; 
No.  Ill  was  kept  at  50°  F.  and  showed  1,362;  No.  IV  was  kept  at  45° 
F.  and  showed  448. 

The  number  of  bacteria  in  bottled  milk  from  good  single  dairies 
usually  ranges  from  10,000  to  50,000  per  c.cm.,  according  to  the  season. 
Milk  from  mixed  dairies  delivered  in  cans  usually  ranges  from  100,000 
to  1,000,000,  though  much  higher  figures  are  often  reached  in  very 
hot  weather. 

The  number  of  bacteria  in  cream  is  nearly  always  greater  than  in 
milk.  Freeman's  experiments  with  gravity  cream  showed  that  the  bac- 
teria were  300  times  as  numerous  in  the  cream  as  in  the  milk  left  be- 
hind, the  bacteria  being  apparently  carried  up  with  the  fat  globules. 
This  emphasizes  the  necessity  of  the  greatest  care  w^th  reference  to  the 
use  of  cream. 

A  Bacteriological  Standard  for  Pure  Milk. — It  is  impossible  and  un- 
desirable to  fix  a  numerical  bacteriological,  standard  for  pure  milk.  One 
milk  commission  requires  that  the  milk  shall  not  have  more  than  10,000 
bacteria  in  each  cubic  centimeter;  another  fixes  the  limit  at  30,000.  A 
milk  commission  should  insist  that  milk  be  produced  from  healthy  ani- 
mals and  under  the  most  hygienic  conditions,  that  it  be  handled  only  by 
healthy  persons,  and  that  every  possible  precaution  be  taken  to  exclude 
pathogenic  germs.  It  is  possible  to  lay  too  much  stress  upon  the  mere 
number  of  bacteria.  There  is  no  evidence  that  when  the  conditions  men- 
tioned have  been  fulfilled  the  results  in  infant  feeding  are  better  with 
a  milk  containing  5,000  bacteria  or  less,  than  with  one  containing  20,000. 
Nor  is  there  any  proof  that  milk  containing  20,000  or  30,000  bacteria 
per  c.cm.  is  for  this  reason  alone  injurious.    A  low  bacterial  count  may 


148 


NUTRITION 


X 


beHaken  as  presumptive  evidence  that  the  milk  is  produced  under  hy- 
gienic conditions  and  carefully  handled^  and  in  such  circumstances  the 
entrance  of  pathogenic  germs  is  improbable.  Such  a  milk  is  therefore 
preferable.  While  it  is  quite  possible  to  produce  milk  which  is  prac- 
tically sterile,  the  expense  entailed  is  so  great  as  to  make  the  com- 
mercial production  of  such  milk  impracticable. 

The  Means  of  Excluding  Pathogenic  Bacteria,  and  of  Checking  the 
Spread  of  Contagious  Diseases  through  Milk. — Eules  are  readily  de- 
ducible  from  a  study  of  the  records  of  how  milk  has  usually  been  infected. 

1.  No  person  suffering  from,  or  in  contact  with,  a  contagioiis  disease 
should  enter  a  dairy  building  or  come  in  contact  with  the  milk  or  milk- 
utensils.  Children,  domestic  animals,  and,  so  far  as  possible,  flies  should 
be  excluded  from  rooms  where  milk  is  handled. 

2.  Milk  should  not  be  handled  in  or  near  dwellings,  privies,  or  sta- 
bles; cans  and  pails  should  be  washed  only  at  the  dairy,  and  after  ordi- 
nary cleansing  they  should  be  boiled  or  sterilized  with  live  steam. 

3.  Dairies  should  be  subject  to  regular  city  or  state  inspection.  Milk 
from  cows  showing  physical  evidence  of  tuberculosis  should  be  excluded; 
also  that  from  animals  which  are  in  any  way  sick  or  are  suffering  from 
disease  of  the  udder.  Milk  from  apparently  healthy  animals  which  re- 
spond to  the  tuberculin  test  should  not  be  used  for  food  in  a  raw  state. 

4.  During  epidemics  of  scarlet  or  typhoid  fever  or  septic  sore  throat 
no  raw  milk  should  be  used;  and  all  cases  of  such  diseases  occurring  in 
the  families  of  those  who  produce  or  handle  the  milk  should  be  imme- 
diately reported  and  isolated  by  the  authorities.  Most  of  the  rules  men- 
tioned are  enforced  by  milk  conimissions  which  supervise  the  production 
of  "certified  milk.". 

Composition  of  Cow's  Milk. — Except  in  the  percentage  of  fat,  the 
composition  of  mixed  or  herd  milk  does  not  vary  greatly  with  the  dif- 
ferent breeds.  The  fat  is  lowest  in  the  Holsteins,  and  highest  in  the 
Jerseys. 

Composition  of  Cow's  Milk  ^ 


Jerseys 

Holsteins 

Average  Good 
Herd  Milk. 

Fat 

5.61. 
5.15 
3.91 
0.74 
15.41 
84.59 

3.46 

4.84 

3.39 

0.74 

12.43 

87.57 

4.00 

Sugar 

4.75 

Protein 

3.50 

Ash 

0.75 

Total  Solids 

13.00 

Water 

87.00 

Total 

100.00 

100.00 

100.00 

*In  the  table  the  figures  for  Jersey  and  Holstein  herds  are  the  averages 
given  by  the  New  York  State  Experiment  Station.  The  requirements  in  New 
York  and  most  of  the  States  are,  fat,  at  least  3  per  cent;  total  solids,  12  per  cent. 


COW'S  MILK  149 

In  a  poor  milk  the  only  important  difEerence  to  be  considered  is  that 
the  fat  is  from  0.5  to  1  per  cent  lower  than  the  averages  given.  In 
Jersey  milk  the  chief  difference  is  that  the  fat  is  1  to  1.5  per  cent  higher 
than  the  averages ;  there  is  also  an  increase,  thongh  a  less  important  one, 
in  the  other  solids.  As  to  the  relative  advantages  of  the  different  breeds 
for  infant .  feeding,  the  difference  does  not  seem  great,  provided  all 
are  equally  healthy.  Jerseys  and  all  highly  bred  animals  are  more 
prone  to  disease  and  minor  disturbances  than  the  hardier  common 
breeds. 

The  Examination  of  Cow's  Milk. — The  application  of  heat  often 
causes  coagulation  in  milk  which  is  near  the  souring  point,  and  also  in 
colostrum  milk.  Both  are  unfit  for  use.  The  normal  reaction  of  cow's 
milk  is  amphoteric  or  slightly  acid;  if  alkaline,  it  is  pretty  certain  that 
something  has  been  added  to  it. 

The  specific  gravity  is  from  1.028  to  1.033.  If  the  cream  has  been 
removed,  the  specific  gravity  is  raised;  if  water  has  been  added,  the 
specific  gravity  is  lowered. 

The  best  of  all  ready  methods  of  determining  the  fat  content  is  the 
Babcock  test.  The  cream-gange  may  be  used  as  for  woman's  milk,  the 
100  c.c.  size  to  be  preferred;  but  it  is -not  to  be  relied  upon  unless  the 
milk  is  put  into  the  cylinder  soon  after  it  is  drawn  and  cooled  rapidly 
by  being  placed  in  ice-water.  Under  these  conditions,  if  the  reading  is 
made  after  eight  to  twelve  hours,  the  percentage  of  cream  to  that  of 
fat  is  about  three  to  one. 

A  microscopical  examination  of  the  cream  and  the  sediment  may 
give  valuable  information.  Not  much  can  be  learned  from  a  study  of 
the  fat  globules,  but  among  them  may  be  found  colostrum  corpuscles, 
which  are  usually  present  for  nearly  a  week  after  calving.  The  sedi- 
ment after  centrifuging  should  be  examined  to  ascertain  the  number  and 
character  of  the  cells  present  and'  should  be  stained  for  bacteria.  The 
character  of  the  cells  can  best  be  determined  by  the  use  of  a  differential 
blood  stain.  A  few  leucocytes  are  almost  invariably  found  in  normal 
milk;  epithelial  cells  and  lymphocytes  may  be  present  in  quite  large 
numbers  without  impairing  the  quality  of  the  milk.  However,  eosino- 
phile  cells  and  polymorphonuclear  neutrophiles,  when  in  large  numbers 
or  in  clumps,  invariably  indicate  disease  in  the  cow  and  the  milk  should 
be  rejected.  Such  milk  is  often  ropy  in  consistency  owing  to  the  pres- 
ence of  mucus  and  usually  contains  many  long  chains  of  streptococci. 
When  used  for  infants  it  may  excite  severe  digestive  disturbances,  usually 
diarrhea.  Eed  blood  cells  in  milk  may  be  due  to  traumatism,  to  in- 
flammation or  to  the  fact  that  milk  is  taken  too  soon  after  calving. 
Whenever  polymorphonuclear  leucocytes,  blood  or  streptococci  are  at  all 
numerous,  the  milk  should  not  be  used  and  a  thorough  inspection  of 


150 


NUTRITION 


the  herd  should  be  made.  The  only  sure  way  of  demonstrating  the 
presence  of  tubercle  bacilli  in  milk  is  by  animal  inoculation. 

The  casein  ^  of  cow's  milk  is  readily  coagulated  by  rennet  and  by 
acids.  The  curd  formed  by  the  gastric  juice  is  tough  and  firm  and  is 
more  slowly  dissolved  by  the  action  of  the  digestive  fluids.  The  casein  of 
woman's  milk  is  not  regularly  coagulated  by  rennet,  and  only  slightly 
and  with  difficulty  hj  acids.  The  curd  formed  by  the  gastric  juice  is 
loose  and  flocculent,  and  is  readily  and  completely  dissolved. 

The  inorganic  salts  in  cow's  milk  are  about  three  and  a  half  times 
as  abundant  as  in  woman's  milk;  but  as  will  be  seen  in  the  following 
table,  the  proportion  in  which  the  principal  salts  are  present  is  very 
nearly  the  samC;,  the  only  notable  exception  being  in  the  phosphoric  acid. 


CaO 
MgO 
P2O5 
K2O. 

NaaO 
CI.. 


Cow's  2 


22.8% 
2.8% 
27.4% 
24.7% 
10.9% 
15.5% 


Woman's  ' 


23.3% 

3.7% 
16.6% 

28.3% 

7.2% 

16.5% 


The  large  amount  in  cow's  milk  is  mainly  derived  from  the  casein. 
Even  when  diluted  twice  the  chief  salts  of  cow's  milk  are  still  in  excess 
of  those  in  woman's  milk.  In  all  dilutions  of  cow's  milk  the  total  salts 
may  be  calculated  as  one-fifth  the  protein.  The  ratio  thus  is  about  the 
same  as  salts  to  protein  in  woman's  milk.  The  larger  amount  of  total 
salts  in  cow's  milk  apparently  has  no  injurious  effect  upon  the  digestion 
of  healthy  infants ;  most  of  the  excess  is  not  absorbed  or  retained.  Thus 
while  an  infant  fed  on  woman's  milk  absorbs  about  80  to  85  per  cent 
of  the  salts  in  the  milk  and  retains  from  40  to  50  per  cent,  one  fed  on 
cow's  milk  absorbs  only  about  60  per  cent  and  retains  about  15  per  cent. 
The  ash  of  milk,  however,  does  not  accurately  represent  its  mineral 
constituents.  About  8  per  cent  of  the  phosphoric  acid  of  the  ash,  accord- 
ing to  Eichmond,  is  derived  from  the  casein;  sulphuric  acid,  though 
traces  are  found  in  milk,  is  not  to  be  regarded  as  one  of  its  true  mineral 


^  By  Haliburton  and  some  other  chemists  the  term  caseinogen  is  given  to 
this  protein  as  it  exists  in  milk.  When  this  is  acted  upon  by  rennet  it  splits 
up  into  two  substances:  One,  the  firm,  insoluble  coagulum  to  which  gnlj'-  the 
term  casein  is  applied;  the  other,  a  soluble  protein  which  is  known  as  whey- 
protein;  this  is  present  in  but  small  amount.  Those  who  use  the  term  casein 
to  designate  the  protein  as  it  exists  in  milk,  refer  to  the  curd  formed  by  the 
action  of  rennet  in  the  stomach  as  paracasein. 

^  Average  of  four  standard  authorities. 

3  Average  of  sixteen  analyses  of  mature  milk,  Courtney  and  Fales. 


COW'S  MILK 


151 


constituents.  The  most  recent  analyses  show  the  presence  of  citric  acid 
in  both  woman's  and  cow's  milk. 

The  amount  of  iron  in  milk  is  extremely  small.  In  woman's  milk  it 
is  about  1.5  mgm.  per  liter  or  .00015  per  cent  (Bahrdt  and  Edelstein). 
In  cow's  milk  it  is  only  about  one-third  this — really  a  negligible  quantity. 

Bacteria. — Cow's  milk  always  contains  a  large  number  of  bacteria 
which  increase  in  proportion  to  the  age  of  the  milk;  woman's  milk  is 
seldom  quite  sterile  but  contains  a  few  cocci  from  the  milk  ducts.  To 
what  degree  the  bacterial  content  of  cow's  milk  affects  its  digestibility  by 
healthy  infants,  it  is  impossible  to  make  positive  statements.  There 
seems  abundant  clinical  evidence  that  excessive  bacterial  contamination 
of  the  varieties  commonly  present  in  milk  are  detrimental  even  to  healthy 
infants,  and  that  to  the  delicate,  the  feeble  and  the  diseased  their  effects 
are  most  injurious.  So  far  as  the  production  of  disease  is  concerned,  it  is 
of  course  the  luiture,  not  the  number  of  bacteria  which  is  important. 
The  beneficial  effects  seen  of  sterilizing  or  boiling  the  milk  fed  to  feeble 
children  are  only  in  part  to  be  ascribed  to  the  destruction  of  bacteria. 

Cream. — A  great  misapprehension  exists  as  to  its  composition.  It  is 
often  spoken  of  as  if  it  were  something  entirely  different  from  milk. 
It  should  be  regarded  rather  as  milk  -which  contains  an  excess  of  fat. 
Cream  was  formerly  obtained  by  skimming — the  gravity  process;  at 
present,  almost  entirely  by  the  use  of  a  centrifugal  machine  known  as  a 
separator.  The  latter  process  has  the  advantage  in  point  of  time,  as 
centrifugal  cream  can  be  liui  upon  the  market  from  twenty-four  to  thirty- 
six  hours  earlier  than  gravity  cream. 

The  following  table  gives  the  composition  of  an  average  milk  and  of 
centrifugal  cream  of  different  densities  removed  from  the  same  milk: 


Whole 
Milk. 

Gream. 

I. 

II. 

III. 

IV. 

V. 

Fat 

4.00 
4.75 
3.. 50 
0.75 

8.00 
4.60 
3.40 
0.70 

12.00 
4.50 
3.30 
0.65 

16.00 
4.15 
3.20 
0.60 

20.00 
3.90 
3.05 
0.55 

40.00 

Sugar 

Protein 

Salts 

3.00 
2.20 
0.45 

The  percentages  of  protein  and  sugar  in  the  8  and  12-per-cent 
cream  are  but  little  lower  than  in  milk;  in  the  very  rich  creams  they 
are  reduced  by  about  one-third. 

It  is  unfortunate  that  no  general  standard  exists  as  to  what  shall  be 
sold  as  cream.  In  New  York  State  the  law  provides  that  cream  shall 
contain  at  least  18  per  cent  fat.  Very  rich,  centrifugal  cream  has  from 
35  to  40  per  cent  fat;  the  usual  centrifugal  cream  has  about  18  to  20 


152  NUTRITION 

per  cent.     Gravity  cream  has  generally  from   16  to   20  per  cent  fat. 

None  of  the  methods  for  determining  the  fat  in  milk  is  applicable 
to  cream^  except  the  Babcock  test.  Such  variation  exists  in  the  strength 
of  cream  that  the  physician  who  is  prescribing  it  for  infants  should  have 
tests  frequently  made. 

Methods  of  Obtaining  Milk  Containing  Various  Proportions  of  Fat 
— Top-Milk,  Skimmed  Milk. — To  secure  a  milk  for  infant  feeding  which 
is  fresh  and  at  the  same  time  one  which  contains  a  larger  jjroportion  of 
fat  than  does  whole  milk,  one  may  remove  only  a  certain  number  of 
ounces  from  the  top  of  a  quart  bottle.  If  cow's  milk  is  put  into  bottles 
soon  after  it  is  drawn  and  rapidly  cooled,  the  top-milk  may  be  removed 
after  four  hours.  Milk  bottled  at  dairies  and  then  transported  should 
be  allowed  to  stand  aft^r  it  is  received  for  at  least  two  hours  before 
removing  the  top-milk.  This  may  be  done  with  a  siplion,  spoon,  or  a 
small  special  dipper;  pouring  off  is  not  accurate. 

Skimmed  milk,  or  milk  which  contains  a  smaller  proportion  of  fat 
than  does  whole  milk,  may  be  obtained  from  bottled  milk  by  removing 
a  certain  number  of  ounces  from  the  top  of  the  quart  bottle  and  using 
only  the  remainder. 

It  is  unnecessary  in  practice  to  have  a  top-milk  which  contains  more 
than  7  per  cent  fat;  while  it  is  desirable  at  times  to  obtain  milk  which 
is  practically  fat-free.  It  is  also  desirable  to  know  the  percentage  of 
fat  that  is  obtained  when  one  uses  various  quantities  from  the  top  or 
bottom  of  a  quart  of  milk.  These  values  are  only  approximate,  but  if 
the  top-milk  is  carefully  removed,  are  sufficiently  accurate  for  practical 
j)urposes.  These  may  be  obtained  from  average-  herd  milk  or  very  rich 
milk  as  follows: 


From  one  quart  4  per  cent  milk  From  .5  per  cent  milk 

Upper  16  oz.  has  7%  fat; 

"       20  "  "  6%   " 

«       24  "  "  5% 

AU  "  4% 

Rest  after  removing  top  2  oz.  has  3% 

«         «  "  "     4    «     "  2% 

"     8    "     "  1% 

Fat-free  milk  can  be  obtained  onlj^  by  the  removal  of  the  cream  by  a  separator. 


upper  20  oz. 
"     24   " 
aU 
rest  after  removing  toi^  2  oz. 

"  ■     "  "  "    3  " 


In  general  it  is  wise  for  one  who  has  much  to  do  with  infant  feeding 
to  have  his  patients  take  milk  from  the  same  supply  to  secure  uniformity 
in  his  results. 

In  or  near  large  cities  it  is  possible  to  obtain  from  milk  laboratories 
cream  or  milk  with  any  desi"red  percentage  of  fat. 

Milk  Sterilization. — The  term  sterilization  is  widely  and  rather 
loosely  used  to  signify  the  heating  of  milk  for  the  destruction  of  germs. 


COW'S  MILK  153 

It  should,  however,  be  borne  in  mind  that  none  of  the  methods  com- 
monly employed  renders  milk  sterile  in  the  bacteriological  sense  of  the 
word.  What  is  accomplished  is  the  destruction  of  such  pathogenic  germs 
as  may  be  present,  and  from  95  to  99  per  cent  of  the  other  bacteria,  so 
as  to  retard  for  a  considerable  time  the  ordinary  fermentative  changes. 
The  advantages  of  sterilizing  milk  are  obvious.  When  we  consider 
the  enormous  number  of  bacteria  present  in  cow's  milk  with  the  usual 
methods  of  handling,  and  that  they  are  frequently  the  cause  of  disease, 
it  is  not  strange  that  after  its  introduction  by  Soxhlet  in  1886  the 
practice  of  heating  milk  used  for  infant  feeding  rapidly  extended  over 
the  world.  Following  him,  the  earlier  experiments  in  sterilization  were 
made  at  212°  F.,  usually  continued  for  an  hour  and  a  half,  and  this 
temperature  is  still  largely  employed  on  the  Continent  of  Europe.  Even 
this  does  not  render  milk  safe  for  very  long.  Spores  are  not  destroyed, 
and  at  ordinary  room  temperatures  spore-bearing  bacteria  may  soon  de- 
velop in  such  numbers  as  to  make  the  milk  dangerous.  Since  some  of 
these  bacteria  act  upon  the  milk-protein  and  not  upon  the  sugar,  such 
milk  may  not  be  sour,  and  hence  its  danger  may  not  be  recognized. 

There  are  some  disadvantages  in  heating  milk.  The  change  in  taste 
and  the  constipating  effects  of  sterilized  milk  are  very  noticeable.  Some 
of  the  lactose  is  converted  into  caramel,  causing  a  slight  change  in  color ; 
the  lactalbumiu  is  partially  coagulated,  this  beginning  at  160°  F,  (70° 
C),  and  the  casein  is  rendered  less  coagulable  by  rennet;  Eettger  has 
shown  that  when  milk  is  heated  above  185°  F.  (85°  C.)  a  volatile 
sulphid  is  liberated,  conclusive  evidence  of  some  change  in  the  protein; 
the  organic  phosphorus  is  changed  into  an  inorganic  phosphate;  the 
citric  acid  is  partially  precipitated  as  calcium  citrate,  and  some  lime 
salts,  which  are  usually  soluble,  are  converted  into  insoluble  com- 
pounds. Some  changes  also  occur  in  the  fat.  Moreover,  certain  natural 
ferments  in  fresh  milk  are  destroyed  by  heat. 

Many  of  these  changes  are  doubtless  without  any  injurious  effect 
upon  nutrition.  Thei-e  is,  however,  one  important  clinica]  reason  for 
believing  that  the  nutritive  properties  of  milk  may  be  impaired  liy  heating 
to  212°  F. — viz.,  the  occurrence  of  scurvy  in  infants  who  are  fed 
solely  upon  such  milk  for  a  long  time.  Of  379  cases  of  infantile  scurvy 
brought  together  in  the  Report  of  the  American  Pediatric  Society, 
sterilized  milk  was  the  previous  diet  in  107.  Many  such  cases  have 
come  under  our  own  notice.  Again  and  again  cases  of  scurvy  have  been 
cured  by  simply  changing  from  sterilized  to  raw  milk. 

Heating  at  Lower  Temperatures — Pasteurizing  Milk. — To  obviate 
the  disadvantages  above  referred  to,  the  practice  has  come  largely  into 
use  in  America  of  employing  much  lower  temperatures  for  milk  steri- 
lization. 


154  NUTRITION 

At  present  150°  to  155°  ¥.  (G5°  to  68°  C.)  are  the  temperatures 
generally  employed.  These  temperatures  are  maintained  from  twenty  to 
thirty  minutes.  This  is  sufficient  to  kill  the  bacilli  of  tuberculosis,  diph- 
theria, and  typhoid  fever,  and  from  98  to  99.8  per  cent  of  all  other 
bacteria  in  milk.  Nearly  all  of  the  objectionable  changes  produced  in 
sterilized  milk  are  avoided  when  the  temperature  is  raised  only  to  150° 
F.  (65°  C;),  while  it  accomplishes  the  purpose  for  which  milk  is  heated. 
The  advantages  of  this  form  of  heating  are  therefore  obvious.  But 
spores  are  not  destroyed,  and  such  milk  requires  special  handling.  It 
should  be  rapidly  cooled,  kept  at  a  low  temperature,  and  used  within 
twenty-four  hours  after  heating. 

Commercial  Pasteurization  of  Milk. — This  was  first  accomplished  by 
passing  milk  through  hot  pipes  in  which  it  was  exposed  to  a  temperature 
of  140°  to  160°  F.  for  a  brief  period,  usually  less  than  one  minute. 
This  has  been  found  practically  to  be  insufficient  to  destroy  ^the  patho- 
genic organisms  in  milk.  At  present  the  method  followed  is  known  as 
the  "holding  process.^'  By  this  the  milk  is  slowly  passed  through  a 
succession  of  vats  being  held  at  a  temperature  of  about  150°  F.  for 
thirty  or  forty  minutes.  It  is  afterwards  cooled,  then  drawn  into  ster- 
ilized containers,  bottled  and  labeled  "pasteurized"  milk.  For  this 
process  expensive  and  complicated  apparatus  is  necessary  and  even  when 
done  on  a  large  scale  it  adds  to  the  cost  of  the  milk.  The  limited  control 
which  it  is  possible  for  a  municipality  to  exercise  over  milk  producers 
and  distributors,  the  impossibility  of  securing  adequate  inspection  of 
dairy-farms  and  creameries,  a  conviction  that  a  large  part  of  the  typhoid 
seen  in  cities  and  towns  is  milk-borne,  and  the  occurrence  of  extensive 
epidemics  of  septic  sore  throat  fvopa.  milk  infection,  have  forced  upon 
many  boards  of  health  the  necessity  of  compelling  pasteurization  of 
all  milk  used  for  food  in  an  uncooked  state  unless  the  same  is  from 
"certified  dairies"  supervised  by  competent  milk  commissions.  This 
practice  bids  fair  to  become  general.  The  objections  to  and  disadvantages 
of  pasteurized  milk  should  also  be  considered.  There  is  a  temptation  to 
an  unscrujmlous  producer  to  neglect  precautions  necessary  to  keep  milk 
clean,  and  at  the  same  time  to  a  dealer  to  deliver  milk  that  otherwise 
would  be  unsalable  because  near  the  souiring  point.  The  necessity  of 
keeping  pasteurized  milk  cold  and  of  using  it  within  twenty-four  hours 
if  possible,  must  ])e  taught  the  public.  The  label  "pasteurized  milk" 
.too  often  conveys  a  false  sense  of  security  and  leads  to  the  neglect 
of  the  precautions  mentioned.  The  date  of  pasteurization  should  be 
stamped  upon  the  label.  It  should  be  known  that,  unless  milk  is 
kept  cold  and  used  soon  it  may,  even  though  pasteurized,  contain  an 
immense  number  of  bacteria  although  it  does  not  turn  sour.  The 
closest  kind  of  supervision  should  be  exercised  by  authorities  which 


COW'S  MILK  155 

permit  or  require  the  general  pasteurization  of  the  milk  of  a 
community. 

Pasteurization  vs.  Sterilization.— From  what  has  already  heen  said 
it  would  appear  that  the  argument  is  altogether  in  favor  of  pasteuriza- 
tion. The  lowest  temperature  and  the  shortest  time  that  will  surely 
destroy  the  objectionable  bacteria  in  milk  would  seem  to  merit  general 
adoption.  Pasteurization,  however,  requires  considerable  care,  intelli- 
gence, and  special  apparatus.  When  all  these  can  be  secured  it  should 
be  employed  as  the  method  of  choice. 

Sterilization  at  212°  F.  (100°  C.)  is  much  simpler;  it  can  be  done 
with  many  simple  and  inexpensive  forms  of  apparatus  or  even  without 
any  special  apparatus.  Where  no  ice  is  available,  it  is  safer  in  hot 
weather  than  pasteurization.  Among  the  poor  of  our  large  cities,  in 
summer,  boiling  is  to  be  advised  as  the  most  satisfactory,  and  indeed 
the  only  efficient,  method  of  sterilization.  It  should  not  be  forgotten 
that  the  use  of  such  milk  as  the  sole  diet  for  a  long  time  is  attended 
with  a  certain  amount  of  risk,  even  though  a  small  one;  and  one  should 
always  be  on  the  watch  for  the  soreness  of  the  legs  and  the  spongy  gums 
that  indicate  the  beginning  of  scurvy.  Heating  to  212°  F.  on  two  suc- 
cessive days  is  also  to  be  recommended  where  milk  must  be  kept  for  one 
or  two  weeks,  as  upon  ocean  journeys. 

Methods  of  Heating^  Milk. — Milk  for  infant  feeding  should  be 
sterilized  at  home  preferably  in  small  bottles,  each  one  of  which  con- 
tains a  sufficient  quantity  for  one  feeding.  These  bottles  may  be  plugged 
with  cotton  or  corks,  or  special  stoppers  may  be  used.  Soxhlet's  ap- 
paratus may  be  employed,  or  Arnold's,  or  any  one  of  a  half  dozen  others 
sold  in  the  shops.  All  that  is  really  necessary  is  to  expose  the  bottles 
on  all  sides  to  live  steam  in  a  closecl  vessel.  It  can  be  done  efEectively 
in  any  tin  vessel  which  has  a  closely  fitting  cover  and  a  perforated  bot- 
tom, and  which  can  be  placed  over  a  pot  of  boiling  water.  Steriliza- 
tion at  212°  F.  is  usually  continued  for  one  hour.  The  bottles  should 
then  be  cooled  in  water  as  quickly  as  possible  and  placed  upon  ice  or  in 
the  coolest  place  available. 

A  simple  apparatus  for  pasteurizing  milk  has  been  devised  by  Free- 
man in  which  the  temperature  is  raised  to  150°  F.  (65°  C.)  by  hot 
water.^    An  essential  step  in  pasteurizing  milk  is  rapid  cooling.     After 

*  Milk  may  be  effectively,  but  not  very  accurately,  pasteurized  in  the  home 
without  any  apparatus  in  the  following  manner:  Place  the  bottles  of  milk 
in  a  covered  pot  containing  enough  tepid  water  to  cover  the  bottles  to  the  neck. 
Allow  this  to  stand  on  the  top  of  a  stove  until  the  water  begins  to  simmer. 
Now  remove  the  pot  from  the  stove  to  a  table  and  let  it  stand  for  twenty 
minutes  covered.  Then  cool  the  bottles  of  milk  by  placing  them  first  in  water 
at  room  temperature   and   afterwards   in  ice  water. 


156  NUTPJTION 

thirty  minutes  the  bottles  should  be  removed  from  the  pasteurizer, 
placed  in  water  at  the  room  temperatiire  and  afterward  in  ice-water, 
where  they  should  remain  half  an  hour  before  being  placed  in  the  cold 
room  or  ice  chest. 

The  sterilization  of  milk  is  useful,  first,  for  the  destruction  of  patho- 
genic germs;  secondly,  for  the  destruction  of  the  bacteria  causing  fer- 
mentation, thus  enabling  one  to  feed  with  safety  milk  in  which,  though 
it  may  be  forty-eight  hours  old,  no  important  fermentative  changes  have 
occurred.  As  a  therapeutic  measure  sterilized  milk  is  useful  in  various 
forms  of  gastric  or  intestinal  infection  such  as  typhoid  fever,  dysentery, 
diarrhea,  etc.  It  is  a  matter  of  clinical  observation  that  sterilized  milk 
is  sometimes  well  borne  when  raw  milk  is  not,  particularly  by  very  young 
infants. 

Shall  All  Milk  Used  for  Infant  Feeding  Be  Sterilized? — In  warm 
weather  only  the  very  cleanest  milk  can  safely  be  used  without  heating. 
In  winter,  the  heating  of  milk  is  not  so  necessary ;  but  so  long  as  milk 
is  produced  and  handled  as  the  bulk  of  milk  is  at  present,  not  being 
delivered  in  large  cities  until  it  is  considerably  over  twenty-four  hours 
old,  and  not  consumed  until  over  forty-eight  hours  old,  some  form  of 
heating  should  invariably  be  practiced,  unless  it  is  known  to  be  pro- 
duced and  handled  under  the  best  conditions.  In  the  country  where 
milk  is  obtained  fresh  and  used  before  it  is  twenty-four  hours  old,  ster- 
ilizing is  unnecessary  if  the  cows  are  healthy  and  the  milk  properly 
handled. 

,  It  is  quite  possible  to  produce  milk  which  does  not  need  sterilization. 
There  are  special  dairies  supplying  such  certified  milk  to  many  of  our 
large  cities,  and  their  number  may  be  very  greatly  increased  if  the  med- 
ical profession  will  use  its  influence  in  this  direction.  Our  preference 
for  infant  feeding  is  a  milk  so  clean  and  fresh  that  it  may  be  safely  given 
even  in  summer  without  heating,  but  this  is  at  present  available  only  for 
the  small  minority.  Healthy  infants  with  good  digestion  usually  do  well 
upon  raw  milk  even  though  the  number  of  bacteria  is  quite  large;  while 
delicate  infants  or  those  with  digestive  disturbances  may  be  seriously 
affected  by  such  milk. 

The  feeding  of  boiled  or  sterilized  milk  must  be  considered  quite 
apart  from  the  question  of  microorganisms.  There  are  unquestionably 
some  very  young  and  some  delicate  infants  with  feeble  digestion  who 
thrive  better  upon  heated  than  raw  milk  even  though  the  number  of 
bacteria  in  the  latter  may  be  very  small.  Experiments  in  feeding  raw 
and  boiled  milk  to  young  animals  for  comparative  results  have  not  been 
numerous,  nor  quite  conclusive.  Those  which  have  been  published  in 
Europe  are  rather  in  favor  of  boiled  milk.  The  latest  experiments  of 
Daniels  and  Stuessy  in  this  country,  however,  indicate  that  animals  do 


COW'S  MILK  157 

not  thrive  for  a  long  period  upon  boiled  milk ;  although  for  the  first  two 
or  three  months  those  fed  on  boiled  milk  did  distinctly  better  than  those 
fed  upon  raw  milk.  Brennemann  (Chicago)  has  made  some  experiments 
upon  the  human  subject  (a  young  adult)  which  show  conclusively  that 
boiling  has  a  marked  effect  upon  the  coagulation  of  the  casein  in  the 
stomach.  Under  certain  conditions  this  seems  to  produce  a  distinctly 
beneficial  effect  upon  digestion.  However,  this  is  far  from  proving  that 
all  milk  used  for  infant  feeding  shall  be  so  heated.  The  use  of 
boiled  milk  for  long  periods  is  not  to  be  recommended;  although  with 
young  infants  and  for  short  periods  it  is  frequently  of  the  greatest 
service. 

Frozen  Milk. — During  very  cold  weather  milk  is  often  unavoidably 
delivered  in  a  partially  or  completely  frozen  condition  and  the  question 
frequently  is  raised  whether  any  important  change  is  produced  by  freez- 
ing which  affects  its  digestibility  by  young  infants.  So  far  as  is  known 
the  changes  brought  about  are  purely  physical  ones.  Only  the  water  of 
the  milk  freezes,  the  fat  undergoing  separation  in  consequence.  When 
such  milk  is  warmed  again,  the  fat  globules  may  coalesce  to  form  an 
oily  layer  of  butter  fat.  While  older  children  or  robust  infants  are  sel- 
dom affected  by  such  milk,  considerable  disturbance  may  be  produced  in 
delicate  or  susceptible  infants.  Occasionally  vomiting  is  excited,  but 
more  often  there  is  diarrhea  which  may  become  severe.  The  higher  the 
fat  percentage  in  the  milk  fed,  the  more  severe  are  the  symptoms  likely 
to  be. 

Peptonized  Milk. — Milk  is  peptonized  through  the  agency  of  a  sub- 
stance derived  from  the  pancreas,  usually  that  of  the  pig.  This  is  known 
in  the  market  as  "extractum  pancreatis,"  the  active  ferment  being  the 
trypsin.  As  this  acts  only  in  an  alkaline  medium,  bicarbonate  of  soda 
should  first  be  added  to  the  milk.  The  purpose  of  peptonizing  is  to 
secure  a  partial  digestion  of  the  protein  of  milk  before  feeding. 

Milk  which  has  been  peptonized  ten  minutes  is  not  altered  in  taste; 
if,  however,  the  process  is  continued  for  twenty  minutes,  a  slightly  bitter 
taste  is  noticed  which  increases  with  the  duration  of  the  process.  Pep- 
tonizing may  be  arrested  at  any  stage  by  raising  the  milk  to  the  boiling 
point;  but  if  the  milk  is  to  be  fed  at  once  this  is  not  necessary. 

Peptonized  milk  is  useful  only  when  the  stomach  is  so  sensitive  as 
to  be  affected  by  the  coagulation  of  milk,  something  which  is  rarely  seen. 
The  prolonged  use  of  peptonized  milk  as  the  sole  food  is  sometimes  fol- 
lowed by  scurvy. 

Condensed  Milk. — This  is  prepared  by  heating  fresh  cow's  milk  to 

212°  F.  for  twenty  minutes  for  sterilization,  and  then  evaporating  in 

vacuo,  so  that  one  part  of  condensed  milk  represents  about  two  and  a 

half  parts  of  the  original  milk.     Sweetened  condensed  milk  is  preserved 

7 


158 


NUTRITION 


in  tin  cans,  with  the  addition  of  about  seven  ounces  of  cane  sugar  to  a 
pint. 

The  composition  of  sweetened  condensed  milk  is  shown  in  the  follow- 
ing table ;  also  the  results  obtained  when  it  is  diluted : 


Condensed 

Milk.i 

With  6  Parts 
of  Water 
Added. 

With  12 
Parts  of 
Water. 

With  18 
Parts  of 
Water. 

Fat ' 

Per  cent. 

9.61 
8.01 

54.94 

1.78 
25.66 

Per  cent. 

1.37 
1.14 

7. 89 

0.25 
89.35 

Per  cent. 

0.73 
0.61 

4.75 

0.13 

94.28 

Per  cent. 
0.50 

Protein 

«„„o.   /Cane,  42.91  \ 

'^"g^^    IMilk,    12.03/ 

Salts 

Water 

0.42 

2.90 

0.09 
96.09 

Analysis  of  Borden's  Eagle-Brand  condensed  milk. 


The  reasons  both  for  the  success  and  for  the  failure  of  sweetened 
condensed  milk  as  an  infant-food  are  apparent  from  a  study  of  its  com- 
position. As  a  temporary  food  it  is  often  useful,  first  because  it  is  nearly 
sterile,  but  chiefly  because  the  fat  of  cow's  milk  has  been  reduced  by  the 
usual  dilution  to  a  point  at  which  an  infant  with  a  very  weak  digestion 
can  bear  it,  Avhile  it  furnishes  an  abundance  of  sugar;  but  it  is  low 
in  protein.  Infants  fed  upon  condensed  milk  are  often  fat,  but  have,  as 
a  rule,  feeble  resistance  when  attacked  by  acute  disease,  especially  of  the 
intestinal  tract.  It  is  rare  to  see  a  child  reared  on  condensed  milk  who 
does  not  show  some  evidence  of  rickets.  The  prolonged  use  of  con- 
densed milk  is  sometimes  a  cause  of  scurvy.  Condensed  milk  is  admis- 
sible for  temporary  use  during  attacks  of  indigestion,  for  infants  with 
feeble  digestion,  especially  in  summer,  for  very  young  infants  during 
the  first  two  or  three  months,  or  among  the  very  poor,  when  the  cow's 
milk  which  is  available  is  still  more  objectionable.  It  should  not  be 
used  as  a  permanent  food  when  good,  fresh  cow's  milk  can  be  obtained. 
In  travelling  it  is  often  the  most  convenient  as  well  as  the  safest 
food  to  use.  It  should  usually  be  diluted  ten  to  twelve  times  for  an 
infant  under  one  month,  and  from  six  to  ten  times  for  those  who  are 
older. 

During  recent  years  condensed  milk  without  any  addition  of  sugar  is 
sold  in  the  market;  in  many  large  cities  this  is  delivered  fresh  daily  in 
bulk;  it  is  also  sold  in  tin  cans  in  a  sterilized  form.  To  distinguish  it 
from  other  condensed  milk  it  is  called  "evaporated  milk."  Its  strength 
is  about  the  same  as  that  of  the  better  known  condensed  milk,  i.  e.,  one 
part  representing  about  two  and  a  half  parts  of  the  original  milk,  with- 
out any  addition  of  sugar  or  other  preservative.     Evaporated  milk  re- 


\>h^  COW'S  MILK  ]50 

quires  the  same  modification  as  ordinary  cow\s  milk.  For  routine  use  it 
should  be  diluted  with  from  eight  to  twelve  parts  of  water,  and  sugar 
added.  Wlien  diluted  with  water  the  proportion  of  "fat  and  protein  will 
be  approximately  the  same  as  in  condensed  milk  given  in  the  foregoing 
table.  Additional  carbohydrates  may  be  introduced  in  whatever  form 
may  seem  desirable,  either  as  sugar  (milk  sugar,  cane  sugar,  or  maltose) 
or  as  starch  (barley,  oat  or  wheat  flour).  It  is  a  sterile,  cooked  milk. 
Some  children  thrive  upon  it  who  cannot  so  well  digest  either,  raw  milk 
of  the  same  percentage  composition  or  even  freshly  pasteurized  milk.  It 
should  not  be  long  continued  as  the  sole  food  wheii  good  fresh  milk  can 
be  obtained. 

Dried  Milk. — Dried  milk  sold  under  various  names  has  more  recently 
been  put  upon  the  market.  It  is  prepared  either  from  whole  milk  or 
from  skimmed  milk.  The  process  of  manufacture  most  extensively  em- 
ployed is  that  of  spraying  the  milk  upon  hot  revolving  cylinders  by  which 
means  the  water  is  driven  olf  almost  instantaneously.  A  preparation  of 
dried  milk  made  from  partially  skimmed  milk  to  which  milk  sugar  has 
been  added  is  sold  under  the  name  of  "mammala."  It  contains  12  per 
cent  of  fat;  51  per  cent  of  sugar;  24  per  cent  of  protein,  and  5  per  cent 
oi  salts.  A  soniewliat  similar  preparation  but  higher  in  fat  is  sold  in 
England  under  the  name  of  "glaxo."  Dried  milk  is  a  sterile,  white 
powder  and  in  sealed  cans  keeps  indefinitely.  When  eight  parts  by  vol- 
ume of  water  are  added  (one  level  teaspoonful  to  the  ounce)  it  approx- 
imates in  composition  the  original  milk.  It  may  be  further  modified  if 
desired.  Its  application  is  similar  to  that  of  condensed  milk  over  which 
it  presents  some  obvious  advantages  in  travelling;  it  is  open  to  the  same 
objections  as  a  permanent  food,  and  should  not  be  advised  when  fresh 
milk  can  be  obtained. 

Buttermilk  and  Other  Forms  of  Fermented  Milk. — Various  forms  of 
fermented  milk  are  in  use  wliicb  diU'cr  accordijig  to  tlic  milk  iised  and 
the  procpss  j'olhtUtMl.  'I'bcy  resemble  (>;i('li  otliei'  in  tluii  ilie  fermentatioii 
is  excited  by  sunie  of  the  vm-ielics  of  lactic  acid  organisms,  in  some  cases 
with  the  addition  of  yeast,  wliieli  ferment  a  portion  of  the  milk  sugar. 
The  ordinary  buttermilk  of  commerce  is  sometimes  made  from  sweet,  but 
usually  from  sour  cream.  If  from  the  latter,  it  resembles  the  fermented 
milks  in  that  it  contains  little  or  no  fat  but  a  certain  amount  of  lactic 
acid,  the  result  of  fermentation.  It  differs  from  th(!m  in  that  the  fer- 
mentation in  buttermilk  is  due  to  a  great  variety  of  lactic  acid  organ- 
isms; besides,  it  contains  many  other  forms  of  bacteria  than  those  con- 
cerned in  the  process  of  fermentation.  Buttermilk  should  be  made  with 
care  or  it  may  be  grossly  contaminated.  It,  therefore,  varies  greatly  in 
taste  and  considerably  in  composition  under  different  conditions.  The 
following  is  an  average  of  many  analyses. 


160  NUTEITION 

Buttermilk 

Fat 0. 50  per  cent 

Milk  sugar 4.00    "      " 

Lactic  acid 0.80    "      " 

'Protein b.60    "      " 

Inorganic  salts 0.75     "      " 

Water 90.35     "      " 

100.00 

"When  used  as  an  infant  food  it  is  sometimes  sterilized  and  sometimes 
not.  The  sugar  content  is  raised  by  the  addition  of  milk  sugar  or  cane 
sugar;  sometimes  also  barley  flour  or  other  farinaceous  food  is  added 
A.  formula  much  used  is:  buttermilk,  one  quart;  barley  flour,  two  evej 
tablespoonfuls ;  water,  four  ounces :  cook  slowly,  constantly  stirring,  for 
twenty  minutes;  then  add  two  teaspoonfuls  of  cane  sugar.  The  advan- 
tages of  buttermilk  as  an  infant  food  are  chiefly  due  to  its  low  fat  con- 
tent and  to  the  small  amount  of  lactic  acid  which  it  contains.  Its  cheap- 
ness is  an  important  consideration  and  makes  it  available  for  the  very 
poor. 

Other  fermented  milks,  sometimes  called  buttermilk,  are  known  also 
as  lactic  acid  milk,  lactohacilline,  lactohaciTlary  millc,  lactone  huttermillc, 
etc.  They  are  sometimes  made  from  whole  milk  but  chiefly  from  skimmed 
milk.  This  is  usually  first  sterilized  and  then  the  ferment  added  in  the 
form  of  a  tablet,  mixture  or  culture  from  some  previously  fermented  milk. 
The  ferment  consists  of  different  varieties  of  lactic  acid  organisms ;  the 
one  most  frequently  employed  is  known  as  the  Bulgaricus.  The  product 
]-esembles  ordinary  buttermilk  in  its  composition  except  that  it  usually 
has  a  higher  acidity.  It  is  a  purer  product  since  the  fermentation  takes 
place  from  one  or  two  selected  varieties  of  organisms  and  not  from  a 
great' number  as  in  ordinary  buttermilk.  It  differs  according  to  the 
exact  varieties  or  combinations  used,  also  according  to  the  temperature 
maintained  and  the  duration  of  the  fermentation.  A  temperature  of  80° 
to  85°  F.  is  usually  employed  and  this  is  continued  from  six  to  twelve 
hours  according  to  the  degree  of  acidity  desired.  The  milk  is  then 
bottled  and  put  on  ice,  Avhere  a  slight  change  continues,  although  the 
milk  alters  but  little  for  several  days.  The  taste  is  rather  pleasant  unless 
the  acidity  is  too  pronounced.  It  should  not  contain  alcohol  or  acetic 
acid.  These  fermented  milks  are  sometimes  used  in  acute  disease,  but 
chiefly  in  chronic  intestinal  conditions  after  the  first  year.  They  are  not 
adapted  to  continuous  use  in  infant  feeding. 

Kumyss  has  been  made  by  the  Tartars  for  centuries  from  mare's  milk. 
It  is  made  in  this  country  from  cow's  milk,  sometimes  skimmed,  but 
usually  from  the  whole  milk.  The  fermentation  is  generally  started  with 
yeast  and  is  continued  in  corked  bottles  usually  for  several  days,  with 


COW'S  MTLK  1(>1 

frequent  agitation.  Kuniyss  contains  carbon  dioxid,  lactic  acid,  alcohol 
and  traces  of  butyric  and  acetic  acids.  The  acidity  and  the  taste  depend 
upon  the  duration  of  the  process. 

Zoolak  or  matzoon  is  made  from  whole  milk  which  is  first  sterilized 
and  then  has  added  to  it  a  ferment  which  contains  some  form  of  yeast. 
It  differs  from  kumyss  chiefly  in  that  the  process  is  carried  on  in  open 
vessels  and  the  carbon  dioxid  allowed  to  escape.  It  is  a  thick  smooth 
liquid  and  has  a  taste  resembling  that  of  sour  cream. 

Both  kumyss  and  zoolak  are  better  adapted  for  use  with  older  children 
than  with  infants ;  they  are  chiefly  valuable  in  cases  of  chronic  intestinal 
indigestion.  For  infants  they  should  be  diluted  with  water  and  often 
given  with  a  spoon  since  they  are  too  thick  to  go  through  the  ordinary 
nipple. 

Protein  Milk  (Eiweiss-Milch  of  Finkelstein). — In  this  milk  modifica- 
tion is  secured  a  mixture  low  in  sugar  with  a  moderate  fat  and  a  high 
protein.  It  must  be  carefully  prepared  to  secure  a  uniform  product. 
The  average  composition  when  made  as  directed  below  ^  is  fat  3.0  to  3.5 
per  cent;  sugar  1.8  per  cent;  protein  3.75  per  cent;  salts  0.65  per  cent. 
Its  caloric  value  is  about  15  to  the  ounce.  The  fat  percentage  varies 
considerably  according  to  that  of  the  fat  of  the  milk  used  and  the  care 
exercised  in  its  preparation.  When  less  fat  is  desired  partially  skimmed 
milk  may  be  substituted.  The  proportion  of  the  ingredients  other  than 
the  fat  is  pretty  uniform.  The  total  salts  are  a  little  lower  than  in 
whole  milk;  the  proportion  of  insoluble  salts,  especially  calcium,  is, 
however,  greater,  while  that  of  the  soluble  salts  of'  sodium  and  potas- 
sium is  somewhat  less.  Protein  milk  has  a  slightly  sour,  rather  in^'pid 
taste,  so  that  its  arlministration  to  some  infants  is  difficVilt.     It  is  made 

". ^. ' 

' To   one   quait   of   whole   milk  warmed  to   about    100°    F.   qpe-half   ounce 

of  liquid  rennet  or  better  one  junket  tablet  dissolved  in  water  is  added,  stirring 

for  a  moment  only;   after  standing  at  room  temperature  for  twenty  or  thirty 

minutes,  or  until  it  is  firmly  coagulated,  it  is  poured  vipon  two  layers  of  gauze  or 

cheesecloth  and  suspended  for  about  one  hour  to  drain  off  the  whey.    The  curd  is 

then  washed  twice  with  cold  boiled  water,  after  which  the  dry  curd  is  rubbed 

through  a  very  fine  sieve  with  a  vegetable  masher,  or  some  similar  instrument, 

with   the   gradual   addition   of   one   pint   of   buttermilk.     Enough   boiled   water 

is  added  to  make  one  quart.     When  needed  in  quantity  for  hospital  use,  from 

five  to  ten  quarts  may  readily  be   prepared  at   one   time.     After   coagulation 

it  is  poured  upon  the   cheesecloth   and  allowed  to  drain  undisturbed  for   ten 

to  fifteen  minutes.     The  curd  is  then  rolled  from  side  to  side  by  manipulating 

the   cheesecloth   and    the   whey   removed    in   a   few    minutes.     It   should   then 

be   washed.     Protein  milk,  made  as  above  described,  will  contain  the   greater 

part  of  the  fat,  casein  and  insoluble  salts  of  the  original  milk,  also  the  salts, 

sugar  and  protein   of  the  buttermilk,  which   makes  up  half  its  volume.     The 

sugar,  the  albumin,  the  soluble  salts  and  a  little  of  the  fat  are  removed  with 

the  whey  and  the  wash. 


162 


NUTPvTTION 


more  palatable  by  the  addition  of  one  grain  of  saccharine  to  the  quart. 

The  advantages  of  protein  milk  dejDend  upon:  (1)  its  low  sugar;  (2) 
its  relatively  high  fat  and  insoluble  salts  whose  soaps  favor  the  produc- 
tion of  formed  stools  and  check  intestinal  fermentation;  (3)  the  high 
protein  (nearly  all  casein),  which,  having  been  precipitated  and  then 
mechanically  subdivided,  is  well  borne  by  the  stomach;  (4)  probably  to 
some  degree  the  lactic  acid  organisms  contained  in  the  buttermilk.  The 
high  percentage  of  casein  is  readily  held  in  suspension.  When  properly 
made  protein  milk  is  smooth  and  homogeneous  and  readily  passes  through 
an  ordinary  rubber  nipple.  It  can  be  warmed  to  the  usual  temperature 
before  feeding,  but  if  heated  much  above  this  point  the  curd  separates. 
Protein  milk  is  to  be  regarded  as  a  therapeutic  agent,  not  as  an  infant 
food  for  prolonged  use.  It  has  a  wide  field  of  usefulness  in  both  acute 
and  chronic  disturbances  of  digestion  with  intolerance  of  carbohydrates, 
particularly  those  associated  with  diarrhea. 

Junket  or  Curds  and  Whey. — Junket  is  made  as  follows:  To  one 
pint  of  fresh  lukewarm  cow's  milk  are  added  two  teaspoonfuls  of  essence 
of  pepsin,  liquid  rennet,  or  half  a  junket  tablet.  It  is  stirred  for  a  mo- 
ment and  then  allowed  to  stand  at  the  room  temperature  until  firmly 
coagulated.  Junket  is  useful  in  the  feeding  of  older  children,  but  should 
not  be  given  to  infants. 

Whey. — The  milk  is  coagulated  with  rennet  as  above,  the  curd  is  then 
broken  up,  and  the  whey  strained  through  muslin  by  suspension.  The 
composition  of  whey  varies  somewhat,  depending  upon  the  way  in  which 
it  is  prepared.  If  it  is  desired  to  have  as  little  fat  as  possible,  skimmed 
or  fat-free  milk  should  be  used,  and  the  whey  should  be  strained  through 
fi]ie  muslin  without  pressure.  If  it  is  desired  to  retain  some  of  the  fat, 
whole  milk  may  be  used,  cheesecloth  as  a  strainer,  and  more  pressure. 
The  protein  of  whey  is  chiefly  lactalbumin. 

Whey  is  useful  for  infants  with  gastric  symptoms  when  low  fat  is 
desired.  Its  high  sugar  and  salt  content  usually  contraindicate  its  use 
in  cases  with  intestinal  symptoms,  especially  if  diarrhea  is  present. 


Whey 


Average 

46  Analyses 

(Koenig). 

Fioiii 
Wliole  Milk 
(A(lri:in<.-e). 

From 

Fat-free  Milk 

(Adriance). 

Protein 

0.86 
0.32 
4.79 
0.65 
93.38 

0.94 
0.96 
5.49 
0.48 
92.13 

1.17 

Fat 

0.04 

Sugar 

5.36 

Salts 

0.52 

Water 

92.91 

Total 

100.00 

100.00 

100.00 

BEEF  PREPARATIONS  16M 

Wine  whey  is  made  by  simply  adding  sherry  wine  to  whey  prepared 
in  the  usual  manner,  in  the  proportion  of  one  part  to  four  of  whey,  pos- 
sibly better  by  using  the  wine  to  coagulate  the  milk  (Still).  The  wine 
(cooking  sherry  preferred)  is  added  to  the  milk  in  the  proportion  men- 
tioned and  the  mixture  slowly  brought  to  the  boiling  point.  After  stand- 
ing off  the  fire  for  three  or  four  minutes  it  is  strained  through  two  layers 
of  coarse  muslin,  or  cheesecloth.  Sherry  whey  is  useful  as  an  emergency 
food  for  short  periods  in  acute  illness  for  children  who  will  take  very 
little  food ;  it  is  seldom  given  alone,  but  alternating  with  some  other  food. 


BEEF   PREPARATIONS 

The  nutrient  value  of  these  preparations  is  to  be  measured  by  the 
amount  of  albumin  they  contain — their  stimulant  properties  lj»y  the  pro- 
portion of  extractives. 

Beef  Juice. — Expressed  beef  juice  is  made  as  follows:  A  piece  of 
round  steak  is  slightly  broiled,  and  the  juice  pressed  out  by  a  meat-press 
or  a  lemon-squeezer.  Two  or  three  ounces  can  ordinarily  be  obtained 
from  one  pound  of  steak.  This  is  seasoned  with  salt  and  given  cold  or 
warm,  but  not  heated  sufficiently  to  coagulate  the  albumin  in  solution. 

An  excellent  method  of  making  beef  juice  without  cooking  is  by 
taking  one  pound  of  finely  chopped  lean  beef  and  eight  ounces  of  water 
and  allowing  this  to  stand  in  a  covered  jar  upon  ice  from  six  to  twelve 
hours.  The  meat  is  then  squeezed  by  twisting  in  coarse  muslin.  It  is 
seasoned  with  salt  and  given  as  above. 

Beef  extracts  are  not  to  be  considered  in  any  sense  as  foods.  Kem- 
merich  has  shown  that  animals  receiving  nothing  else  died  of  starvation, 
and  sooner  even  than  when  everything  was  withheld.  They  contain  no 
nitrogen  in  the  form  of  protein,  but  only  in  combination  with  the  soluble 
extractives.    They  are  stimulants,  but  as  such  are  seldom  required. 

Meat. — Eare  scraped  beef  is  easily  digested  by  most  young  children. 
There  are  many  conditions  in  which  other  forms  of  protein  are  not  well 
borne,  where  children  even  as  young  as  twelve  months  appear  to  digest 
this  beef-pulp  without  difficulty.  It  should  be  made  from  very  rare  or 
raw  steak,  finely  scraped  and  well  salted.  A  tablespoonful  may  be  given 
at  one  feeding  to  a  child  of  eighteen  months.  In  nutrient  properties  this 
far  exceeds  the  beef  preparations  in  the  market.  The  alleged  danger  of 
tapeworm  from  the  use  of  rare  scraped  beef  or  beef  juice  is  in  this  country 
so  slight  that  it  may  be  disregarded. 

Broths,. — -Animal  broths  may  be  made  from  mutton,  veal,  chicken,  or 
beef.  A  good  formula  for  general  use  is  the  following:  One  pound  of 
lean  meat,  one  pint  of  water;  let  stand  for  two  hoiirs,  then  cook  over  a 


164  NUTRITION 

slow  fire  for  two  hours  down  to  half  a  pint.  After  it  has  cooled,  skim  off- 
the  fat  and  strain  through  a  cloth.  The  composition  of  a  broth  so  made 
is  given  by  Cheadle  as  follows: 

Beef  Broth 

Protein 1.02 

Extractives 1 .82 

Fat 0.00 

Salts 0.88 

Water 96.28 

100.00 

From  their  composition  it  will  be  seen  that  broths  contain  very  little 
nutritive  material.  They  are  stimulating  and  they  furnish  an  excellent 
means  of  adding  inorganic  salts  to  the  diet  in  the  latter  part  of  the  first 
year.  A^egetables  and  barley,  rice  or  wheat  flour  may  be  cooked  with  the 
broth. 

Albumin  Water. — This  is  prepared  as  follows :  The  white  of  one 
fresh  egg  is  mixed  with  a  pint  of  cold  water,  a  little  salt,  and  a  teaspoon- . 
ful  of  brandy  added.  It  should  be  given  cold.  The  nutritive  value  of 
this  preparation,  it  should  be  borne  in  mind,  is  very  small. 


CEREALS 

Barley  Water. — This  may  be  made  either  from  the  grains  or  from 
the  barley  flour.  When  the  grains  are  used,  the  following  is  the  formula 
which  we  have  been  accustomed  to  employ :  To  two  tablespoonfuls  of 
pearl  barley,  add  one  quart  of  water  and  a  pinch  of  salt,  and  boil  con- 
tinuously for  six  hours,  keeping  the  quantity  up  to  a  quart  by  the  addi- 
tion of  water ;  strain  through  coarse  muslin.  It  is  an  advantage  to  soak 
the  barley  for  a  few  hours  before  cooking.  The  water  in  which  it  is 
so^aked  is  not  used.  When  cold  this  preparation  makes  a  rather  thin  jelly. 
Its  composition  by  analysis  is  as  follows: 

Barley  Water 

Starch 1.63 

Fat 0.05 

Protein 0.09 

Inorganic  Salts 0.03 

Water 98.20 

100.00 

An  almost  identical  product  may  be  obtained  in  an  easier  way  by 
using  barley  flour,  one  even  tablespoonful  to  each  twelve  ounces  of  water, 


INFANT  FOODS  165 

and  cooking  for  twenty  minutes.     A  thicker  jelly  when  desired  can  be 
made  by  using  twice  as  much  of  the  barley. 

Rice,  Wheat,  or  Oatmeal  Water,  etc. — These  may  be  made  in  the 
same  manner  as  the  barley  water,  using  the  same  proportions  either  of 
the  flour  or  the  grains.  These  are  useful  as  additions  to  milk  for  healthy 
infants  who  have  reached  the  age  of  five  or  six  months;  they  may  also 
be  given  in  many  cases  of  acute  or  chronic  indigestion  when  milk  must 
be  omitted  or  given  in  small  quantities.  When  there  is  a  tendency  to 
constipation  oatmeal  is  preferred;  when  to  looseness,  barley,  wheat,  or 
rice  water. 

INFANT   FOODS 

It  is  not  possible,  nor  even  desirable,  for  a  physician  to  know  all  about 
the  infant  foods  with  which  the  market  is  flooded.  He  should,  however, 
know  at  least  that  they  are  not  perfect  substitutes  for  breast-milk,  that 
as  permanent  foods  they  are  greatly  inferior  to  properly  modified  cow's 
milk,  and  that  they  are  capable  of  doing  and  have  done  much  positive 
harm.  Scurvy  has  so  frequently  followed  their  prolonged  use,  when  given 
without  the  addition  of  fresh  milk,  and  sometimes  even  when  they  have 
been  given  with  it,  that  there  can  be  no  escaping  the  conclusion  that  they 
were  the  active  cause.  Their  general  use  is  condemned  with  practical 
unanimity  by  authorities  on  infant  feeding.  Yet  by  industrious  and 
skilful  advertising  they  are  forced  upon  public  attention,  and  are  exten- 
sively used  by  the  laity  and  even  by  the  medical  profession.  They  are 
expensive.  They  add  little  or  nothing  to  our  resources  in  infant  die- 
tetics; in  fact,  they  tend  to  retard  rather  than  advance  our  knowledge 
of  this  subject. 

There  are,  however,  a  few  occasions  when  some  of  these  preparations 
may  be  useful  as  temporary  expedients  or  when  nothing  better  can  be 
obtained.  They  should  be  used  only  with  a  very  definite  knowledge  of 
exactly  what  they  do  and  what  they  do  not  contain.  Their  name  is 
legion;  but  those  most  commonly  employed  in  this  country  may  be 
grouped  as  follows: 

1.  The  Milk  Foods. — Nestle's  food  is  perhaps  the  most  widely  known. 
The  others  closely  resembling  it  in  composition  are  the  Anglo-Swiss,  the 
Franco-Swiss,  the  American-Swiss,  and  Gerber's  food.  These  foods  are 
essentially  sweetened  condensed  milk  evaporated  to  drj^ness,  with  the 
addition  of  some  form  of  flour  which  has  been  dextrinized;  they  all 
contain  a  considerable  proportion  of  unchanged  starch. 

2.  The  Liebig  or  Malted  Foods. — ^Mellin's  food  may  be  taken  as  a 
type  of  the  class.  Others  which  resemble  it  more  or  less  closely  are 
Liebig's,  Horlick's  malted  milk,  and  cereal  milk.     Mellin's  food  is  com- 


166 


NUTEITION 


posed  principally  (80  per  cent)  of  soluble  carbohydrates.  They  are  de- 
rived from  malted  wheat  and  barley  flour,  and  are  composed  chiefly  of 
a  mixture  of  dextrins,  dextrose,  and  maltose. 

3.  The  Farinaceous  Foods. — These  are  imperial  granum,  Ridge's 
food,  Hubbell's  prepared  wheat,  and  Robinson's  patent  barley.  The  first 
consists  of  wheat  flour  previously  prepared  by  baking,  by  which  a-  small 
proportion  of  the  starch — from  one  to  six  per  cent — has  been  converted 
into  sugar.  In  chemical  composition  these  four  foods  are  very  similar, 
consisting  mainly  of  unchanged  starch  which  forms  from  seventy-five  to 
eighty  per  cent, of  their  solid  constituents. 

4.  Miscellaneous  Foods. — Under  this  head  may  be  mentioned  Carn- 
rick's  soluble  food  and  Eskay's  food.  The  composition  of  these  is  given 
in  the  following  table  : 

Composition  of  Infant-Foods  ^ 


Nestl6's 

Mellin's 

Eskay's 

Malted 

Ridge's 

Imperial 

Camrick's 

Food. 

Food. 

Food. 

Milk. 

Food. 

granum. 

food. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent 

Per  cent. 

Per  cent. 

Per  cent. 

Fat 

5.50 

0.24 

1.16 

8.78 

1.11 

1.04 

7.45 

Protein 

14.34 
25.00 

11.50 

5.82 

16.35 

11.81 

14.00 

10.25 

Cane  sugar 

Dextrose 

6.57' 

1  53 . 46  2 

149.153 
18.80 

0.52 

0.42 

Lactose  (milk  sugar) 

Maltose 

Dextrins 

}  27.36 

60.80 
19.20 

14^35 

'i'28 

rss 

Total  Soluble  carbo- 

hydrates   

58.93 

80.00 

67.81 

67.95 

1.80 

1.80 

27.08 

Insoluble      carbohy- 

drates (Starch) . .  . 

15.39 

21.21 

76.21 

73.54 

37.37 

Inorganic  salts 

2.03 

3.59 

1.30 

3.86 

0.49 

0.39 

4.42 

Moisture 

3.81 

4.73 

2.70 

3.06 

8.58 

9.23 

3.42 

^  With  the  exception  of  Nestl6's  food  and  Carnrick's  soluble  food,  these  analyses 
were  made  for  the  authors  by  E.  E.  Smith,  Ph.D.,  M.D.,  of  samples  purchased  in  the 
open  market.  ^  Chiefly  lactose.  ^  Largely  maltose. 


The  essential  feature  of  all  infant  foods  is  that  they  are  composed 
principally  of  carbohydrates  and  are  lacking  in  fat.  Some  of  them  con- 
tain a  large  proportion  of  unchanged  starch.  Furthermore,  their  pro- 
tein, though  often  sufficient  in  amount,  is  chiefly  vegetable,  not  animal 
protein.  No  one  of  them  can  be  regarded  in  any  sense  as  a  proper  sub- 
stitute for  breast-milk. 

Some  of  these  foods — Nestle's  and  other  milk  foods,  malted  milk, 
cereal  milk,  and  Carnrick's  food,  and  even  some  of  the  farinaceous  foods 
like  imperial  granum — are  advertised  as  substitutes  for  breast-milk  and 
recommended  for  use  alone.  Others,  such  as  Mellin's,  Liebig's,  and 
Eskay's  foods,  are  intended  to  be  used  with  milk.    The  use  of  any  of  the 


CHOICE  01   METHODS  OF  FEEDING^  167 

commercial  foods  alone  is  admissible  only  for  short  periods  during  de- 
rangements of  digestion,  when  we  wish  to  withhold  for  the  time  all  milk 
fat.  Their  prolonged  use  almost  invariably  produces,  some  grave  dis- 
order of  nutrition,  most  frequently  scurvy.  Those  foods  which  require 
in  their  preparation  the  addition  of  milk  are  open  to  less  serious  objec- 
tions, but  are  not  necessary  or  even  desirable.  They  should  never  be 
used  with  condensed  milk.  When  added  to  fresh  milk  they  may  furnish 
the  additional  carbohydrates  required  by  an  infant  fed  upon  a  diluted 
cow's  milk.  In  such  a  case  they  take  the  place  of  milk  sugar  or  cane 
sugar  in  the  milk  modification.  There  is  no  proof  to  sustain  the  claim 
that  they  increase  the  digestibility  of  cow's  milk.  Farinaceous  foods  may 
be  used  as  an  addition  to  milk  after  the  sixth  or  seventh  month  and 
during  the  second  year. 


CHAPTEE  III 

INFANT  FEEDING 
CHOICE   OF   METHODS   OF   FEEDING 

The  different  methods  of  feeding  which  are  available  are : 

1.  Breast-feeding,  either  by  the  mother  or  by  a  wet-nurse. 

2.  Mixed  feeding,  or  a  combination  of  nursing  and  artificial  feeding. 

3.  Artificial  feeding  exclusively. 

In  deciding  by  which  one  of  these  methods  a  child  shall  be  fed,  many 
circumstances  must  be  taken  into  consideration :  the  vigor  of  the  child, 
the  health  of  the  mother,  and  especially  the  surroundings,  since  these 
determine  very  largely  the  success  or  failure  of  any  method  employed. 

Maternal  Wursing. — Tiiis  is  the  natural  and  the  ideal  method  of 
infiint  feeding.  Every  molhcr  should  uurse  lici'  infaut  unless  there  are 
some  very  Aveighty  rc^asons  in  ihc  coulrnry.  HMic  physicinn  sliould  do  al! 
in  his  power  to  ciicourjige  iuat<-'riin]  nursing  and  to  proniotc  its  success. 
He  should  explain  to  the  mother  how  important  breast-milk  is  for  the 
child;  that  fully  four-fifths  of  the  deaths  under  one  year  are  in  infants 
who  are  artificially  fed.  He  should  also  make  clear  the  conditions  by 
which  alone  successful  nursing  can  bo  aeeoniplished;  viz.,  proper  diet, 
regular  habits  of  sleep  and  exercise,  and  a  simple  life,  in  so  far  as  possible 
free  from  causes  of  nervous  excitement,  fatigue,  overwork,  or  worry. 
Social  engagements  should  be  avoided.  Much  can  be  done  by  patience 
and  persistence  even  in  the  face  of  many  discouraging  circumstances. 
Xursing  may  be  furthered  by  proper  care  of  the  nipples  before  de- 
livery, and  by  attention  to  them  during  the  early  days  of  nursing  to 


168  NUTRITION 

prevent  fissures  and  mastitis,  which  often  interrupt  successful  nurs- 
ing. 

As  a  result  of  extensive  propaganda  the  number  of  mothers  of  all 
classes  of  society  who  nurse  their  children  in  the  United  States  has 
beyond  question  materially  increased  during  the  last  ten  years.  This  is 
a  hopeful  sign.  Among  the  poor  and  ignorant  where  artificial  feeding  is 
not  likely  to  be  well  done,  all  possible  efforts  should  be  made  to  increase 
maternal  nursing  as  the  most  effective  means  of  reducing  infant  mor- 
tality. 

When  Maternal  Nursing  Should  not  he  Attempted. —  (1)  No  mother 
who  is  the  subject  of  tuberculosis  in  any  form,  whether  latent  or  active, 
should  nurse  her  infant;  it  can  only  hasten  the  progress  of  the  disease 
in  herself,  while  at  the  same  time  it  exposes  the  infant  to  the  danger  of 
infection.  (2)  Nursing  should  seldom  be  allowed  when  serious  compli- 
cations have  been  connected  with  parturition,  such  as  severe  hemorrhage, 
puerperal  convulsions,  nephritis,  or  puerperal  septicemia.  After  severe 
hemorrhage  and  even  after  sepsis,  women  may  recover  so  as  to  nurse 
successfully.  There  is  great. danger  to  the  child  in  nursing  after  eclamp- 
sia; even  when  put  to  the  breast  two  or  three  days  after  the  mother's 
last  attack,  fatal  convulsions  have  followed.  (3)  If  the  mother  is  suf- 
fering from  any  serious  chronic  disease  or  is  very  delicate,  since  great 
harm  may  be  done  to  her  without  any  corresponding  benefit  to  the 
child.  With  reference  to  the  last-mentioned  condition,  an  absolute  opin- 
ion can  not  always  be  given  at  the  outset.  As  a  rule,  mothers  are  more 
likely  to  succeed  in  nursing  first  ©r  second  children  than  subsequent 
ones.  One  should  not  be  too  ready  to  decide  that  there  will  be  no  milk, 
but  should  persist  in  stimulating  the  breasts  by  suckling  the  child.  The 
milk  may  be  delayed  until  the  tenth  or  twelfth  day,-  and  yet  come  in  such 
abundance  that  nursing  may  be  successfully  carried  on  for  many  months. 
In  general  the  capacity  for  lactation  diminishes  with  each  successive 
pregnancy. 

Artificial  Feeding  vs.  Wet-Nursing-. — When  maternal  nursing  is  im- 
possible or  undesirable,  the  milk  of  another  woman  would  seem  to  be 
the  most  natural  and  best  substitute.  While  this  is  theoretically  true, 
the  practical  obstacles  are  so  many  as  to  put  wet-nursing  out  of  the 
question  as  a  general  method  of  feeding.  We  have  in  America  no  peasant 
class  like  that  of  Europe  to  draw  upon ;  and  in  the  class  which  furnishes 
most  of  our  wet-nurses  the  capacity  to  nurse  has  steadily  diminished. 
The  expense  of  a  wet-nurse — thirty  to  forty  dollars  a  mouth  in  New 
,York — the  danger  of  transmitting  contagious  disease,  and  the  difficulty 
of  obtaining  proper  care  for  her  own  infant,  are  all  very  serious  objec- 
tions to  wet-nursing.  The  recent  advances  in  artificial  feeding  have 
placed  it  now  on  quite  a  different  footing  from  that  which  it  formerly 


CHOICE  OF  METHODS  OF  FEEDING  169 

occupied.  While  it  is  true  that  good  breast-milk  is  unquestionably  the 
best  food,  it  is  equally  true  that  properly  modified  cow's  milk  is  a  far 
better  food  than  the  milk  of  many  wet-nurses  who  are  employed.  These 
facts  added  to  the  constantly  increasing  difficulty  of  obtaining  good  wet- 
nurses  have  caused  wet-nurses  to  be  pretty  generally  discarded,  even  in 
our  large  cities,  where  formerly  no  other  substitute  for  maternal  nursing 
was  considered. 

There  are,  however,  some  conditions  in  which  wet-nurses  are  neces- 
sary, even  indispensable.  Some  infants,  usually  those  who  have  been 
badly  started,  can  not  be  made  to  thrive  upon  any  form  of  artificial  feed- 
ing. There  are  also  premature  infants  and  other  very  delicate  ones 
whose  powers  of  assimilation  are  so  feeble  that  they  are  reared  in 
any  circumstances  only  with  the  greatest  difficulty,  l)ut  whose  chances 
of  life  are  much  increased  by  a  good  wet-nurse.  Again,  in  young  infants 
who  have  been  sufl:ering  for  some  time  from  chronic  indigestion  and 
failing  nutrition,  the  symptoms  of  acute  inanition  sometimes  develop 
with  great  rapidity  and  severity.  From  such  a  condition,  apparently 
hopeless,  infants  may  sometimes  be  rescued  by  the  timely  assistance  of 
a  good  wet-nurse. 

The  difficulties  in  the  way  of  successful  infant  feeding  in  hospitals, 
foundling  asylums  and  other  institutions  for  young  infants  are  such 
that  in  them  partial  wet-nursing  should  be  employed  whenever  possible, 
at  least  long  enough  to  give  the  infant  a  good  start. 

Mixed  Feeding. — Mixed  feeding,  or  a  combination  of  nursing  and 
artificial  feeding,  may  be  employed  whenever  the  supply  of  the  nurse  is 
insufficient.  The  use  of  one  or  two  feedings  a  day  from  the  bottle  after 
the  third  or  fourth  month  may  do  much  to  relieve  the  mother  from  the 
strain  of  nursing  entirely,  without  disturbing  the  infant's  progress.  Dur- 
ing the  later  months  more  feedings  may  be  introduced  for  the  purpose 
of  gradual  weaning. 

BREAST-FEEDING 

Care  of  the  Breasts  during  Lactation. — For  the  safety  of  both  mother 
and  child  it  is  essential  that  the  most  scrupulous  attention  be  given  to 
cleanliness.  The  nipples,  and  the  breasts  as  well,  should  always  be  care- 
fully washed  after  each  nursing.  Usually  plain  water  is  sufficient,  or  a 
weak  boric-acid  solution  may  be  employed. 

Nursing"  during  the  First  Days  of  Life. — This  is  necessary,  to  accus- 
tom the  child  and  the  mother  to  the  procedure,  and  to  empty  the  breasts 
of  the  colostrum;  it  probably  also  promotes  uterine  contractions.  All 
these  results  can  be  attained  by  putting  the  child  to  the  breast  on  the 
first  day  once  in  six  hours,  on  the  second  day  once  in  four  liours.     The 


170  NUTKITION 

child  gets  from  the  breast  only  from  four  to  six  ounces  a  day  during 
the  first  two  days.  Did  he  require  more  nourishment  before  the  milk- 
flow  is  fully  established,  we  may  be  sure  that  Nature  would  not  haTe 
been  so  late  with  her  supply.  The  common  practice  of  administering 
to  an  infant  a  few  hours  old  all  sorts  of  decoctions,  with  the  idea  that 
because  he. cries  he  is  suifering  from  colic,  can  not  be  too  strongly  con- 
demned. A  certain  amount  of  crying  is  desirable.  In  exceptional  cir- 
cumstances, when  an  infant  is  unusually  large  and  strong  and  cries 
excessively,  it  may  be  necessary  to  give  food  even  on  the  first  day;  but 
this  is  not  to  be  the  rule.  A  little  warm  water  should  first  be  given; 
from  two  to  four  teaspoonfuls  at  a  time  are  sufficient.  If  this  does  not 
satisfy  the  child,  regular  feeding  should  be  begun  on  the  second  day. 
Should  the  milk  be  delayed  beyond  the  second  day,  the  child  should  be 
put  to  the  breast  at  regular  intervals,  but  only  for  tAvo  or  three  minutes, 
and  then  given  the  bottle  afterwards  if  still  hungry.  It  is  important  not 
to  cease  in  our  efforts  to  induce  a  secretion  for  several  days  longer,  and 
the  best  of  all  means  is  the  stimulation  of  the  child's  sucking. 

Nursing  Habits. — Good  habits  of  nursing  and  sleep  are  almost  as 
easily  formed  as  bad  ones,  provided  one  begins  at  the  outset.  Much  of 
the  wear  and  tear  incident  to  the  nursing  period  may  be  avoided  if  the 
child  is  trained  to  regular  habits.  Attention  to  these  minor  points  often 
makes  all  the  difference  between  successful  and  unsuccessful  nursing. 
After  the  third  day,  seven  nursings  in  the  twenty-four  hours  are  suffi- 
cient, and  no  more  should  l)e  allowed.  An  infant  at  this  age  can  usually 
be  depended  upon  to  take  at  least  one  long  sleep  of  from  four  to  six  hours 
jn  the  twenty-four.  For  the  rest  of  the  day  the  child  should  be  awakened, 
if  necessary,  at  the  regular  nursing  time,  and  put  to  tlie  breast ;  this  plan 
being  continued  until  ten  o'clock  at  night.  He  should  then  be  allowed 
to  sleep  as  long  as  he  will,  and  but  one  nursing  given  between  this  hour 
-and  six  in  the  morning.  In  the  course  of  two  or  three  weeks  a  healthy 
infant  can  usually  be  trained  to  nurse  and  sleep  with  almost  perfect 
.regularity — frequently,  when  a  month  old,  going  six  hours  regularly  at 
night  without  feeding.  A  trained  nurse  of  our  acquaintance  states  that 
out  of  thirty-three  infants  of  Avhich  she  had  the  care  from  birth,  thirty- 
one  were  trained  without  difficulty  in  the  manner  stated.  So  far  as  the 
child  is  concerned,  regular  habits  of  feeding  and  sleep,  and  regular 
evacuations  from  tlie  ])0we]s,  which  nearJy  always  go  with  them,  are  most 
important  factors  in  infant  hygiene. 

Less  frequent  nursing  and  relieving  the  mother  of  night  nursing  after 
the  child  is  three  months  old  are  of  the  greatest  value,  and  by  lessening 
the  wear  and  tear  of  nursing  will  often  enable  her  to  continue  lactation, 
when  otherwise  it  would  be  brought  to  an  abrupt  termination.  On  no 
account  should  the  child  be  allowed  to  sleep  upon  the  mother's  breast. 


BREAST-FEEDING 

Schedule  for  Breast-Feeding 


171 


Age. 


Number  of 

Interval 

Nursings  in 

During 

24  Hours. 

the  Day. 

Hours. 

4 

6 

6 

4 

7 

3 

6 

3 

5 

4 

Night  Nursings 

Between  10  p.m. 

and  6  a.m. 


First  day 

Second  day 

Three  days  to  three  months 

Three  to  six  months 

After  six  months 


nor  in  the  same  bed  with  the  mother.  The  temptation  to  frequent 
nursing  is  thus  largely  removed.  No  mere  sentiment  in  regard  to  these 
matters  should  be  allowed  to  interfere  with  the  plain  dictates  of  reason 
and  experience. 

Symptoms  of  Unsuccessful  Nursing  during  the  Early  Weeks. — ki- 
tempts  at  maternal  nursing  so  often  result  in  failure,  jeopardizing  the 
health,  and  even  endangering  the  life  of  the  child,  that  it  becomes  a 
matter  of  the  greatest  importance  to  decide  this  question  of  nursing 
aright,  and  as  early  as  possible.  On  the  one  hand,  one  should  not  hastily 
wean  a  child  on  account  of  symptoms  which  may  have  no  connection  with 
the  food,  nor  should  one  advise  weaning  when  the  indigestion  from  which 
the  infant  is  suffering  is  due  to  causes  which  are  temporary  and  reme- 
diable. On  the  other  hand,  nursing  should  not  be  continued  simply 
because  a  conscientious  mother  desires  it,  when  every  indication  points 
to  failure.  If  artificial  feeding  is  to  be  employed  the  difficulties  are 
fewer  when  it  is  begun  early  than  after  the  digestive  organs  have  been 
deranged  by  several  weeks  of  poor  nursing.  These  cases  form  a  very 
considerable  group  and  present  peculiar  difficulties  in  practice.  While  a 
decision  is  being  reached  as  to  the  ability  of  the  mother  to  nurse,  there 
is  required  close  observation  and  a  careful  study  of  all  the  conditions, 
and  even  then  the  physician  is  liable  to  make  mistakes. 

The  body-weight  gives  valuable  information.  The  child  does  not  gain 
or  continues  to  lose  after  the  usual  initial  loss  of  the  first  three  or  four 
days.  Observations  on  the  weight  at  least  twice  a  week  are  necessary, 
and  in  cases  presenting  special  difficulties  the  weight  should  be  taken 
daily. 

At  times  there  may  be  no  vomiting,  diarrhea,  or  even  severe  colic,  yet 
the  child  may  fret  and  worry  continually,  sleep  but  little,  and  show 
general  discomfort.  Such  symptoms  are  sometimes  due  to  indigestion 
but  are  more  frequently  due  to  hunger.  In  other  cases  definite  symptoms 
of  gastric  indigestion  may  be  present,  usually  vomiting  or  frequent  regur- 
gitation of  small  amounts  of  undigested  milk,  later  mixed  with  mucus; 


172  NUTRITION 

eructations  of  gas  with  or  without  vomiting  may  occur^  and  distention 
of  the  stomach  with  gas  and  gastric  colic  may  follow. 

More  often  the  symptoms  of  indigestion  are  intestinal.  Occasionally 
there  is  constipation,  but  as  a  rule  the  stools  are  frequent,  thin  and 
green,  containing  flaky  masses  of  undigested  milk,  and,  after  a  short 
time,  mucus  is  present.  At  times  there  is  much  gas  and  the  stools  are 
sour  and  irritating.  If  constipation  is  present  there  is  apt  to  be  severe 
colic  and  sometimes  abdominal  distention.  The  almost  uniform  absence 
of  any  elevation  of  temperature  in  these  cases  points  strongly  against 
the  existence  of  any  infection,  which  is  further  indicated  by  the  prompt 
recovery  under  appropriate  treatment. 

Before  considering  the  case  one  of  inadequate  nursing,  or  simple 
indigestion  in  a  nursing  infant,  one  should  be  careful  to  exclude  organic 
conditions,  particularly,  if  vomiting  is  present,  hypertrophic  stenosis  of 
the  pylorus. 

As  the  first  step  one  should  endeavor  to  gain  some  idea  as  to  the 
quantity  of  milk  secreted.  During  the  first  week,  particularly  from  the 
second  to  the  fourth  day,  the  temperature  may  be  elevated  quite  apart 
from  septic  or  inflammatory  conditions  or  even  evidences  of  indigestion. 
This  is  particularly  seen  where  the  breasts  secrete  almost  nothing  (see 
Inanition  Fever).  Often  when  the  milk  is  very  scanty  something  may 
be  learned  from  the  manner  in  which  the  child  takes  the  breast.  When 
the  milk  is  abundant,  five  or  six  minutes  are  often  sufficient.  If  the  milk 
is  very  scanty,  an  infant  will  frequently  nurse  half  or  three-quarters  of 
an  hour  and  then  stop,  more  because  he  is  exhausted  than  because  he  is 
satisfied.  Sometimes,  when  the  breasts  are  practically  empty,  the  child 
will  seize  the  nijDple  and  nurse  vigorously  for  a  few  moments,  then  drop 
it  in  apparent  disgust  and  refuse  to  make  any  further  efforts.  The  only 
satisfactory  way  of  determining  the  quantity  of  milk  secreted  is  to  weigh 
the  infant  before  and  after  nursing.  This  should  be  done  at  each  nursing 
until  all  doubt  is  removed.  If  the  milk  is  merely  scanty,  but  not  other- 
wise abnormal,  the  infant  does  not  gain,  but  may  show  no  symptoms  of 
indigestion,  such  as  vomiting,  colic,  or  undigested-  stools,  and  he  frets 
and  cries  from  hunger  only. 

An  excessively  rich  niilk  is  usually  found  under  the  following  con- 
ditions :  The  mother  is  in  good  health,  has  large  breasts  which  are  full 
and  tense  at  nursing  time.  In  most  cases  she  is  upon  a  very  abundant 
diet,  getting  little  or  no  exercise,  and  frequently  taking  some  alcoholic 
beverage  with  the  notion  that  because  the  child  is  not  thriving  the  milk 
is  poor.  The  child  may  be  colicky,  sleepless,  and  uncomfortable,  may 
vomit,  may  have  frequent  stools  containing  much  undigested  food,  and 
may  be  losing  in  weight.  A  similar  condition  is  often  seen  when  a  wet- 
nurse  makes  a  change  from  the  simple  life  and  habits  of  her  own  home 


BKEAST-FEEDING  173 

to  the  more  luxurious  life  aud  diet  of  the  family  to  which  she  goes. 
The  milk  then  has  usually  a  high  specific  gravity,  is  high  in  fat  and 
usually  high  in  protein. 

A  scanty  milk  of  a  poor  quality  is  most  often  seen  when  the  mother 
is  delicate  or  anemic,  or  perhaps  has  had  a  difficult  or  complicated 
labor,  and  who  besides  is  anxious  and  worried.  It  is  often  with  the 
greatest  difficulty  that  one  can  secure  the  necessary  half  ounce  required 
for  examination.  The  milk  is  usually  low  in  total  solids  and  very  low 
in  fat.  The  specific  gravity  may  be  only  1.024  to  1.027,  and  the  fat 
only  one  per  cent  or  less.v 

A. disturbed  or  disordered  milk  secretion  is  sometimes  seen  when  the 
milk  is  scanty,  often  when  it  is  very  abundant.  Like  the  group  of  cases 
just  mentioned,  this  is  frequently  met  with  when  the  mother's  general 
health  is  below  the  normal,  but  particularly  is  it  influenced  by  her 
nervous  condition.  It  is  the  highly  nervous,  emotional,  worried  woman 
whose  milk  we  are  now  considering.  During  the  first  week  or  two  the 
secretion  may  be  excessive  and  then  rapidly  diminish;  or,  though  the 
milk  continues  abundant,  the  infant  does  not  thrive.  It  is  most  fre- 
quently found  on  examination  that  the  milk  is  low  in  fat  (0.50  to 
1  per  cent),  while  it  may  be  high  in  protein  (1.75  to  3.50  per  cent). 
The  child's  symptoms  are  usually  those  of  intestinal  indigestion — severe 
colic,  flatulence,  and  frequent,  green,  undigested  stools. 

Management. — The  cause  of  the  symptoms  being  in  the  food  and  not 
in  the  child,  the  futility  of  all  medicinal  treatment  will  be  at  once  appar- 
ent. He  who  expects  to  relieve  the  symptoms  of  indigestion  by  the  use  of 
digestive  ferments,  by  giving  something  before  the  nursing  to  dilute  the 
milk,  or  to  check  frequent  intestinal  discharges  by  opium  or  astringents, 
will  be  disappointed.  Temporary  beneflt  often  follows  a  dose  of  castor 
oil,  but  unless  the  milk  can  be  materially  changed  in  composition  no 
permanent  improvement  in  the  child  is  to  be  looked  for.  The  question 
usually  to  be  decided  relates  to  the  continuance  of  nursing.  We  have  a 
choice  of  four  courses:  (1)  To  continue  nursing,  endeavoring  to  correct 
the  milk  through  treatment  of  the  mother;  (2)  partly  to  nurse  and 
partly  feed  from  the  bottle;  (3)  to  stop  all  nursing  temporarily,  pump- 
ing the  breasts  meanwhile  to  keep  up  the  secretion  while  we  attempt  to 
improve  its  character;  (4)  to  wean  at  once  and  entirely.  In  deciding 
which  of  these  courses  is  to  be  adopted  we  must  take  into  consideration 
the  condition  of  the  child,  the  severity  and  duration  of  his  symptoms, 
the  findings  of  the  milk  examination,  and  the  condition  of  the  mother. 

While  the  analysis  of  the  milk  is  of  some  value  in  determining  the 
course  to  be  pursued,  and  should,  if  possible,  be  made,  it  is  of  much  less 
importance  than  the  child's  symptoms.  We  must  be  guided  not  by  what 
the  milk  contains,  but  by  how  seriously  it  disagrees.     The  chemical  ex- 


174  NXTTRITION 

amination  may  show  the  milk  to  be  of  normal  average  in  the  proportion 
of  its  different  ingredients  and  yet  the  child  be  seriously  upset  by  it; 
on  the  other  hand,  a  child  may  be  doing  admirably  iipon  a  milk  which 
shows  proportions  which  differ  very  greatly  from  the  normal  average. 
The  question  always  concerns  the  effect  of  the  particular  milk  upon  the 
particular  child. 

When  the  symptoms  of  indigestion  are  severe  or  have  been  prolonged 
it  is  usually  a  mistake  to  attempt  to  relieve  the  condition  by  simply 
substituting  some  other  food  for  part  of  the  nursings.  This  seldom 
leads  to  any  material  improvement  in  the  symptoms,  while  it  does  eon- 
fuse  the  result,  since  we  can  not  now  tell  whether  it  is  the  breast  or  the 
bottle  feeding  which  disagrees.  A  better  plan  is  to  stop  nursing  en- 
tirely for  a  time  and  try  the  bottle  alone.  If  the  symptoms  are  at  once 
relieved  the  weaning  should  be  permanent. 

When  symptoms  point  to  a  scanty  milk,  but  of  fair  quality — i.  e., 
infant  not  gaining  but  without  any  particular  symptoms  of  indigestion 
— one  is  often  able  to  overcome  the  difficulties  and  continue  the  nursing 
to  advantage.  Until  a  decided  increase  in  the  milk  has  occurred  the 
child  should  have  supplementary  feedings  from  the  bottle  in  Sufficient 
number  to  insure  his  being  properly  nourished.  This  may  be  done 
by  giving  one  or  two  entire  feedings  a  day  from  the  bottle  or  a  smaller 
amount  may  be  given  immediate!}^  after  each  nursing.  In  this  way  the 
advantage  of  the  stimulating  effect  of  suckling  upon  the  secretion  of 
milk  is  secured. 

In  the  treatment  of  the  mother  the  first  thing  is  to  secure  for  her  an 
undisturbed  rest  at  night.  If  possible,  she  should  be  entirely  relieved  of 
the  care  of  the  infant  at  this  time,  and  if  feeding  is  necessary  the  bottle 
should  be  given.  She  should  have  a  certain  amount  of  fresh  air  every 
day,  driving  if  possible,  or  walking  as  soon  as  she  is  able  to  take  more 
active  exercise.  Gentle  massage  of  the  breasts  is  often  useful  in  stimu- 
lating secretion.  It  should  be  done  with  care  and  with  every  precaution 
against  infection,  and  may  be  repeated  two  or  three  times  a  day  for  ten 
minutes.  The  diet  should  be  abundant,  with  a  large  allowance  of  milk 
and  meat,  especially  beef.  If  there  is  anemia,  iron  should  be  given. 
Every  means  should  be  taken  to  improve  her  general  nutrition,  and 
allay  her  nervous  symptoms  for  whatever  benefits  these  improves  the 
milk.  If  the  conditions  present  are  incident  to  the  confinement  or  the 
convalescence,  the  prognosis  is  good;  and  in  the  course  of  a  week  or 
two  very  marked  improvement  may  be  evident,  and  lactation  may  be 
successfully  continued.  If,  however,  the  conditions  depend  upon  con- 
stitutional debility,  the  prognosis  is  much  worse.  Temporary  im- 
provement may  take  place,  but  it  soon  becomes  evident  that  the  nursing 
is  a  failure. 


BEEAST-FEEDING  175 

When  the  symptoms  are  found  to  be  associated  with  an  over-rich 
milk  the  prospects  for  continuing  nursing  are  much  better  than  when  \ 
the  milk  is  poor.    Unless  the  infant's  digestion  is  very  feeble  or  has  been    \ 
seriously  upset  either  with  vomiting  or   diarrhea,  one  can  usually  so     \ 
alter  the  milk  by  treating  the  mother  as  to  make  it  possible  to  keep  the     ' 
baby  at  the  breast.     Alcohol  should  be  prohibited;  the  diet,  especially 
the  amount  of  solid  food,  should  be  reduced,  and  the  mother  required  to 
take  daily  exercise  in  the  open  air,  particularly  by  walking.     The  in- 
tervals between  nursings  should  be  lengthened,  always  to  three  hours,     ^ 
and  often  to  four.     In  some  cases  there  is  an  advantage  in   diluting     | 
the  milk  by  allowing  the  child  to  take  water  before  putting  him  to  the     ! 
breast.     The  improvement  following  such  a  change  in  regimen  is  often 
immediate,   and  with   increasing   age   and   weight   the   child   gradually 
becomes  accustomed  to  and  is  able  to  digest  the  rich  milk.     If,  how- 
ever, the  child's  symptoms  of  indigestion  are  of  an  aggravated  type,  1 
whether   gastric   or   intestinal,   it   will   be  necessary,   even   though   the  \ 
weight  is  increasing  normally,  to  stop  nursing  entirely  for  a  time.     The 
breasts  should  be  pumped  at  regular  intervals  and  the  child  placed  upon    \ 
some  other  food  until  the   symptoms  are   relieved,   and  then   brought 
back  gradually  to  breast-feeding. 

If  the  examination  shows  the  milk  to  be  of  very  poor  quality  (i.  e., 
low  in  fat,  low  in  total  solids),  whether  scanty  or  abundant,  the  outlook 
is  not  good.  It  is  seldom  that  the  conditions  affecting  the  mother,  to 
which  such  a  milk  is  due,  can  be  removed. 

When  we  see  a  fretful,  colicky,  sleepless  infant  with  either  no  gain 
in  weight  or  a  loss  of  a  few  ounces  a  week,  and  with  stools  which  never 
approach  the  normal,  and  these  conditions  have  lasted  for  three  or  four 
weeks,  we  are  justified  in  taking  the  child  from  the  breast  at  once. 
When  the  symptoms  are  less  pronounced,  and  especially  when,  in  spite 
of  all  discomfort  and  indigestion,  the  infant  is  gaining  m  weight,  even 
though  not  rapidly,  further  efforts  may  be  made  .before  Aveaning  is 
ordered. 

Summary. — Poor  milk  is  usually  low  in  fat  and  scanty  in  quantity, 
while,  the  protein  may  be  either  high  or  low.  Very  rich  milk  is  usually 
high  both  in  fat  and  protein.  Very  poor  milk  can  seldom  be  perma- 
nently improved  unless  the  causes  are  very  definite  and  of  a  temporary 
cliaracter.  Over-rich  milk  can  usually  be  improved  if  the  true  expla- 
nation for  it  can  be  reached.  Kesults  are  to  be  judged  not  so  much 
by  the  change  in  the  composition  of  the  milk  as  by  improvement  in  the  . 
infant's  symptoms.  Since  good  feeding  gives  so  much  better  results 
than  poor  nursing,  if  circumstances  are  such  that  artificial  feeding  can 
be  properly  done,  it  is  advisable  to  stop  nursing  after  a  fair  trial — e.  g., 
of  two  to  three  weeks — has  been  made,  rather  than  waste  time  in  pro- 


176  NUTRITION 

longed  efforts  to  improve  the  breast-milk.  On  the  other  hand,  under 
conditions  in  which  feeding  is  likely  to-  be  very  badly  done,  one  should 
persist  for  a  longer  time  in  efforts  to  promote  lactation.  But  in  no 
circumstances  should  one  hastily  and  without  carefully  considered  reasons 
advise  a  woman  not  to  try  to  nurse  her  baby. 

Wet-Nursing. — In  the  selection  of  a  wet-nurse,  it  is  by  no  means 
so  essential  as  has  generally  been  supposed,  that  her  child  shall  be  of 
about  the  same  age  as  the  child  she  is  to  nurse,  for,  after  the  first  two 
or  three  weeks,  the  changes  in  the  composition  of  breast-milk  are  in- 
significant. It  is  always  desirable  that  the  wet-nurse  shall  have  nursed 
her  own  infant  long  enough  to  demonstrate  the  fact  that  she  has  an 
abundance  of  good  milk;  hence,  taking  a  wet-nurse  at  the  end  of  the 
first  or  second  week  is  always  fraught  with  considerable  uncertainty. 
It  is  the  quality  of  the  milk,  not  its  age,  which  determines  whether  or 
not  it  will  agree.  For  an  infant  over  one  month  old,  a  good  wet-nurse 
whose  milk  is  anywhere  between  one  and  six  months  old  will  usually 
answer  perfectly  well;  and  even  for  premature  infants  such  a  milk  may 
be  used  without  hesitation,  but  it  should  at  first  be  diluted. 

A  good  nurse  must,  first  of  all,  be  a  healthy  woman,  free  from 
syphilitic  or  tuberculous  taint.  The  evidence  afforded  by  a  careful  physi- 
cal examination  of  the  nurse  and  her  own  child  may  be  considered  suf- 
ficient. The  tuberculin  skin  test  is  of  no  value  in  deciding  whether  a 
nurse  shall  be  accepted  or  rejected.  We  are  not  yet  in  a  position  to 
assert  that  a  Wassermann  test  should  be  employed  in  every  case  before 
selecting  a  nurse.  The  nurse  must  have  good  mammary  glandular 
development.  The  breasts  shoiild  be  full  and  hard  three  hours  after 
nursing.  They  may  be  very  large  and  yet  supply  very  little  milk,  being 
then  composed  almost  entirely  of  fat.  On  the  other  hand,  some  smaller 
breasts  may  be  almost  all  glandular  tissue  and  secrete  an  abundance 
of  milk.  The  difference  in  the  size  of  a  breast  before  and  after  nursing 
is  one  of  the  best  guides  as  to  the  amount  of  milk  it  is  secreting.  The 
nipples  should  be  free  from  erosions  or  fissures,  and  long  enough  for 
the  needs  of  the  child.  Preferably  a  wet-nurse  should  be  of  a  phleg- 
matic temperament,  and  of  a  good  moral  character.  This  is  desirable 
for  personal  reasons,  although  there  is  no  evidence  of  moral  qualities 
being  transmitted  through  the  milk.  It  is  desirable  that  she  should 
be  between  twenty  and  thirty  years  of  age,  although  much  more  depends 
upon  the  individual  than  upon  the  age.  An  examination  of  the  milk 
may  be  of  some  assistance  in  selecting  a  nurse;  but  the  best  evidence 
to  be  obtained  of  the  character  of  a  woman's  milk  is  the  condition  of 
her  own  child,  which  should  always  be  seen  before  she  is  accepted.  It 
often  happens  that  a  woman  who  has  had  an  abundant  supply  of  milk 
for  her  own  infant  has  very  little  for  another  infant  for  the  first  few 


BREAST-FEEDING  177 

days  in  her  new  surroundings.  It  should  not  be  too  readily  decided 
that  she  is  incompetent  as  a  nurse,  for,  under  most  circumstances,  with 
proper  treatment  the  regular  flow  of  milk  will  be  re-established. 

Weaning. — Weaning  should  always  be  done  gradually,  when  pos- 
sible, for  the  sake  of  both  mother  and  child.  Sudden  weaning  is  apt  to 
be  followed  by  an  attack  of  acute  indigestion  in  the  infant.  This,  how- 
ever, is  not  a  necessary,  result,  and  usually  depends  upon  the  fact  that 
the  child  is  given  too  high  percentages  of  cow's  milk  at  the  outset. 
Weaning  in  hot  weather  is  usually  to  be  avoided,  but  the  harm  from 
this  is  not  nearly  so  great  as  sometimes  results  when  lactation  is  unduly 
prolonged  because  of  a  prejudice  against  a  change  of  food  at  this  time. 
While  there  are  many  women  of  the  lower  classes  who  are  able  to  nurse 
their  children  to  advantage  for  the  entire  first  year,  the  number  of  such 
among  the  upper  classes  is  small.  By  the  latter,  nursing  can  rarely  be 
continued  beyond  the  ninth,  and  often  not  beyond  the  sixth  month, 
without  unduly  draining  the  vitality  of  the  mother  and  at  the  same  time 
harming  the  child.  Since  the  early  months  of  breast  feeding  are  the 
most  important,  every  effort  should  be  made  to  have  the  mother  continue 
nursing  for  five  or  six  months.  There  i-s  seldom  trouble  in  feeding  a 
baby  for  the  second  half  year  who  has  done  well  upon  the  breast  for 
the  first  half. 

The  late  months  of  lactation,  like  the  early  months,  require  close 
watching.  It  is  a  common  mistake  to  continue  both  maternal  and 
wet-nursing  too  long,  owing  to  a  dislike  of  making  a  change  when 
things  are  going  tolerably.  If  it  has  not  been  done  before  for  reasons 
previously  considered,  breast-feeding  should  be  supplemented  by  other 
food  by  the  ninth  or  tenth  month  in  any  case.  The  child's  progress  in 
M^eight  is  a  good  guide  as  to  time  of  beginning.  In  the  absence  of 
evident  signs  of  disease,  a  stationary  weight  for  several  weeks  makes 
weaning  advisable;  a  steady  loss  makes  it  imperative. 

The  accompanying  weight-chart  (Fig.  17)  illustrates  this  point. 

When  a  nursing  infant  has  been  accustomed  from  birth  to  take  one 
feeding  a  day  from  the  bottle — always  a  great  convenience  to  a  nursing 
mother — gradual  weaning  is  generally  an  easy  matter;  otherwise  it  is 
sometimes  an  impossibility,  the  child  refusing  all  food  except  the  breast 
so  long  as  this  is  given,  and  nothing  but  starvation  inducing  him  to  take 
food  either  from  a  bottle  or  a  spoon. 

Sudden  weaning  may  be  required  at  any  time  from  the  development 
in  the  mother  of  acute  disease  of  a  serious  nature,  such  as  typhoid  fever 
or  pneumonia,  or  grave  chronic  disease,  such  as  tuberculosis  or  nephritis, 
from  the  intercurrence  of  pregnancy,  or  from  disease  of  the  mammary 
gland.  Through  many  of  the  minor  ills — mild  attacks  of  bronchitis, 
pharyngitis,  indigestion,  and  even  malarial  fever — mothers  frequently 


178 


NUTRITION 


nurse  their  children  without  any  seeming  detriment  to  them  or  to  them- 
selves. In  acute  illness  of  short  duration,  if  severe,  it  is  usually  better, 
unless  we  decide  to  wean  altogether,  to  feed  the  child  from  the  bottle 
and  to  maintain  the  flow  of  milk  by  the  occasional  use  of  the  breast-pump 
three  or  four  times  a  day  rather  than  to  allow  it  to  dry  up.  The  previous 
flow  can  often  be  re-established  after  an  interruption  of  a  week  or 
two,  and  sometimes  after  a  much  longer  time. 


MONTH   OF  AGE.                                                               ] 

GMS. 

LBS. 

1          2         3          4          5          6          7          8          9        10        11      121 

9530 
9070 
8620 
8M0 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 

21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
6 
5 

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,^ 

/ 

^ 

/ 

y' 

y 

- 

/ 

y" 

/ 

/ 

^ 

■ 

/ 

/ 

/ 

/ 

/ 

1 

/ 

/ 

/ 

/ 

/ 

■ 

V 

/ 

c 

/ 

v 



J 

Fig.  17. — Chabt  showing  the  Effect  of  Peegnancy  Upon  the  Weight  of  a  Nursing 
Infant.  The  upper  line  is  that  of  the  patient;  the  lower  one  is  the  average  line 
for  the  first  year.  The  infant  did  unusually  well  until  the  sixth  month.  As  it  did 
not  seem  ill,  the  parents  were  not  disturbed  until  the  loss  had  reached  3  lbs.  Feeding 
was  at  once  begun,  and  child  gradually  regained  its  lost  weight.  It  was  subsequently 
discovered  that  the  mother  was  pregnant. 

In  cases  of  sudden  weaning,  the  food  should  in  the  beginning  be  very 
much  AA-eaker  than  for  an  artificially  fed  cbild  of  the  same  age.  The 
change  can  then  be  made  without  causing  disturbance.  When  the  infant 
has  become  somewhat  accustomed  to  cow's  milk  the  strength  of  the  food 
may  be  gradually  increased. 

The  difficulties  in  weaning  a  child  who  up  to  nine  or  ten  months  has 
had  no  food  but  the  breast,  are  sometimes  great.  Much  time  and  taet 
are  necessary  on  the  part  of  both  physician  and  nurse  in  these  cases. 
To  try  to  teach  older  infants  to  take  the  bottle  is  unwise;  feeding  from 
cup  or  spoon  is  usually  quite  as  easy.  Continued  coaxing  of  food  is 
objectionable;  forcing  is  much  worse  and  prolongs  the  struggle.  In 
our  experience  we  have  found  the  best  way  to  offer  food  at  regular  in- 
tervals and  to  take  it  away  at  once  if  refused.  This  is  repeated  every 
three  or  four  hours.    A  variety  of  things  may  be  offered — modified  cow's 


ARTIFICIAL  FEEDIXG  179 

milk^  thick  gruels,  beef  juice,  broths,  bread  and  milk,  etc.  The  nature 
of  the  food  seems  to  make  very  little  difference.  A  strong-willed  child 
will  often  hold  out  for  twenty-four  or  thirty-six  hours,  and  occasionally 
a  very  stubborn  one  is  found  who  will  do  so  for  forty-eight  hours.  xA.t 
the  end  of  this  time  the  pangs  of  hunger  are  generally  so  acute  that  he 
capitulates.  Serious  symptoms  from  withholding  food  in  such  circum- 
stances we  have  never  seen. 

MIXED   FEEDING 

By  mixed  feeding  is  meant  a  combination  of  nursing  and  artificial 
feeding.  There  are  no  objections  to  this  practice;  on  the  contrary,  there 
are  great  advantages  in  giving  an  infant  only  a  few  breast-feedings  a 
day  when  more  are  impossible.  This  may  frequently  be  done  in  hospital 
practice,  and  thus  a  single  wet-nurse  may  assist  in  the  feeding  of  several 
infants.  Mixed  feeding  may  be  resorted  to  whenever  the  milk  supply 
of  the  mother  is  insufficient.  If  at  any  time  the  mother^s  health  be- 
gins to  suffer,  she  may  be  relieved  of  night  nursing  or  of  one  or  more 
nursings  during  the  day,  and  the  bqttle  substituted.  In  this  way  she 
may  be  enabled  to  continue  lactation  for  some  time  longer  than  would 
otherwise  be  possible.  Mixed  feeding  is  often  necessary  during  the  first 
few  weeks,  while  the  mother's  milk  is  insufficient  in  consequence  of 
something  which  has  retarded  her  convalescence.  For  the  advantage 
of  the  stimulation  to  secretion  afforded  by  the  child's  nursing,  it  is 
usually  better,  rather  than  alternate  the  breast  and  the  bottle,  to  put 
the  child  at  first  to  the  breasts.  After  he  has  emptied  them,  additional 
food  may  be  given  from  the  bottle  if  the  baby  is  still  hungry.  The  milk 
may  become  abundant  and  of  good  quality  as  soon  as  the  mother  is  well 
enough  to  be  up  and  out  of  doors,  although  it  was  previously  scanty  and 
of  inferior  quality.  Two  or  three  feedings  a  day  from  the  bottle  helps 
to  bridge  over  this  period  and  prevent  the  child's  nutrition  from  suffer- 
ing. But  before  allowing  a  mothe.  partly  to  nurse  and  partly  to  feed 
her  infant,  one  should  be  sure  that  the  quality  of  her  milk  is  good. 


ARTIFICIAL  FEEDING 

The  scientific  feeding  of  infants,  whether  with  woman's  milk  or  some 
substitute,  demands  as  a  basic  principle  that  the  food  furnish  what  the 
body  needs  for  heat  and  the  repair  of  waste  or  the  "maintenance  re- 
quirements'' and  also  for  its  normal  development  or  "^growtli  require- 
ments." In  breast  feeding  there  is,  under  normal  conditions,  a  certain 
automatic  adjustment  between  the  amount  of  food  needed  and  the  amount 


180  XUTRITTOX 

supplied.  If  the  milk  taken  is  greatty  in  excess  of  requirements,  this 
excess  is  either  disposed  of  b}-  vomiting  or  passes  through  the  bowels  in 
large  partly  digested  stools.  Sometimes  this  results  in  considerable 
disturbances  of  digestion;  but  usually  they  are  slight.  If  the  milk  se- 
creted is  much  below  the  child's  requirements,  this  fact  becomes  evident 
by  slower  groT\i:h  and  by  symptoms  of  defective  nutrition,  of  which  the 
weight  is  the  best  guide. 

In  artiiicial  feeding,  simply  because  the  food  given  is  not  a  normal 
one  for  the  individual,  it  becomes  even  more  important  that  the  require- 
ments of  the  infant,  as  nearly  as  they  can  be  determined,  shall  be  met. 
With  any  substitute  both  an  excess  and  a  deficiency  are  more  potent 
for  harm  than  with  the  natural  food  of  the  infant.  The  best  results 
with  artificial  feeding,  1.  e.,  most  satisfactory  growth  and  freedom  from 
disturbances  of  digestion,  are  seen  when  all  that  the  body  needs  is  sup- 
plied but  no  more  than  this. 

The  appetite  of  the  child  has  been  deemed  by  many  a  sufficient 
guide  to  the  amount  of  food  needed;  to  give  a  child  all  he  will  take 
at  one  time  and  postpone  the  next  feeding  until  he  shows  that  he  is 
hungry  has  been  advocated  as  a  "natural"  method  of  feeding  as  opposed 
to  the  more  commonly  followed  plan  of  definite  quantities  at  regular 
intervals.  Though  important,  the  child's  appetite  alone  can  hardly  be 
relied  upon.  There  are  many  infants,  like  many  adults,  who  will  habitu- 
ally take  too  much  food  if  it  is  offered.  Disorders  of  digestion  not  in- 
frequently are  accompanied  by  an  unnatural  desire  for  food. 

Formerly,  it  was  customary  to  indicate  the  amount  of  food  given 
to  an  infant  by  stating  the  number  of  ounces  in  twenty-four  hours. 
This,  however,  is  really  meaningless  unless  the  strength  of  the  food 
is  also  mentioned.  In  deciding  the  amount  of  food  to  be  given  the 
nutritive  or  caloric  value  of  the  food  must  be  taken  into  account.  We 
must  know  approximately  the  infant's  needs,  best  stated  in  calories, 
and  then  in  what  form  these  mjy  best  be  furnished,  best  stated  in  the 
percentages  of  the  different  food  elements. 

From  numerous  observations  the  nutritive  needs  of  an  infant  of 
average  size  and  weight  and  activity  in  health  have  been  shown  to  be 
100  to  110  calories  per  kilo.  (45  to  48  per  pound)  of  body  weight  for 
the  early  months  of  the  first  year;  gradually  diminishing  to  70  to  80 
per  kilo.  (30  to  35  per  pound)  by  the  end  of  the  year.  A  food  much 
above  or  one  much  below  normal  requirements  may  b3  equally  unsuit- 
able and  therefore  unsuccessful.  The  physician  should  therefore  be  able 
to  calculate  the  caloric  value  ^  of  the  food  given  to  see,  if  possible,  when 
an  infant  is  not  thriving,  where  the  mistake  lies. 

^The  caloric  value  of  anj'  modification  of  cow's  milk  of  known  percentages 
may  be  calculated  as  follows: 


ARTIFICIAL  FEEDING 


181 


For  the  average  healthy  infant  the  weight  is  perhaps  the  most  im- 
portant single  factor,  but  age,  size,  appetite  and  general  behavior  must 
also  be  taken  into  account.  The  experienced  physician  or  nurse  by  closely 
watching  a  child's  symptoms  is  able  to  decide  whether  the  food  is  ade- 
quate, excessive  or  deficient.  Food  needs  based  on  weight  are  useful 
as  a  general  guide  until  the  individual  factor  can  be  determined. 

General  Principles. — There  are  certain  principles  in  infant  feeding 
upon  which  all  pediatrists  are  agreed :  Woman's  milk  is  not  only  the 
best,  it  is  the  ideal  infant  food;  in  any  substitute  certain  conditions 
must  be  fulfilled. 

1.  All  the  different  food  constituents — fat,  carbohydrate,  protein, 
salts  and  water,  must  be  furnished. 

2.  They  must  be  supplied  in  sufficient  quantity  for  the  physiological 
requirements  of  the  infant  for  growth,  energy  and  repair. 

In  this  respect  as  in  many  others  Nature  tolerates  considerable  varia- 

For  instance,  36  ounces  of  food  having  fat,  3.50;  sugar,  7.00;  protein,  1.75 
per  cent. 

.035      (fat  percent)  x  9 . 3  caloric  value  of  fat         =.  325  caloric  value  of  fat  in  1  gram  of  food 

.07        (sugar       "       "  )  x4.1      "  "       "  sugar     =.287       "  "       "  sugar       "  1       "      "     " 

.0175    (protein  "        "  )  x4.1      "  "       "  protein  =.072       "  "       "  protein    "  1       "      "     " 

.684        "  "       "  one  gram  of  food 

.684  X  30  =  20.5  (caloric  value  1  ounce  of  food)  x  36  =  738,  caloric  value  total  food 

Such  calculations  are  too  laborious  for  practical  use.  Fraley  (Archives  of 
Pediatrics,  1912,  p.  123)  has  deduced  a  simple  formula  which  makes  this  an  easy 
matter  and  gives  results  quite  accurate.     This  we  have  slightly  modified: 

Twice  the  fat  percentage,  plus  sugar  percentage,  plus  protein  percentage,  mul- 
tiplied by  1.3,  gives  the  calories  per  ounce  of  food.  Applying  this  to  the  formula 
above  mentioned:     7 -)- 7  +  1.75  =  15.75  X  1-3  =  20.5  calories  per  ounce.  ' 

Another  simple  way  is  to  multiply  the  caloric  value  of  each  of  the  ingredients 
in  the  food  by  the  amount  of  each  that  is  taken. 


Approximate  Caloric  Value  of  Different  Foods 


Woman's  milk 

Cow's  milk 

Cream  (20  per  cent) 

Top-milk  (7  per  cent) 

Skimmed  milk  (13^%  fat) 

Whey,  buttermilk,  fat-free  milk  . 

Sweetened  condensed  milk 

Evaporated  milk 

Dried  milk  (Mammala) 

Milk  sugar 

Cane  sugar 


Ounce 

Even 

Tabl'sp'l 

20 

20 

60 

V 

30 

14 

y/ 

10 

100 

55 

127 

40 

120 

40 

120 

60 

Dextrimaltose 

Malt  soup  extract 

Barley  flour 

Wheat  flour 

Oat  flour 

Barley  gruel  (1  oz.  to  10  oz.) .... 
Barley  water  ( 1  tablesp'f ul  to  1  pt) 
Albumin  water  (white  one  egg  to 

1  pt.) 

Beef  .iuice 

Orange  juice 

Olive  oil 


Ounce 


120 

80 

100 

100 

115 

10 

2 

1 

6 

15 

245 


Even 
Tabl'sp'l 


40 
40 
35 
28 
40 


122 


Milk  sugar 

Cane  sugar 

Dextrimaltose 

Barley  or  oat  flour . 
Wheat  flour 


Approximate  Measures 

3  even  tablespoonfuls  =  1  ounce  by  weight 

2     "  "  =1       "       " 

3     "  "  =1        "       " 

3     "  "  =1        "       " 

4     "  •  =1        "       " 


182 


NUTRITION 


tion  from  what  is  best  without  seriously  hampering  health  or  growth. 
Yet  there  is  a  maximum,  which  if  exceeded  causes  disturbances  of  diges- 
tion from  overfeeding,  and  a  minimum  below  which  the  body  suffers  from 
imperfect  nutrition.  Mistakes  in  the  amount  of  food  may  be  just  as 
serious  as  those  in  its  composition. 

3.  The  food  constituents  must  be  furnished  in  suitable  proportions. 
The  proportions  best  suited  to  the  infantas  needs  are  shown  in  the  com- 
position of  an  average  specimen  of  woman's  milk.  But  as  the  normal 
variations  in  woman's  milk  may  be  considerable  without  affecting  the 
infant  unfavorably,  so  a  certain  amount  of  latitude  in  the  composition 
of  the  artificial  food  which  is  substituted  for  woman's  milk  is  tolerated. 
To  a  certain  extent  the  different  food  elements,  notably  the  fats  and 
carbohydrates,  are  interchangeable;  but  this  substitution  must  not  be 
carried  too  far  nor  continued  too  long.  In  the  scientific  feeding  of 
animals  much  stress  is  laid  upon  the  importance  of  a  properly  "balanced 
ration"  or  one  in  which  all  the  food  elements  are  adequately  repre- 
sented. The  same  necessity  exists  in  infant  feeding.  Woman's  milk 
is  such  a  balanced  ration  and  we  cannot  give  for  a  long  time  a  food  in 
which  the  proportion  of  the  different  food  elements  differs  widely  from 
those   which  woman's   milk   contains   without  incurring   serious   risks. 

Cow's  milk  in  some  form  is  now  almost  universally  accepted  as  the 
basis  of  artificial  feeding.  The  milk  of  the  goat  or  of  other  animals, 
though  at  times  advantageous  where  good  cow's  milk  is  not  available, 
has,  because  of  many  circumstances,  never  been  general.  In  adapting 
cow's  milk  for  infant  feeding  we  must  realize  at  the  outset  that  no 
matter  how  it  may  be  altered  it  is  not  a  perfect  substitute  for  woman's 
milk.  There  is  no  perfect  substitute.  But  while  its  disadvantages  may 
not  be  altogether  removed,  they  may  be  lessened  by  certain  changes, 
technically  known  as  the  "modification"  of  cow's  milk. 

Differences  between  Cow's  Milk  and  Woman's  Milk. — There  ai?e  cer- 
tain differences  between  cow's  milk  and  woman's  milk  upon  which  these 
modifications  are  based.  These  relate  both  to  the  amount  of  the  several 
constituents  and  their  digestibility.  The  following  table  gives  the  pro- 
portions of  the  various  elements  which  make  up  the  two  milks: 


Woman's  Milk 
Average. 

Cow's  Milk 
Average. 

Fat 

Per  cent 

3.50 
7.50 
1.25 
0.20 

87.55 

Per  cent 

4.00 

Sup:ar           .                  

4.75 

Protfiin           '            

3.50 

Salts                                      

0.75 

Water     

87.00 

100.00 

100.00 

ARTIFICIAL  FEEDING  183 

These  quantitative  differences  are  important.  It  will  be  seen  that 
cow's  milk  has  a  great  excess  of  protein  and  salts  and  is  deficient  in 
sugar,  while  the  proportion  of  fat  in  the  two  milks  is  nearly  the  same. 
When  we  come  to  use  cow's  milk  in  infant  feeding,  certain  qualitative 
differences  are  discovered  which  from  a  practical  point  of  view  are  of 
even  more  importance.  The  proper  modification  of  cow's  milk  must 
take  account  of  all  these.  During  the  past  twenty-five  years  widely 
different  opinions  have  been  held  as  to  the  character  of  these  differences 
between  the  two  milks  and  consequently  as  to  the  nature  of  the  difficul- 
ties which  the  infant  has  in  digesting  cow's  milk.  At  different  times 
the  fat,  the  protein,  the  sugar  and  the  salts  have  all  been  accused  of 
being  the  chief  cause  of  disturbances  of  digestion,  and  it  is  no  doubt  true 
that  under  certain  circumstances  any  one  of  them  may  be  a  source  of 
trouble. 

Protein. — Cow's  milk  contains  nearly  three  times  as  much  total 
protein  as  does  woman's  milk;  the  greater  part,  about  five-sixths,  being 
casein,  and  one-sixth,  albumin.  In  the  protein  of  woman's  milk  the 
proportion  of  casein  is  about  one-third;  of  lactalbumin,  tAvo-thirds. 
The  casein  of  cow's  milk  differs  in  many  respects  from  the  casein  of 
woman's  milk.  The  excess  of  protein,  especially  the  excess  of  casein, 
and  the  differences  i]i  the  two  caseins  was  long  believed  to  be  the  chief 
cause  of  difficulty  in  digesting  cow's  milk.  The  studies  of  the  past  few 
years  have,  however,  shown  that  the  casein  of  cow's  milk  is  remarkably 
well  digested  and  aljsorbed  under  nearly  all  conditions.  Like  that  of 
woman's  milk  it  is  converted  into  peptones  and  finally  broken  up  into- 
amino  acids.  Metabolism  experiments,  moreover,  have  shown  that  nitro- 
gen retention  in  infants  taking  cow's  milk  is  quite  normal  and  examina- 
tion of  stools  rarely  shows  evidences  of  undigested  protein. 

The  chief  difficulty  in  digesting  casein  of  cow's  milk  seems  to  be 
mechanical,  owing  to  its  coagulation  in  the  stomach  of  certain  infants 
in  large  solid  masses  which  offer  some-  resistance  to  the  action  of  the 
digestive  fluids.  Coagulation  in  large  masses  may  be  prevented  in  several 
ways:  (1)  by  greater  dilution  of  the  milk;  (2)  by  the  use  of  gruels 
in  the  place  of  water  as  a  diluent;  (3)  by  boiling.  Coagulation  of  milk 
in  the  stomach  may  be  almost  entirely  prevented  by  the  addition  to  the 
food  of  certaiji  substances  su(^h  as  sodium  citrate.  It  seems  A'ery  doubtful 
if  this  is  wliolly  desirable. 

The  amount  of  ])roteiji  of  cow's  milk  required  for  infant  nutrition 
is  greater  thaJi  that  of  woman's  milk. '  The  reason  apparently  being 
that  the  casein  of  cow's  milk,  which  is  five-sixths  of  the  protein,  is  defi- 
cient in  certain  amino  acids  essential  for  growth.  These  are  supplied 
abundantly  in  woman's  milk,  whose  protein  is  two-thirds  lactalbumin. 
The  defects  of  tlie  casein  of  cow's  milk  are  in  a  measure  overcome  by 


184  NUTKITION 

increasing  the  quantity  given.  There  is  no  evidence  that  the  protein 
of  cow's  milk  is  harmful  to  the  infant  even  when  given  in  considerable 
excess  of  the  amount  contained  in  woman's  milk.  Disturbances  of 
infant  digestion  are  very  rarely  due  to  the  protein  of  cow's  milk. 

Fat. — The  high  fat  content  of  woman's  milk  indicates  the  importance 
of  fat  in  the  nutrition  of  the  infant.  The  amount  of  fat  in  cow's  milk 
is  about  the  same  as  in  a  good  average  sample  of  woman's  milk,  i.  e.,  3  to 
4  per  cent.  But  there  are  certain  important  differences  in  the  fat  in 
the  two  milks.  Thus  the  fat  of  cow's  milk  contains  a  much  greater 
proportion  (nearly  eight  times  as  much)  of  the  volatile  fatty  acids.  The 
marked  difference  in  digestibility  of  the  fat  in  the  two  milks  is  believed 
to  depend  to  a  considerable  degree  upon  this  fact.  It  is  possible  also 
that  the  freshness  of  the  fat  may  have  an  influence.  Be  this  as  it  may, 
it  is  found  practically  impossible  to  give  to  most  infants  as  much  of 
the  fat  of  cow's  milk  as  woman's  milk  contains.  It  is  not  wise  to  in- 
crease the  amount  of  fat  until  symptoms  of  intolerance  appear,  for  the 
intolerance  to  fat  is  more  persistent  than  to  any  other  ingredient  of  the 
food.  Such  intolerance  once  established,  it  may  be  weeks  or  months 
before  a  reasonable  quantity  can  again  be  digested  and  absorbed.  The 
tolerance  to  the  fat  of  cow's  milk  varies  greatly  in  different  children. 
Some  can  take  a  large  quantity  and  some  only  a  small  quantity.  The 
difficulty  is  greatest  with  infants  in  the  first  few  weeks,  with  the  feeble 
and  with  those  who  have  suffered  from  previous  nutritional  disturbances. 
Fat  is  also  badly  borne  when  there  is  disturbance  of  gaetric  or  intestinal 
digestion,  also  in  all  febrile  conditions,  no  matter  from  what  cause, 
and  during  periods  of  very  hot  weather.  A  fiailure  to  regard  these  contra- 
indications is  a  constant  source  of  trouble  in  practice.  The  ability  to 
digest  fat  is  probably  the  best  index  of  an  infant's  digestive  capacity, 
'^rhose  who  cannot  take  the  usual  amount  certainly  do  not  thrive  as 
well  as  those  who  can.  Hence  it  follows  that  no  part  of  the  milk  modi- 
fication needs  to  be  more  carefully  watched  than  the  amount  of  fat 
given.  The  percentage  of  fat  that  can  safely  be  allowed  to  a  healthy 
infant  varies  from  1  to  4  per  cent.  The  latter  figure  should  not  be 
exceeded  with  any  infant  and  with  very  many  even  this  cannot  be 
reached  until  the  end  of  the  first  year. 

CarhoJiydrates. — That  all  the  carbohydrates  of  woman's  milk  are  in 
the  soluble  form  is  a  strong  indication  that  soluble  carbohydrates,  or 
sugars,  should  be  the  form  supplied  in  artificial  feeding.  The  high 
proportion  in  which  sugar  exists  in  woman's  milk — being  considerably 
greater  than  all  the  other  solid  constituents  combined — shows  hoAV  im- 
portant a  part  sugar  serves  in  infant  nutrition.  In  case  sugar  is  not 
furnished  in  the  food  in  sufficient  amount,  there  must  be  more  fat  and 
protein  supplied. 


ARTIFICIAL  FEEDING  185 

The  sugar  in  cow's  milk  is  identical  with  that  in  woman's  milk,  in 
both  cases  being  lactose  in  solution.  In  artificial  feeding  we  have  a 
choice  between  milk  sugar,  cane  sugar,  and  maltose.^  All  of  these  sugars 
are  about  equally  well  borne  in  health ;  they  all,  alike,  have  the  capacity 
of  increasing  weight  and  furnishing  heat.  Yet  there  are  some  differences 
in  their  effects  which  make  it  advantageous  at  times  to  choose  one  rather 
than  another.  Milk  sugar,  being  identical  with  the  sugar  in  woman's 
milk,  on  theoretical  grounds  would  seem  preferable.  It  does  not  fer- 
ment with  yeast.  It  is  not  so  readily  broken  down  in  the  stomach 
and  hence  with  infants  who  have  a  disposition  to  vomit  it  is  usually  to 
be  preferred  to  maltose  or  cane  sugar.  It  is  slightly  laxative.  It  is 
usually  well  borne  in  health  in  proportions  up  to  6  or  7  per  cent  of  the 
food.  In  all  intestinal  disturbances,  particularly  where  there  is  a  ten- 
dency to  looseness  of  the  bowels,  lactose  is  badly  borne. 

Cane  sugar  has  the  great  advantage  of  cheapness.  In  a  very  large 
proportion  of  cases  it  apparently  does  quite  as  well  as  lactose  or  maltose. 
It  is  distinctly  less  laxative  but  rather  more  likely  to  ferment  in  the 
stomach  and  cause  or  aggravate  vomiting  when  given  in  the  quantities 
mentioned  for  lactose. 

Maltose,  in  the  preparations  in  wjiich  it  is  used,  has  some  peculiar 
advantages;  first,  its  laxative  efi^ect  which  is  rather  greater  than  that 
of  the  other  sugars ;  secondly,  in  inducing  a  more  rapid  gain  in  weight ; 
and,  finally,  in  a  certain  corrective  action  upon  some  digestive  dis- 
turbances, especially  when  given  with  considerable  amounts  of  starchy  t 
food.  Maltose  preparations  have  the  disadvantage  in  breaking  down 
more  readily  both  in  the  stomach  and  in  the  intestine,  often  provoking 
and,  in  susceptible  infants,  always  aggravating  both  vomiting  and 
diarrhea.    . 

For  routine  use  lactose  is  to  be  preferred  except  where  cost  is  a  con- 
sideration ;  the  other  sugars  are  to  be  used  with  the  special  indica- 
tions mentioned.     There  is  often  an  advantage  in  using  the  different 

^  Pure  maltose  is  expensive  and  practically  not  available  for  infant  feeding. 
The  maltose  preparations  used  for  infant  feeding  are  mixtures  of  maltose  and 
dextrins.  In  speaking  of  the  use  of  maltose  hereafter  these  preparations  will  be 
meant.  Many  stlch  preparations  are  on  the  market.  Loeflimd's  "malt  soup 
extract"  is  reliable  but  expensive.  Reliable  and  more  moderate  in  price  are  the 
"neutral  maltose"  of  the  Maltzyme  Co.,  the  malt  soup  of  the  Maltine  Co.  and 
the  "malt  syrup"  of  the  Freihofer  Co.,  Philadelphia.  These  preparations  are 
somewhat  acid.  To  the  first  five  grains  and  to  the  last  ten  grains  of  potassium 
carbonate  should  be  added  for  each  ounce  of  the  malt  used  in  the  food.  All  of 
these  liquid  preparations  contain  from  65  to  85  per  cent  of  carbohydrates,  of 
which  about  two-thirds  is  maltose  and  the  balance  chiefly  dextrins.  Besides 
these  liquid  preparations,  Borcherdt's  "malt  soup  extract"  and  Mead's  "dextri- 
maltose"  in  powder  should  be  mentioned  as  convenient  and  reliable  forms  of 
maltose.     None  of  the  above  preparations  has  any  appreciable  diastatic  action. 


186  XTTRITIOX 

sugars  together  since  the  amount  that  is  well  tolerated  of  the  combined 
sugars  is  often  greater  than  if  the  entire  amount  were  one  form  of 
sugar. 

Starches.— 'Eybu  very  young  infants  are  able  to  digest  starch,  though 
their  capacity  during  the  early  months  is  limited.  After  the  fourth 
month  it  notably  increases  and  after  six  or  seven  months  nipst  healthy 
infants  can  readily  digest  "as  much  as  one  ounce  of  starch  daily,  and 
some  can  do  muclv-niore /f han  this.  This  fact  makes  it  possible  to 
use  starch  in  the  form  6t  cereal  gruels  under  a  variety  of  conditions 
when  they  may  be  thought  desirable.  With  very  young  infants  ^heir  use 
is  mainly  as  diluents  for  milk  when  the  coagulation  of  the  casein  in  the 
stomach  in  large  masses  is  an  obstacle  to  digestion.  With  older  infants 
starches  may  supply  a  coHsfdefable  part  of  the  carbohydrates  when 
there  is  marked  intolerance  of  all  sugars.  For  the  very  slow  change  of 
the  starch  into  sugar  in  jthe  int_estines  is  much  less  likely  to  caus^  "symp- 
toms than  when  sugar  itself  in  considerable  amount  is  thrown  at  once 
into  tbe  intestine.  Again,  starches  are  useful  to  increase  the  total  car- 
bohydrates Avlien  all  the  sugar  is  l)eing  given  tl'iat  the  patient  can  readily 
tolerate  and  especially  when,  on  account  of  intolerance  of  fats,  it  is  de- 
sirable to  raise  the  total  carbohydrates  to  a  point  consider afjly  higher 
than  is  usually  given. 

Salts. — It  has  been  customary  in  the  past  to  add  certain  inorganic 
constituents  to  cow's  milk  used  for  infant  feeding.  Lime  water  has 
been  most  widely  employed.  As  has  already  been  stated  in  the  previous 
chapter,  not  only  calcium  but  practically  all  the  salts  of  woman's  milk 
are  present  in  greater  abundance  in  cow's  milk,  even  when  the  latter  has 
been  diluted  to  the  customary  degree.  These  substances  need  not  be 
added  to  milk  to  supply  a  deficiency  in  inorganic  constituents,  for  there 
is  none,  except  in  iron.  Their  addition  to  correct  the  '^^excessive  acid- 
ity" of  coAv's  milk  is  unimportant,  for  as  used  they  do  not  do  this. 
In  considerable  amounls.  lime  water,  sodiuui  bicarbonate  and  sodium 
citrate  all  delay  the  coagulation  of  milk  in  the  stomach,  and  in 
large  amounts  may  entirely  prevent  it.  Under  certain  conditions  the 
first-mentioned  effect  may  possibly  be  desirable.  It  is  questionable 
whether  the  latter  ever  is.  At  the  present  time  we  are  not  in  a  position 
to  assert  that  the  addition  to  milk  of  lime  water  or  any  of  the  substances 
mentioned  is  of  value  as  a  routine  practice  in  infant  feeding.  They  may 
therefore  be  wisely  omitted  with  all  healthy  children. 

Feeding  of  Healthy  Infants  during  the  First  Year. — It  is  absolutely 
necessary  to  consider  separately  the  changes  required  by  healthy  infants 
with  normal  digestion  and  those  required  by  infants  with  feeble  or  dis- 
ordered digestion.  From  a  failure  to  make  this  distinction  much  con- 
fusion has  arisen.     The  digestion  of  all  healthy  infants  is  very  much 


ARTIFICIAL  FEEDING 


187 


alike  and  they  can  be  fed  in  much  the  same  way;  while  the  variations 
afforded  by  infants  with  disordered  digestion  are  very  great. 

There  are  two  general  plans  according  to  which  the  indications  out- 
lined in  the  previous  pages  may  be  met.  The  first  plan  is  to  use  whole 
milk  as  indicated  in  the  table  given  below,  the  different  formulas  being 
derived  iDy  simple  dilution  and  the  addition  of  needed  sugar  or  other 
carbohydrates.  The  table  gives  the  quantities  of  the  different  ingredients, 
the  approximate  percentage  composition  and  caloric  value  per  ounce 
of  the  formula  obtained.  The  age  indications  are  not  intended  to  be 
closely  followed.  Successful  infant  feeding  cannot  be  done  by  rule  of 
thumb.  However,  these  formulas  are  a  useful  guide  as  a  starting-point 
with  an  average  child  until  his  individual  needs  and  capacity  can  be 
determined  by  observation.  They  indicate  what  such  a  child  in  health 
may  be  expected  to  take  and  also  how  rapidly  and  in  what  way  the 
food  may  be  increased.^ 

Formulas  from  Whole  (Jf  per  cent)  Milk 
Giving  Approximate  Percentage  Composition  and  Caloric  Value 


I.     1 

II. 

t 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

14 
20. 

•.    7 

\2y2 

8 
234 

9 
11 

'2J4 

10 
10 

'23^ 

11 
9 

'2y2 

12 

7 
1 

2  ,' 

13 
5 

.2 

iy2 

14 
1 

5 

1 

15 

0 

Gruel  1  (ounces) 

Sugar2  (eventabl'sp'ls)  .^ .  . 

5      - 
1 

Total . . '    . 

"20,     , 

20. 

20. 

20. 

20. 

20. 

20 

20 

20 

1.20 

5.70 

1.00 

1.40 
6.00 

l!20 

1.60 
6..  00 

i!46 

1.80 
6.60 

i'.m 

2.00 
6.50 

i;76 

2.20 
6.50 

i^go 

2.40 

6.00 

.40 

2.10 

2.60 

5.50 

.80 

2.25 

2.80 
5.50 
2.00 
2.40 

3.00 

5.00 

Starch,  per  cent 

2.00 
2.60 

Calories  per  ounce 

l^U* 

12.5 

13.5 

14.5 

15.5 

16.5 

17.0 

18.0 

20.0 

21.0 

Approx.  age  indication  . . 

2  da. 

1  wk. 

3  wk. 

2  mo. 

3  mo. 

4  mo. 

5  mo. 

6  mo. 

8  mo. 

9-11 
mo. 

^1- 


1  The  gruel  here  indicated  is  made  in  the  proportion  of  1  oz.  by  volume  to  10  oz.  of  water. 

2  Milk  sugar  is  here  indicated;  of  cane  sugar  use  two  scant  tablespoonfuls  instead  of  two  and  a  half, 
and  one  instead  of  one  and  a  half,  etc.     Maltose  may  be  used  in  the  same  amounts  as  milk  sugar. 

^  A  simple  method  of  calculating  a  milk  formula  for  an  average  healthy 
infant  on  the  basis  of  caloric  requirements  is  to  start  with  the  daily  amount  of 
protein  of  cow's  milk  needed.  This  by  experience  has  been  found  to  be  furnished 
in  Ih  ounces  of  rnilk  for  each  pound  of  body  weight.  An  infant  weighing  10 
pounds  will  thus  require  15  ounces  of  milk.  His  caloric  ne^s  calculated  at  45 
per  pound  will  be  4g^.  Of  this  there  will  be  furnished  in  the  milk  (20  calories 
per  ounce)  300  calories,  leaving  150  to  be  made  up  by  more  fat  or  by  carbo- 
hydrates— sugar  or  starch.  One  ounce  of  sugar  will  add  120  calories;  or  11 
ounces,  150  calories.  This  will  give  the  food  values  for  a  day.  There  is  still  to 
be  determined  the  amount  of  diluent,  which  will  depend  upon  the  infant's  daily 
need  of  fluid.  This  has  been  shown  to  be  about  3  ounces  for  each  pound  of  \ 
body  weight  in  the  early  months,  and  2  ounces  for  each  pound  in  tlie  later  ^ 


188  NUTRITION 

According  to  the  second  plan  of  feeding,  after  the  first  few  weeks 
somewhat  higher  fat  is  employed  than  indicated  above.  This  is  accom- 
plished by  using  the  upper  half  of  a  quart  bottle  of  milk,  i.  e.,  a  7  per  cent 
top-milk  ^  instead  of  whole  milk.  If  this  is  done  the  amount  of  the 
milk  used  should  be  one-fourth  or  one-third  less  than  is  given  in  the 
table.  These  formulas  may  be  used  up  to  seven  or  eight  months,  when, 
with  the  introduction  of  larger  amounts  of  starchy  food,  formulas  from 
whole  milk  may  be  given.  Such  formulas  are  designed  for  infants  who 
are  able  to  take  more  fat  than  is  contained  in  the  formulas  from  whole 
milk.     In  this  group  will  be  found  strong  children  with  good  digestion. 

Relative  Advantages  of  Formulas  from  Whole  Milk  and  Those  with 
Higher  Fats. — Whole  milk  formulas  are  somewhat  simpler  to  prepare 
and  the  method  is  therefore  more  easily  understood  by  the  average 
mother  or  nurse.  With  the  ignorant  or  careless  there  is  less  chance  of 
going  wrong,  for  it  eliminates  one  error,  by  no  means  an  uncommon 
one,  of  using  too  high  fats.  There  is  quite  a  large  group  of  infants 
who  are  unable  to  digest  higher  proportions  of  fat  than  are  given  in 
this  series  of  formulas  and  who  are  seriously  disturbed  if  they  are  given : 
but  there  is  a  third  group,  also  a  large  one,  who  can  easily  take  higher 
fats  and  some  thrive  much  better  when  they  are  given.  Constipation 
also  is  somewhat  less  frequently  seen  when  top-milk  mixtures  are  used. 
There  are  then  advantages  in  having  formulas  with  higher  fats  for 
use  under  proper  conditions.  If  no  more  fat  is  used  than  is  obtained  by 
using  a  7  per  cent  top-milk,  as  here  advised,  disturbances  from  fat 
will  very  seldom  be  seen  in  healthy  children.  When  less  fat  is  given 
the  caloric  value  of  the  food  must  be  made  up  by  increasing  the  carbo- 
hydrates and  the  protein.  Only  to  a  limited  degree  is  such  a  substitu- 
tion possible.  When  fats  are  replaced  by  carbohydrates  chiefly,  quite 
serious  disturbances  of  digestion  may  be  produced.  The  great  argument 
for  the  need  of  more  fat  than  is  obtained  with  dilutions  of  whole  milk 
is  the  proportion  present  in  woman's  milk.     On  the  whole,  while  one 

months;  i.e.,  for  a  10-pound  infant  it  will  be  30  ounces  a  day.    There  will  need 

to  be  added,  therefore,  15  ounces  of  water.    The  formula  will  then  be: 
/ 
15    ounces  milk,  giving  300  calories 
1i       "       sugar      "       150        " 
15         "       water 

The  30  ounces  of  food  could  be  divided  into  seven  feedings  of  41  ounces  each, 
or  into  six  feedings  of  5  ounces  each  according  to  circumstances.  The  approxi- 
mate percentage  composition  of  the  formula,  using  4-per-cent  milk,  would  be : 
fat  2.00;  sugar  6.00;  protein  1.75. 

^Before  this  top-milk  is  removed  the  milk  should  stand  in  the  bottle  at 
least  four  hours,  and  the  top-milk  should  be  carefully  removed  with  a  milk 
dipper,  not  poured  off. 


ARTIFICIAL  FEEDING 


189 


may  get  on  very  well  with  such  simple  formulas  as  tliose  from  whole 
milk,  in  experienced  hands  excellent  and  sometimes  better  results  are 
obtained  with  healthy  children  with  somewhat  more  fat.  In  infants 
with  feeble  or  disturbed  digestion  top-milk  formulas  should  not  be  used 
at  all.  The  most  important  thing  in  artificial  feeding  is  to  recognize 
at  the  earliest  possible  moment  the  indications  making  necessary  an 
alteration  in  the  food. 

Quantity  at  One  Feeding  and  Frequency  of  Feedings. — The  strength 
of  the  food  and  the  daily  quantity  having  been  decided,  the  next  ques- 
tion is  the  number  of  feedings  in  which  it  is  to  be  divided  and  the  inter- 
vals at  which  they  shall  be  given.  Experience  has  shown  that  the  average 
infant  can  digest  his  food  better  if  the  intervals  are  made  longer  than 
was  formerly  the  practice.  With  longer  intervals  the  quantity  given 
at  one  time  and  the  strength  of  the  food  may  be  correspondingly  in- 
creased. There  are  few  healthy  infants  who  cannot  readily  be  trained 
to  the  intervals  given  in  the  table  below,  in  which  the  infant  is  placed 
upon  three-hour  feedings  at  the  outset  and  upon  four-hour  feedings 
when  six  months  old.  The  reduced  number  of  feedings  also  materially 
lessens  the  labor  of  the  mother  or  nurse. 

Schedule  for  Healthy  Infants  during  the  First  Year 


2nd  to  7th  day 

2nd,  3rd  and  4th  weeks . 
2nd  and  3rd  months  .  .  . 
4th  and  5th  months. .  . 
6th,  7th  and  8th  months 
9th  and  10th  months. 
11th  and  12th  months 


Interval 
Between 
Feedings 


Night 

Feedings 

After  6  p.m. 


Hours 

3 
3 
3 
3 

4 
4 
4 


Feedings 
in  24 
Hours. 


Quantity 
for  One 
Feeding 


Ounces 

1  —  2 

2^  —  41^ 

3V^  —  5 

5  —  6 

63^  —  1V2 

7  —  8 

8  —  9 


Quantity 
for  24 
Hours 


Ounces 
7       —  14 
--  32 

—  35 

—  36 
321^  —  37 H 
3.5       —  40 
40       —  45 


18 
24 
30 


A  large  and  vigorous  infant  will  require  the  larger  quantities  allowed, 
but  these  seldom  need  be  exceeded;  for  a  small  infant  the  smaller  quan- 
tities mentioned,  and  sometimes  less,  will  be  sufficient. 

This  table  really  gives  only  the  volume  of  food  for  the  different  ages. 
This  is  important  as  it  secures  to  the  infant  a  proper  amount  of  water 
daily.  The  following  table  shows  how  the  actual  food  requirements  of 
an  average  infant  may  be  met,  using  the  formulas  given  on  page  187,  and 
in  quantities  mentioned. 

A  schedule  like  the  following  indicates  the  needs  of  a  healthy  infant 
of  average  size,  weight  and  activity.  But  no  schedule  can  be  closely  fol- 
lowed with  any  given  child.     One  cannot  conclude  because  an  infant  is 


190 


NUTEITION 


Age. 

Average 

Caloric 

Requirements. 

Furnished  in 

1  month 

400 
500 
560 
640 
740 

7  feedin 

7       " 
7       " 
5       " 
5       " 

gs  43^  oz.  of  No..  III. 

2  months 

434  "     «  No.  IV. 
5       "     "  No.  V. 

3        "      

6        "      '. 

73^  "     «  No.  VIII. 
7H  "     "  No.  IX. 

9        "      

six  weeks  old  he  is  able  to  digest  a  certain  amount  of  food  and  a  certain 
other  amount  because  he  is  six  months  old.  To  attempt  to  follow  any 
schedule  too  closely  is  to  violate  the  fundamental  principle  of  intelligent 
feeding,  which  is  to  adapt  the  food  to  the  child's  requirements  and 
powers  of  digestion  at  the  time.  Because  these  figures  represent  averages 
they  form  a  useful  basis  for  feeding  healthy  children. 

How  and  Where  to  Begin. — With  all  young  infants,  even  those  having 
presumably  normal  digestion,  it  is  desirable  to  begin  with  a  weaker  food 
than  would  be  indicated  by  their  caloric  requirements,  and  gradually 
increase  both  the  strength  and  quantity  according  to  the  child's  digestion. 
With  small  or  feeble  infants  still  weaker  formulas  should  be  used  and  the 
increase  made  more  slowly. 

For  a  healthy  child  with  normal  digestion  who  has  previously  had  no 
cow's  milk  one  should  begin  with  a  lower  formula  than  would  usually 
be  given  to  a  healthy  child  of  his  size  and  age,  but  may  increase  the 
strength  and  quantity  of  the  food  more  rapidly  than  with  a  younger 
infant. 

A  stationary  weight  for  a  week  or  two,  or  even  a  loss  of  a  few  ounces, 
is  of  no  importance,  provided  the  change  in  diet  can  be  effected  without 
disturbing  digestion ;  for  as  soon  as  a  child  becomes  accustomed  to  cow's 
milk  the  percentages  can  be  raised  and  progress  is  assured.  Nothing  is 
easier  than  to  disturb  the  digestion  in  the  beginning  by  the  use  of  too 
strong  food. 

Indications  for  Increasing  the  i^oofZ.— While  it  is  important  to  begin 
with  weak  food,  it  is  a  serious  mistake  to  continue  long  with  it.  The 
powers  of  digestion  are  strengthened- by  gradually  increasing  the  work 
the  organs  are  given  to  do.  Abrupt  increases  are  almost  certain  to  dis- 
turb digestion. 

How  rapidly  the  increase  is  made  will  vary  much  witli  tbe  individual 
infant.  With  a  vigorous  child  above  average  weight,  and  with  good 
digestion,  the  strength  and  the  quantity  may  be  increased  more  rapidly 
than  with  a  smaller  or  less  robust  one.  We  cannot  increase  the  food  every 
week  or  every  month  regardless  of  other  conditions.  The  progress  in 
weight  is  important,  yet  one  should  not  be  guided  by  it  alone.  When  it  is 
made  the  chief  concern,  there  is  a  constant  temptation,  if  the  child  is  not 


AETIFICIAL  FEEDING  191 

gaining  as  rapidly  as  the  mother  thinks  he  should,  to  increase  the  food,  re- 
gardless of  conditions  and  often  beyond  his  requirements,  usually  with 
the  result  of  seriously  disturbing  the  digestion.  The  best  of  all  guides 
to  increasing  the  food  is  the  child's  demonstrated  capacity  of  digestion. 
To  determine  this  the  child's  symptoms  should  be  carefully  watched. 
If  he  is  not  satisfied  and  is  digesting  well  it  is  usually  safe  to  increase 
the  food;  but  not  more  often  than  every  three  or  four  days  in  the  early 
months,  and  every  week  in  the  later  ones. 

In  increasing  the  quantity,  it  is  not  wise  to  add  more  than  two  or 
three  ounces  to  the  food  for  the  day,  or  a  quarter  or  half  an  ounce  to 
each  feeding.  During  the  early  weeks  both  the  quaijjtit^  and  the  strength 
of  the  food  should  be  increased  every  few  days.  /M/ftj^Q^^  to  alternate, 
first  increasing  the  quantity;  tlicn  after  a  few  f^j^^B  ktill  unsatisfied, 
increasing  the  strength;  the  next  time  increasin^^li^ quantity  again, 
etc.  In  this  way  will  be  avoided  the  error  into  which  mothers  and 
nurses  often  fall  who  adopt  a  single  formula  and  keep  on  simply  in- 
creasing the  quantity  indefinitely  whenever  the  child  is  unsatisfied.  The 
increase  in  strength  should  not  be  greater  than  from  one  formula  to 
the  next  of  the  series  given.  It  is  sometimes  advisable  to  make  the 
increase  by  steps  only  half  as  great  ^s  specified. 

A  caution  is  necessary  against  changing  the  formula  too  frequently. 
It  is  not  possible  to  modify  the  milk  in  such  a  way  as  to  relieve  every 
trivial  discomfort  or  disturbance  an  infant  may  have.  Nurses  are 
usually  ready  to  ascribe  every  slight  symptom  to  the  food,  particularly 
if  they  have  strong  opinions  of  their  own  upon  the  subject  of  feeding 
and  are  not  in  full  sympathy  with  tlie  method  employed.  Very  often 
the  cause  is  outside  the  food  and  even  of  the  organs  of  digestion. 

To  Deterviine  the  Ferceniage  Cornposiiioii  *uf  any  Milk  Formula. — 
In  order  to  appreciate  the  composition  of  any  milk  formula  which  a 
patient  may  be  taking  it  is  desirable  to  reduce  tliis  to  its  approximate 
l^ercentages.  One  who  forms  the  habit  of  making  such  calculations  soon 
finds  it  easy,  and  secures  a  basis  for  comparison  with  the  percentages 
given  as  proper  for  the  average  norma!  child.  A  simple  method  of  cal- 
culation is  as  follows :  To  determine  the  percentage  of  any  constituent 
in  the  food,  multiply  its  percentage  in  the  original  milk,  cream,  or  top- 
milk  by  the  number  of  ounces  of  each  in  the  food,  and  divide  by  the  total 
number  of  ounces  of  food  prepared.^ 

^A  child  is  taking  the  following  food:]  Whole  milk  (4  per  cent)  20  ounces,  milk 
sugar  3  even  tablespoonfuls,  and  water  up  to  35  ounces. 

The  fat  in  the  food  will  be  f^of  4.       or  2.27  per  cent. 

The  protein   "    "       "       "     "   |2   "  3.50  "  2.00    '.'       " 
The  sugar      "    "    milk    "     "   |9  "  4.75  "  2.71    "       " 

Three  even  tablespoonfuls  may  bo  reckoned  as  1  ounce  of  milk  sugar,  which 


192  NUTRITION 

Symptoms  and  Conditions  Eequiring  SpeciaI  Food  Vaeiations. 
— In  a  new  case  the  most  important  guide  in  the  first  food  prescription 
is  a  knowledge  of  the  condition  of  the  digestive  organs.  One  should 
know  besides  the  age  and  weighty  the  nature  and  quantity  of  the  food 
which  has  been  taken,  the  appetite,  the  number  and  character  of  the 
stools,  and  also  whether  digestive  symptomj>  are  present,  such  as  vomiting, 
flatulence,  diarrhea,  colic  or  constant  discomfort.  In  any  case  the  first 
prescription  is  somewhat  in  the  nature  of  an  experiment.  Success  will 
depend  on  how  intelligently  the  symptoms  have  been  Judged. 

Even  with  infants  who  are  properly  fed  there  are  few  whose  digestion 
remains  perfectly  normal  throughout  the  entire  first  year.  Changes  in 
the  food  are  ti^H^c  necessary  from  time  to  time  to  meet  special 
symptoms  whi(ili|E^H|rise.  Many  of  these  are  due  to  disturbances  of 
a  minor  charace^B^Pif  they  are  recognized  early  and  proper  changes 
promptly  made,  n^e  serious  and  protracted  derangements  of  digestion 
can  usually  be  avoided.  This  is  not  always  an  easy  matter,  but  there 
are  some  indications  which  are  very  clear  and  definite. 

Hot  Weather. — The  depressing  effects  of  very  hot  weather  upon 
yormg  infants  should  be  appreciated.  At  such  times  less  food  can  be 
digested  and  less  is  required.  Owing  to  an  increase  in  perspiration,  the 
amount  of  water,  consequently  the  volume  of  the  food,  should  seldom 
be  reduced.  The  indications  are  best  met  by  reducing  the  milk,  the 
sugar  and  the  starch  in  the  formula  and  making  up  the  deficiency  by 
adding  water,  i.  e.,  simply  by  diluting  the  food.  Especially  should  the 
fat  of  the  milk  be  reduced.  An  immediate  change  therefore  should  Ijc 
made  from  any  top-milk  formula  to  one  from  whole  milk  or  at  times 
even  to  one  from  skimmed  milk.  Water  should  also  be  given  freely  be- 
tween the  feedings.  BuJ;  as  some  infants  will  not  take  it,  the  only  alter- 
native is  to  give  an  extra  amount,  half  an  ounce  to  two  ounces,  in  each 
of  the  feedings.  As  soon  as  the  period  of  excessive  heat  has  passed,  the 
infant  can  gradually  be  brought  back  to  the  usual  food. 

Minor  Illnesses. — In  attacks  of  acute  rhinitis,  otitis,  tonsillitis,  bron- 
chitis, etc.,  even  though  not  especially  severe,  the  food  should  be  reduced. 
The  reduction  should  depend  upon  the  severity  of  the  attack  and  the 
amount  of  fever.  The  child's  apparent  appetite  is  often  only  a  demand 
for  water.  At  least  as  much  is  needed  as  in  normal  conditions  and  usu- 
ally more  should  be  ofl'ered.  I'he  indications  may  be  met  in  the  samo 
way  as  outlined  in  the  preceding  paragraph. 

Vomiting. — The  common  causes  of  habitual  vomiting  referable  to  the 


in  a  35-ounce  mixture  adds  about  3  per  cent  of  sugar.    The  total  sugar  in  the 
food  therefore  is  2.71  +  3  =  5.71  per  cent. 

The  percentage  composition  of  the  food  is:  fat,  2.27;  sugar,  5.71;  protein,  2.00. 


ARTIFTCTAL  FEEDING  193 

food  are:  too  frequent  feedings  and  too  ]mH_'li  food  at  oik,'  liiiu';  too,an,ueh 
fat  or  toojnuch  sugar,  especially  if  the  sugar  is  either  maltose  or  cane 
sugar.  An  infant  who  vomits  often  should  not  usually  be  fed  at  shorter 
intervals  than  four  hours,  even  if  only  a  few  weeks  old.  Tf  consider- 
able quantities  are  ejected  almost  immediately  after  feeding,  it  is  gen- 
erally Ijecause  too  nuu-h  food  has  l)een  given.  A  diminution  in  the 
amount  of  food  should  bring  about  immediate  improvement.  When  the 
sugar  is  in  excess,  or  the  fat,  or  both,  there  is  vomiting  or  regurgitation 
of  curdled  milk  or  of  a  sour,  watery  fluid,  which  occurs  frequently  and 
often  long  after  the  feeding.  The  sugar  should  be  greatly  reduced  or 
for  a  time  entirely  removed;  cream  mixtures  or  top-milk  mixtures 
should  not  be  used.  If  this  is  not  sufficient,  the  fat  f?^uld  be  still  fur- 
ther reduced  by  using  less  milk  or  by  partially  skimimng  the  milk.  A 
return  to  the  former  diet  should  be  gradual  and  for  some  time  neither 
maltose  nor  cane  sugar  should  be  given. 

Other  causes  must  be  considered  also.  The  child  may  be  moved  about 
too  much  or  sometimes  the  clothing  may  be  too  tight.  More  often 
this  frequent  regurgitation  of  food  soon  after  feeding  is  in  consequence 
of  swallowed  air  which  the  child  has  taken  with  his  bottle.  This  is 
more  likely  to  be  the  case  when  an  infant  is  fed  while  lying  upon  the  back 
and  when  taking  his  food  very  slowly  owing  to  a  very  small  hole  in  the 
nipple.  He  is  unable  to  expel  the  gas  in  that  position,  but  if  lifted 
to  the  erect  position  or  placed  over  the  shoulder  once  or  twice  during 
the  feeding  or  after  it,  he  will  often  bring  up  a  large  amount  of  gas, 
after  which  the  vomiting  ceases. 

Constipation.- — The  principal  causes  of  constipation  referable  to  the 
food  are,  too  small  an  amount  of  carbohydrates,  and  too  small  an  amount 
of  total  solids,  occasionally  too  low  a  proportion  of  fat.  Habit  and  gen- 
eral training  are  also  important  factors.  Sterilization,  and  to  a  slight 
degree  pasteurization,  cause  milk  to  be  somewhat  constipating.  During 
the  first  few  weeks,  if  the  food  is  rather  small  in  amount,  there  is  often 
a  species  of  constipation  present  which  is  simply  the  result  of  the  low 
total  solids  in  the  food  given.  The  bowels  may  move  every  day,  some- 
times even  twice  a  day,  but  the  stools  are  often  small  and  rather  dry. 
Unless  there  is  manifest  discomfort  on  the  part  of  the  infant,  such  a 
condition  may  be  disregarded,  especially  if  the  odor  and  color  of  the 
stools  are  nearly  normal.  As  the  proportions  of  all  the  elements  of 
the  food  are  gradually  increased  this  form  of  constipation  passes  away. 
Mothers  and  physicians  often  expect  that  the  bottle-fed  infant  will  have 
during  his  first  one  or  two  months  the  two  or  three  large  stools  daily 
to  which  they  have  been  accustomed  with  healthy  breast-fed  infants; 
but  finding  instead  only  one  movement  a  day,  and  that  small  and  some- 
times dry,  they  resort  to  laxatives  or  enemata,  and  by  their  use  really 


194  NUTRITION 

cause  much  of  the  trouble  they  are  seeking  to  ronove.  If  milk  mixtures 
are  made  up  without  the  addition  of  carbohydrates,  constipation  fre- 
quently results.  This  is  often  due  to  the  alteration  in  the  reaction  of  the 
contents  of  the  intestines  brought  about  by  putrefaction  of  the  protein. 

Milk  sugar  is  somewhat  laxative  and  if  a  smaller  amount  is  being 
used  the  raising  of  the  proportion  of  this  ingredient  as  high  as  7  per 
cent  will  often  be  all  that  is  needed.  Maltose  is  more  laxative  in  its 
eifects  and  may  be  substituted  wholly  or  in  part  for  milk  sugar.  Its 
use  will  be  more  fully  discussed  later.  Maltose  should  not  be  given  if 
there  is  vomiting.  Cereal  gruels,  especially  oatmeal,  also  have  a  favor- 
able influence  upon  constipation. 

Colic  and  FJgiulence. — The  habitual  colic  of  early  infancy  may  occur 
with  any  form  o*intestinal  indigestion;  its  causes  therefore  are  varied. 
Colic  and  flatulence  are  especially  common  in  infants  who  suffer  from 
constipation.  Excessive  flatulence  may  occur  also  when  cereal  gruels 
are  added  to  the  milk  of  young  infants,  particularly  if  the  amount  is 
large.  If  symptoms  are  severe  a  reduction  in  all  tlie  elements  of  the  food 
may  be  necessary. 

"Curds"  in  the  Stools. — The  undigested  masses  appearing  in  the 
stools  of  infants  taking  milk  are  usually  spoken  of  as  "curds.'^  These 
may  be  small,  soft  and  white,  and  may  make  up  a  large  part  of  the  loose 
stool.  An  excess  of  mucus  is  usually  present.  Such  masses  are  com- 
posed almost  entirely  of  fat.  There  are  also  seen,  but  much  less  fre- 
quently, larger,  smooth,  hard  masses  of  a  yellowish-brown  color,  but 
white  on  section.  They  are  generally  present  in  small  numbers  in  a 
stool,  the  rest  of  which  may  be  quite  normal.  These  liard  or  "l^ean 
curds,''  so  called  from  their  resemblance  to  lima  l)eans,  are  composed 
chiefly  of  protein,  usually  with  an  envelope  of  fat.  They  are  undoubtedly 
formed  in  the  stomach,  where  the  casein  coagulates  in  masses,  some  of 
which  are  so  firm  and  hard  that  they  pass  the  intestine  without  being 
digested.  Curds  of  this  description  are  rarely  seen  unless  the  proportion 
of  casein  in  the  food  is  high. 

Curds  of  the  first  variety,  if  numerous,  call  for  a  considerable  reduc- 
tion in  the  amount  of  fat.  The  large,  smooth,  hard  curds,  if  numerous 
and  persistent,  may  usually  be  made  to  disappear  by  boiling  the  milk. 
This  causes  the  precipitation  of  the  casein  to  occur  in  smaller  masses 
which  are  more  readily  attacked  by  the  gastric  and  intestinal  secretions. 

Loose,  Green,  or  Yellowish- green  Stools  of  a  Sour  Odor. — These  are 
usually  due  to  too  much  sugar,  especially  lactose,  sometimes  also  to  an 
excess  of  fat.  The  number  of  stools  is  usually  from  two  to  five  daily. 
In  appearance  the  stools  resemble  thin  scrambled  eggs.  Stools  such 
as  those  described  are  often  seen  in  nursing  infants  as  well  as  in  those 
artificially  fed,  and  the  condition  is  not  incompatible  with  steady  and 


ARTIFICIAL  FEEDING  105 

regular  gain  in  weight.  After  it  has  persisted  any  length  of  time,  mucus 
is  regularly  present. 

Large,  Dry,  Light-colored  Stools. — Such  stools  are  seen  only  if  in- 
fants are  fed  preponderately  or  entirely  upon  cow's  milk.  The  bowels 
are  constipated  and  the  stools  may  not  be  passed  oftener  than  once  in 
forty-eight  hours.  They  are  relatively  large,  however,  and  are  so  dry 
that  the  diaper  may  be  hardly  soiled.  In  addition,  they  are  putty- 
colored  or  grayish-green  and  are  very  foul  with  the  odor  of  putrefac- 
tion. On  analysis  they  are  found  to  be  alkaline  in  reaction  and  to  con- 
lain  a  large  proportion  of  calcium  and  magnesium  soaps.  For  a  time, 
infaiits  witli  such  stools  may  improve  and  gain  in  weight.  After  a 
time,  however,  they  cease  gaining  and  eventually  lose  weight  while 
anemia  appears  of  increasing  severity  and  eventually  a  condition  of 
marasmus  may  develop.  To  this  condition  the  name  milchndhr- 
schaden  has  been  given  by  Czerny,  who  believed  that  an  excess  of  fat 
in  the  diet  was  responsible  for  it.  It  is  probably  due  not  so  much  to 
an  excess  of  fat  as  to  an  insufficient  amount  of  carbohydrates.  In  the 
al_)sence  of  this  latter,  putrefaction  of  the  protein  goes  on  unchecked. 
This  accounts  for  the  character  of  the  stools.  It  is  the  insufficient 
amount  of  carbohydrates  that  is  chiefly  responsible  for  the  symptoms. 
i\rany  infants  may  take  diluted  whole  milk  without  additional  carbo- 
hydrate and  never  show  such  sym23toms,-but  some  are  rapidly  and  seri- 
ously affected  by  the  absence  of  carbohydrates. 

The  condition  is  readily  amenable  to  treatment.  The  indications  are 
to  diminish  the  milk  if  this  has  been  in  excess,  and  to  add  sugar  alone  or 
sugar  and  some  cereal.  The  mere  addition  of  milk  sugar  or  cane  sugar  in 
the  quantities  usually  given  may  be  sufficient.  At  times,  however,  even 
when  given  in  amounts  up  to  the  point  of  tolerance,  no  improvement  is 
seen.  It  is  then  advantageous  to  give  a  preparation  of  maltose  in  the 
form  of  one  of  the  malt  soups,  with  wheat  or  barley  flour  in  addition. 
The  improvement  is  seen  at  once.  The  stools  become  acid  in  reaction, 
soft  and  brownish;  the  general  condition  shows  a  distinct  amelioration 
and  gain  in  weight  again  occurs. 

No  Gain  in  Weight  without  evident  Symptoms  of  Indigestion. — 
This  is  sometimes  due  to  too  little  or  too  weak  food,  the  child  usually 
manifesting  signs  of  hunger.  Occasionally  it  is  due  to  the  fact  that 
the  food  has  been  too  concentrated  or  that  too  much  fat  has  been  given. 
In  the  latter  case  it  frequently  happens  that  the  appetite  is  much  re- 
duced, so  that  the  infant  takes  perhaps  less  than  half  his  usual  allow- 
ance. Too  frequent  feedings  and  the  practice  of  constantly  coaxing  the 
infant  to  take  more  food  often  produce  the  same  aversion  to  food. 
It  is  much  better  to  offer  food  only  at  four-hour  intervals  and  take 
away  the  bottle  as  soon  as  the  child  shows  that  he  does  not  want  more. 


196  NUTRITION 

Modifications  in  the  food  to  meet  the  indications  afforded  by  more 
serious  conditions  than  those  here  described  are  considered  in  the  later 
pages  devoted  to  Difficult  Cases  of  Feeding. 

The  Apparatus  Required  for  the  Preparation  of  Milk  at 
Home. — This  includes  a  glass  graduate,  a  glass  or  agate  funnel,  a  cream 
dipper,  a  pitcher  for  mixing  food,  f eeding-bottles^  a  tall  cup  for  warming 
the  food,  and  a  small  ice-box.  Other  articles  needed  are  milk  sugar, 
rubber  nipples,  absorbent  cotton,  bottle-brushes,  borax  or  boric  acid, 
bicarbonate  of  soda,  and  an  alcohol  lamp,  an  electric  stove,  or  a  Bunsen 
l)urner.  The  best  style  of  bottle  is  that  which  can  be  most  readily 
cleaned.  The  graduated  cylindrical  bottles  with  wide  mouths  are  to 
be  preferred.  The  best  nipples  are  those  of  plain  black  rubber,  which 
slip  over  the  neck  of  the  bottle,  and  are  not  so  thick  as  to  prevent 
their  being  turned  inside  out  for  cleansing.  Those  with  a  long  rub- 
ber tube  going  to  the  bottom  of  the  bottle  should  not  be  used.  In 
many  places  their  use  is  prohibited  by  law.  The  hole  in  the  nipple  should 
be  large  enough  for  the  milk  to  drop  rapidly  when  the  bottle  is  inverted, 
but  not  so  large  that  it  will  run  in  a  stream.  New  nipples  should  be 
boiled;  but  the  daily  boiling  of  nipples  is  unnecessary.  It  soon  makes 
them  so  soft  as  to  be  useless.  They  should  be  rinsed  in  cold  water  imme- 
diately after  using  and  washed  daily  in  soap  and  water.  When  not  in 
use,  nipples  should  be  kept  covered  in  a  solution  of  borax  or  boric  acid. 
Bottles  should  first  be  rinsed  with  cold  water,  then  washed  with  hot 
soap-suds  and  a  bottle-brush.  When  not  in  use  they  should  stand  full  of 
water.  Before  the  milk  is  put  into  them  they  should  again  be  placed  in 
boiling  water  for  ten  minutes. 

Directioxs  for  Feeding. — The  food  should  be  warmed  to  about 
100°  F.,  best  by  placing  the  bottle  in  a  tall  pitcher  or  cup  filled  with 
hot  water,  not  by  pouring  the  food  from  the  bottle  into  a  saucepan. 
The  temperature  of  the  food  may  be  tested  with  a  thermometer,  or  by 
pouring  a  few  drops  upon  the  front  of  the  wrist;  it  should  feel  warm, 
but  not  hot.  The  nurse  should  never  take  the  nipple  of  the  bottle  into 
her  own  mouth.  A  bottle  should  not  be  warmed  over  for  a  second 
feeding.  A  child  should  not  be  more  than  twenty  minutes  in  taking 
his  food,  and  should  not  sleep  with  the  nipple  of  the  bottle  in  his 
mouth.  It  is  preferable  to  have  a  young  infant  held  while  taking  his 
bottle.  If  this  is  not  done,  the  bottle  should  at  least  be  held  in  such 
a  position  that  the  neck  of  the  bottle  is  kept  full.  After  feeding,  the 
child  should  be  held  upright  over  the  nurse's  shoulder,  and  patted  on 
the  back,  to  allow  him  to  bring  up  the  gas,  usually  air  which  he  has 
swallowed.  He  is  then  placed  in  his  crib  and  left  alone.  It  is  even 
more  necessary  than  in  breast-feeding  that  rules  as  to  frequency  and 
regularity  of  meals  be  observed. 


ARTIFICIAL  FEEmXG 


197 


Directions  foii  rcEPARiNG  the  Food. — All  the  food  needed  for 
twenty-four  hours  simuld  be  prepared  at  one  time.  The  first  thing  to  be 
decided  is  the  formula  to  be  used ;  next,  the  quantity  of  food  for  twenty- 
four  hours,  lastly  the  number  of  feedings  into  which  it  is  to  be  divided. 

Let  us  suppose  for  example  that  the  child  to  be  fed  is  an  average 
healthy  infant  three  montlis  old,  weighing  about  twelve  pounds.  Formula 
No.  V  of  the  series  given  would  be  an  appropriate  one  to  begin  with.  The 
food  requirements  would  be  furnished  in  about  3.5  ounces.  This  amount 
should  be  given  in  six  feedings.  When  more  than  20  ounces  is  needed  for 
a  day's  supply  the  quantity  of  each  ingredient  should  be  increased :  for  30 
ounces  one-half  more  of  each  is  used ;  for  35  ounces  three-quarters  more ; 
for  40  ounces  twice  as  much.  Thus,  using  No.  V,  the  quantities  would 
be  as  follows : 


For  20  Ounces. 

For  30  Ounces. 

For  35  Ounces. 

For  40  Ounces. 

Whole  milk 

Sugar 

Water 

10      oz. 

21^  tabl'sp'ls 
10      oz. 

15      oz. 

334  tabl'sp'ls 
15     ,oz. 

171^  OZ. 

41-^  tabl'sp'ls 
171^  oz. 

20  OZ. 

5  tabl'sp'ls 
20  oz. 

When  barley  water  or  gruel  is  used  it  replaces  part  or  all  the  water  in  the 
formula. 


The  milk  sugar  should  be  dissolved  in  boiled  water,  which  is  then 
mixed  with  the  milk  in  a  pitcher.  The  food  is  now  divided  into  the 
required  number  of  feedings  and  the  bottles  stoppered  with  cotton. 
They  are  placed  at  once  in  an  ice  chest,  or  first  sterilized,  then  cooled, 
and  afterward  placed  upon  ice. 

Milk  Laboratories. — Many  of  our  large  cities  have  milk  labora- 
tories which  put  up  on  the  prescription  of  physicians  milk  for  infant 
feeding  containing  any  desired  percentages  of  fat,  sugar,  protein,  etc., 
raw  or  heated,  and  with  the  addition  of  any  cereals  when  these  are 
wanted.  In  his  prescription  the  physician  indicates  simply  the  percen- 
tages he  wishes,  together  with  the  number  of  feedings  and  the  quantity 
for  each  feeding.  The  milk  is  delivered  daily  in  the  bottles  from  which 
it  is  to  be  fed,  requiring  only  to  be  warmed.  The  milk  laboratory  is 
of  much  assistance  in  infant  feeding,  particularly  Mdien  there  is  no  one 
in  the  home  who  has  the  time,  the  facilities  or  the  intelligence  to  pre- 
pare the  food  properly  there.  To  one  with  experience  in  ordering 
milk  by  prescription  the  milk  laboratory  is  a  great  practical  aid.  The 
laboratories  are  particularly  useful  in  preparing  milk  for  long  journeys 
or  ocean  travel. 

The  Observation  of  Casrs  of  Infant-Feeding. — Attention  to  de- 


198  NUTRITION 

» 

tail  is  most  essential.     Much  of  the  want  of  success  in  infant  feeding  is 

due  to  a  failure  of  the  physician  to  keep  in  close  touch  with  the  case.    For 

the  first  few  weeks  he  should  see  the  infant  every  few  days,  inspect  the 

stools,  hear  the  nurse's  report,  and  see  how  directions  are  being  carried 

out.    When  the  child  is  well  started  and  has  begun  to  gain  regularly  in 

weight,  a  weekly  visit  may  be  sufficient.     Still  later,  monthly  visits  but 

with  regular  weekly  reports  in  writing  should  be  continued  until  the 

child  is  a  year  old  and  is  taking  whole  milk  and  solid  food.    The  weekly 

report  should  include  answers  to  certain  questions,  viz. : 

1.  Weight :  gain  or  loss  since  last  report. 

2.  Stools:  frequency  and  general  character. 

3.  Vomiting  or  regurgitation :  when  and  how  much  ? 

4.  Flatulence  or  colic? 

5.  Appetite :    Is  the  child  satisfied  ?    Does  he  leave  any  of  his  food  ? 

6.  Is  he  comfortable  and  good-natured  and  sleeping  well? 

7.  The  formula  of  the  food  now  given :  quantity  and  frequency  of 

feedings. 

An  excellent  plan  is  to  furnish  the  mother  with  a  printed  form  con- 
taining the  questions  to  be  filled  out  and  returned.  With  information 
regarding  the  points  indicated,  it  is  possible  for  the  physician  to  know 
pretty  accurately  how  the  child  is  doing,  what  changes,  if  any,  are  desir- 
able in  the  food,  and  whether  he  ought  to  see  the  patient. 

It  is  essential  to  success  with  any  method  of  feeding,  first,  that  one 
should  have  good  raw  materials — the  freshest  and  cleanest  milk  obtain- 
able; second,  that  at  least  the  fat  content  of  the  milk  or  cream  used 
be  definitely  known ;  third,  that  directions  for  the  mother  or  nurse  be 
clear,  explicit  and  in  writing;  fourth,  that  one  have  the  cooperation  of 
an  intelligent  mother  or  nurse;  finally,  it  should  be  remembered  that 
practical  success  in  infant  feeding  depends  upon  how  intelligently  a 
method  is  used,  rather  than  upon  the  method  itself,  and  that  the  one 
indispensable  thing  is  systematic  observation. 

The  Use  of  other  Food  than  Milk  during  the  First  Year. — ^Reference 
has  already  been  made  to  the  addition  of  farinaceous  food  in  the  form 
of  barley  water  and  other  cereal  gruels  in  the  modification  of  cow's  milk. 
These  are  useful  in  the  first  place  for  their  mechanical  effect  upon  casein 
coagulation  in  the  stomach.  For  this  purpose  only  a  small  amount  of 
the  cereal  making  a  weak  gruel  is  necessary,  e.  g.,  one  or  two  teaspoonfuls 
of  the  flour  to  the  daily  food.  Farinaceous  food  may  also  be  given 
when,  because  low  fats  are  used  from  choice  or  necessity,  the  carbohy-- 
drates  should  be  increased.  Instead  of  doing  this  entirely  by  some  form 
of  sugar,  part  of  the  carbohydrates  may  in  many  cases  advantageously  be 
furnished  in  the  form  of  starch.  This  may  be  given  as  a  gruel  made  from 
wheat,  oat,  or  barley  flour,  or  arrowroot.     The  amount  of  the  f|our  used 


ARTIFICIAL  FEEDING  199 

* 

in  the  daily  food  should  seldom  he  over  one-fourth  ounce  under  three 
months  of  age ;  from  three  to  six  months,  from  one-half  to  one  and  one- 
half  ounces  may  be  given;  from  six  to  ten  months,  from  one  and  one- 
half  to  two  ounces ;  all  the  above  being  by  volume,  not  Aveight.  The  flour 
should  be  cooked  for  ten  to  twenty  minutes  in  the  water  used  for  diluting 
the  milk.  If  grains  instead  of  flour  are  used  the  cooking  should  be  for 
at  least  three  hours  and  the  gruel  should  be  carefully  strained  before 
using.  After  ten  or  eleven  months  cereal  may  be  given  with  a  spoon. 
This  may  be  almost  any  form  of  well-cooked  cereal  which  has  been 
strained.  It  may  be  cooked  with  milk  or  the  milk  may  be  added  subse- 
quently. Beginning  with  an  ounce  a  day  the  quantity  may  be  gradually 
increased  to  two  ounces  twice  a  day.  While  many  children  easily  digest 
the  amounts  of  starch  mentioned,  there  are  others  who  are  much  dis- 
turbed by  them,  and  some  to  whom,  owing  to  flatulence  and  other  symp- 
toms of  intestinal  indigestion,  starch  can  not  be  given  at  all. 

The  only  other  things  to  be  advised  during  the  first  year  are  beef 
juice  and  the  juice  of  some  fresh  fruit.  Beef  juice  may  be  begun  in 
the  ninth  or  tenth  month,  earlier  with  anemic  children;  at  first  not 
more  than  two  teaspoonfuls  daily,  later  the  amount  may  gradually  be 
increased  to  one  ounce.  The  best  fruit  juice  is  that  of  the  orange,  which 
should  be  fresh  and  sweet.  It  may  with  advantage  be  given  to  all  healthy 
infants  eight  months  old,  and  to  most  when  six  or  seven  months  old. 
Beginning  with  half  an  ounce,  the  quantity  may  gradually  be  increased 
to  two  ounces  daily,  given  preferably  about  one  hour  before  the  second 
milk-feeding. 

The  Tolerance  of  Healthy  Infants  for  the  Different  Food  Elements. 
— In  the  foregoing  pages  we  have  indicated  the  proportions  and  amounts 
which,  in  our  experience,  have  been  shown  in  the  majority  of  instances 
to  be  the  best  for  feeding  healthy  infants.  However,  Nature  will  often 
tolerate  quite  wide  variations  from  what  is  best.  The  desire  for  a  rapid 
increase  in  weight  often  leads  to  an  increase  of  the  fat  in  the  food  much 
beyond  the  limits  which  are  usually  safe.  There  are  some  children  of 
vigorous  constitution  and  strong  digestion,  living  in  good  surroundings, 
who  tolerate  this  for  a  long  time;  some  may  even  go  through  infancy 
to  a  period  of  mixed  diet  without  any  visible  disturbance,  and  appear 
to  thrive  exceedingly  well.  There  are  others  who  bear  for  a  consider- 
able time  very  high  proportions  of  carbohydrates  and  show  phenomenal 
gains  in  weight.  In  both  the  conditions  mentioned  tolerance  usually 
breaks  down  after  a  time,  often  from  a  trivial  cause.  This  may  be  some 
intercurrent  illness  like  a  cold  or  a  mild  bronchitis,  or  the  advent  of  very 
hot  weather;  or,  sometimes  even  so  slight  a  thing  as  dentition  may  bring 
about  an  upset  of  a  most  alarming  character.  In  other  children  there 
gradually  develop  subacute  or  chronic  disturbances  of  digestion   and 


>(tO  NUTEITION 


nutrition  wliicli  may  last  for  months.  One  should  be  very  cautiouS; 
therefore,  in  inferring  that  because  a  few  infants  thrive  on  unusual  pro- 
])ortioj.is  or  excessive  amounts  of  some  one  of  the  food  elements  this  is 
to  be  taken  as  a  guide  in  feeding  the  average  child. 


FEEDING   IN   DIFFICULT   CASES 

In  the  aggregate  the  number  of  infants  included  under  the  head  of 
"difficult  feeding  cases"  is  a  large  one,  and  their  management  constitutes 
the  most  "special"  branch  of  Pediatrics.  The  problem  is  often  one  of 
great  complexity,  the  symptoms  presented  are  of  almost  endless  variety 
and  even  one  of  large  experience  often  finds  himself  baffled.  Let  no 
one,  therefore,  expect,  to  solve  these  problems  without  careful  study  of  the 
individual  cases  and  the  closest  attention  to  detail. 

Causes. — In  some  of  these  infants  difficult  feeding  is  due  to  feeble 
digestion  or  some  individual  peculiarity  because  of  which  they  do  not 
thrive,  even  from  the  outset,  upon  the  usual  milk  modifications  although 
used  intelligently.  In  a  much  larger  group  the  cause  is  to  be  found 
in  prolonged  disturbances  of  digestion,  the  result  of  previous  improper 
methods  of  feeding.  The  difficulties  are  greatest  in  early  infancy,  in 
cities,  in  institutions,  in  hot  weather,  and  they  are  further  increased 
by  the  existence  of  constitutional  debility,  and  when  the  trouble  is  of 
long  standing.  It  is  not  infrequently  found  that  the  failure  is  due  not 
to  any  fault  with  the  food  prescribed,  but  to  other  conditions.  The  food 
may  be  improperly  prepared  or  given — e.  g.,  it  may  be  cold  or  given 
too  rapidly;  the  bottles  or  nipj)les  may  be  dirty;  the  proper  quantities 
and  intervals  not  observed,  etc.  Another  factor  of  im^^ortance  is  the  en- 
\  ironment  as  affecting  the  nervous  system  of  the  infant.  Among  the 
well-to-do  this  may  be  the  chief  trouble.  The  constant  or  frequent  ex- 
citement by  visitors,  or  playing  with  a  child  by  parents  or  nurses,  may 
result  not  only  in  lack  of  sleep,  but  in  disturbances  of  digestion,  often 
in  habitual  vomiting,  though  the  food  itself  is  proper.  In  such  cir- 
cumstances the  removal  of  the  child  from  its  surroundings  or  placing 
him  in  charge  of  a  competent  nurse  will  often  cause  an  immediate  and 
marked  improvement  without  any  change  in  the  food.  Another  minor 
cause  of  disturbance  is  the  habitual  use  of  the  "pacifier,"  frequently 
resorted  to  in  these  cases,  but  which  should  under  no  conditions  be  tol- 
erated. 

That  a  prolonged  disturbance  of  digestion  in  a  young  infant  is  a 
serious  thing  is  often  not  appreciated.  The  mother  is  apt  to  think  the 
problem  one  easy  of  solution;  she  "only  wants  to  be  told  what  to  feed 
her  baby,"  imagining  that  a  single  food  prescription  should  set  the  child 


FEEDING  IX  DIFFICULT  CASES  201 

right  at  once.  The  pliysiciau  too,  sometimes,  regards  tlie  condition 
liglitly  because  these  infants  do  not  seem  really  ill;  he  therefore  con- 
siders the  subject  hardly  important  enough  for  his  careful,  continuous 
attention.  The  fact  should  be  emphasized  that  these  cases  are  serious, 
that  they  are  difficult,  that  in  most  of  them  nothing  can  be  accom- 
plished without  close  and  continuous  personal  observation,  that  they  do 
not  tend  to  right  themselves,  and  that  infants'  lives  are  often  sacrificed 
as  a  result  of  bad  management. 

Clinical  Types. — The  greater  number  of  these  cases  may  be  divided 
into  three  groups :  ( 1 )  those  whose  chief  symptom  is  habitual  vomiting, 
or  regurgitation  of  food;  (2)  those  with  intestinal  symptoms,  most 
frequently  with  loose  stools;  (3)  those  without  any  marked  symptoms 
of  indigestion,  yet  whose  weight  is  much  below  the  average,  who  do 
not  gain  on  weak  food  and  are  upset  if  stronger  food  is  used.  They 
have  feeble  digestion  rather  than  indigestion. 

Cases  with  Vomiting. — The  causes  producing  this  are  usually  rather 
obvious.  When  cream  and  milk  mixtures  or  top-milk  mixtures  are 
used,  altogether  the  most  frequent  mistake  is  the  use  of  too  much  fat. 
The  amount  used  may  not  be  more  than  many  healthy  children  will 
take,  but  it  is  excessive  for  the  particular  patient.  It  is  surprising 
how  great  the  intolerance  to  fat  is  in  some  of  these  infants  and  also 
when  once  established  how  long  it  persists.  Another  frequent  cause 
is  the  use  of  too  much  cane  sugar,  milk  sugar,  or  one  of  tlie  proprietary 
foods  containing  maltose  or  much  starch.  Other  factors  of  importance 
are  too  frequent  feedings,  too  much  food  and  the  use  of  unsuitable  and 
indigestible  foods.  The  vomiting  may  also  be  the  result  of  a  neuropathic 
constitution.  (Page  262).  The  condition  may  be  a  sequel  of  any  of 
the  acute  infections  and  is  more  intractable  in  the  course  of  a  severe 
constitutional  disease  such  as  rickets,  syphilis  or  tuberculosis. 

With  such  severe  and  prolonged  symptoms  as  are  often  present,  patho- 
logical changes  in  the  stomach  might  be  expected.  These,  however,  are 
strikingly  absent.  The  stomach  may  be.  slightly  dilated  and  there  is 
usually  a  large  amount  of  mucus  present  but  macroscopically  and  even 
microscopically  there  are  no  important  or  even  constant  changes. 

The  most  important  symptom  is  vomiting.  It  may  occur  soon  or 
long  after  feeding.  Some  of  these  infants  vomit  only  occasionally  and 
in  large  quantities;  but  it  is  more  common  for  frequent  regurgitation 
of  small  amounts  of  food  to  take  place.  This  may  begin  soon  after  oii(> 
feeding  and  continue  quite  to  the  time  for  the  next.  After  a  time,  tlie 
vomited  matters  nearly  always  contain  mucus,  and  sometimes  this  is  a 
conspicuous  feature.  The  regurgitation  of  a  sour  irritating  fin  id  oc(iii-s 
even  when  but  little  food  is  ejected,  and  usuallv  accoinpani<'S  tlie  hi'lch- 
ing  of  gas. 


202  NUTRITION 

The  results  obtained  in  the  examination  of  stomach  contents  lia\e  iiul 
been  uniform,  and  in  practice  one  should  not  lay  much  stress  upon 
the  absence  of  the  normal  secretions.  The  presence  of  mucus  in  the 
vomited  matters  or  in  the  washings  from  the  stomach  is  nearly  a  con- 
stant feature.  This  greatly  interferes  with  digestion,  even  though  the 
secretions  are  normal.  The  reaction  of  the  stomach  is  almost  always 
acid.  The  hydrochloric  acid  is  almost  invariably  diminished  in  quan- 
tity. Free  hydrochloric  acid  is  very  seldom  present.  There  is  usually 
a  marked  odor  of  butyric  and  other  volatile  fatty  acids.  One  would 
expect,  therefore,  to  find  these  in  excess,  but  the  studies  of  Huldschinsky 
have  shown  that  they  are  little  if  at  all  increased  in  the  stomach  con- 
tents of  vomiting  infants.  The  rennet  ferment  and  pepsin  are  almost 
invariably  present  in  normal  amount,  hence  the  administration  of  di- 
gestive ferments  is  not  indicated. 

In  addition  to  air  which  is  swallowed,  there  is  an  increased  pro- 
duction of  gas.  Some  of  the  most  striking  symptoms  are  due  to  dis- 
tention. The  epigastrium  may  be  tense  and  hard  most  of  the  time,  and 
often  so  much  gas  is  present  that  infants  find  difficulty  in  taking  food. 
Though  evidently  hungry,  they  can  take  so  little  at  a  time  tlmt  an 
hour  or  more  may  be  required  to  take  four  or  five  ounces.  There  is 
motor  insufficiency  of  the  stomach  and  probably  in  some  cases  a  certain 
degree  of  pyloric  spasm  which  causes  gastric  stagnation.  That  the 
food  remains  long  in  the  stomach  is  best  demonstrated  by  aspiration 
or  stomach-washing.  Instead  of  the  stomach's  being  empty  in  two  and 
a  half  or  three  hours,  as  it  should  be,  food  may  be  found  four  or  five 
hours,  and  in  some  cases  six  or  eight  hours,  after  feeding.  There 
may  be  dilatation  of  the  stomach,  especially  in  older  infants  who  are 
rachitic. 

The  appetite  may  be  abnormally  great,  or  it  may  be  poor.  As  a  rule, 
children  take  less  food  than  in  health.  The  tongue  is  usually  coated. 
The  general  symptoms  are  those  of  malnutrition ;  there  is  constant  fret- 
fulness,  and  sleep  is  irregular  or  disturbed;  the  weight  is  stationary,  or 
there  is  a  steady  loss;  there  is  also  anemia,  and  the  child's  development 
is  arrested.  There  is  nearly  always  some  derangement  of  the  bowels, 
more  often  constipation  than  diarrhea. 

Infants  who  vomit  as  the  result  of  a  neuropathic  constitution  may 
show  at  first  no  symptoms  but  the  vomiting.  If  this  is  severe  and  con- 
tinued, later  they  show  evidences  of  malnutrition,  sometimes  of  an  ex- 
treme grade. 

There  is  little  tendency  to  spontaneous  improvement  or  recovery, 
the  prognosis  depending  almost  entirely  upon  the  treatment  employed. 
Unless  relieved  the  condition  is  apt  to  continue,  until  some  serious 
acute   disease   develops   which   may   be   fatal.      In    very   young   infants 


FEEDINd  IN  DIFFICULT  CASES  'iO.T 

such  gastric  disturbances  should  not  be  confounded  with  hypertrophic 
stenosis  of  the  pylorus.     "\) 

In  the  treatment,  the  question  of  diet  is  of  first  importance.  It  is 
the  chief  therapeutic  measure.  The  indications  for  varying  the  quality 
and  quantity  of  the  food  when  there  is  habitual  vomiting  have  already 
been  discussed  (page  193).  The  feedings  should  be  at  least  four  hours 
apart  and  the  amounts  smaller  than  normal  infants  of  the  same  age 
would  receive.  The  usual  practice  when  an  infant  suffers  from  vomiting 
is  to  dilute  his  food  and,  in  some  instances,  this  is  .perfectly  proper ;  but 
to  continue  increasing  the  dilution  because  the  patient  does  not  do  well 
may  be  the  very  worst  treatment.  Small ,  feedings,  not  weak  food,  are 
what  benefit  some  of  these  children  most,  the  balance  of  the  daily  amount 
of  water  needed  by  the  infant  being  given  between  the  feedings.  Unless 
cream  or  top-milk  mixtures  have  been  employed  the  sugar  is  more  likely 
to  be  the  exciting  cause  of  the  vomiting  than  any  other  ingredient  of 
the  food.  This  should  be  greatly  reduced  in  amount  or  temporarily  re- 
moved altogether.  When  the  vomiting  has  ceased  the  sugar  may  grad- 
ually be  increased.  Milk  sugar  is  less  likely  to  ferment  in  the  stomach 
than  cane  sugar  or  maltose.  The  latter  should  never  be  used  with  vomit- 
ing infants.  Buttermilk,  on  account  of  its  low  fat  and  moderate  sugar 
content,  is  frequently  of  value,  but  it  cannot  advantageously  be  continued 
very  long  without  the  addition  of  carbohydrates  in  some  form.  The  very 
factors  that  make  it  of  value  for  temporary  use  make  it  disadvantageous 
for  permanent  use. 

Wet  nursing  does  not  bring  immediate  improvement  in  the  vomit- 
ing and  sometimes  none  at  all.  The  large  amount  of  sugar  and  fat  in 
breast  milk  sometimes  aggravates  the  symptoms.  Usually,  however,  the 
infant  when  breast-fed  improves;  but  the  vomiting  may  continue  so 
severe  as  to  make  it  necessary  to  return, to  artificial  feeding.  When 
the  vomiting  has  ceased,  however,  nothing  brings  about  such  rapid  re- 
cuperation of  the  general  health  as  does  breast  milk. 

At  times,  nothing  succeeds  so  well  as  giving  semi-solid  food  with 
the  spoon.  Cereals  cooked  with  milk  as  described  on  page  263  are  read- 
ily borne  by  many  infants,  especially  those  with  vomiting  due  to  nervous 
causes. 

Stomach  washing  is  frequently  useful,  especially  with  persistent  cases. 
It  removes  the  mucus,  cleanses  the  organ  and  acts  as  a  stimulant  to  the 
gastric  secretions,  especially  the  hydrochloric  acid.  Plain  boiled  water, 
or  a  weak  alkaline  solution — sodium  bicarbonate,  one  dram  to  the  pint 
— may  be  employed.  In  the  early  part  of  the  treatment  the  washing 
should  be  done  daily;  later,  every  second  or  third  day.  The  lime  se- 
lected is  not  of  great  moment,  but  it  is  better  to  make  this  about  three 
hours  after  feeding. 


204  NUTRITION 

The  general  treatment  is  apt  to  be  ignored,  but  is  important.  The 
best  possible  hygiene  should  be  secured, — a  large,  roomy  nursery,  and 
plenty  of  fresh  air  by  night  and  by  day;  equally  necessary  are  quiet 
surroundings  and  freedom  from  disturbing  conditions  which  sometimes 
obtain  in  the  nursery.  General  friction  of  the  body  is  useful  in  delicate 
children  with  poor  circulation.  Infants  must  be  properly  covered,  and 
it  is  of  the  utmost  importance  that  the  feet  be  kept  warm. 

Drugs  have  a  very  limited  application  in  the  treatment  of  this  con- 
dition in  infairts.  They  have  been  too  much  used,  and  too  little  atten- 
tion has  been  given  to  the  details  of  feeding,  by  wliich  means  alone 
j)ermanent  improvement  is  usually  reached.  The  continued  use  of  pepsin 
and  other  digestive  ferments  is  irrational  and  without  benefit.  Hydro- 
chloric acid  may  at  times  prove  of  value,  but  it  must  be  given  in  rather 
large  doses^ — i.  e.,  five  to  fifteen  drops  of  the  dilute  acid  after  each 
feeding. 

Cases  ivith  Intestinal  Symptoms. — These  are  found  most  frequently 
in  infants  born  prematurely,  in  those  with  constitutional  debility,  who 
have  never  been  vigorous,  in  those  brought  up  in  poor  surroundings  Avith 
unintelligent  care  or  in  those  who  have  suffered  from  any  acute  disease, 
especially  inflammation  of  the  gastro-intestinal  tract,  sucli  as  ileoco- 
litis. Usually  there  has  been  artificial  feeding  from  the  beginning  or 
after  a  few  weeks  of  nursing.  Some  of  the  infants  also  belong  to  the 
neuropathic  type.  To  the  extent  that  it  is  usually  avoided  by  maternal 
nursing,  the  condition  is  a  preventable  one.  But  there  are  a  few  infants 
that  develop  these  symptoms  even  while  nursing;  and  a  considerable 
number,  in  spite  of  intelligent  artificial  feeding.  There  seems  to  be  with 
these  infants  a  particular  lack  of  resistance  on  the  part  of  the  intestinal 
tract.    It  never  seems  capable  of  accomplishing  the  work  devolving  upon  it. 

In  infants  fed  on  top-milk  mixtures,  the  most  common  cause  of  dis- 
turbance is  an  excessive  amount  of  fat.  When  whole-milk  modifications 
are  used  the  fault  is  usually  an  excess  of  sugar,  and  with  older  infants 
too  large  quantities  of  farinaceous  fo.ods,  often  insufficiently  cooked. 
The  carbohydrates  may  not  be  more  than  the  average  child  takes  well, 
but  these  infants  are  particularly  sensitive. 

There  are  no  constant  or  characteristic  pathological  changes.  There 
may  be  a  hyperplasia  of  the  lymphoid  tissue  of  the  intestines  and  some- 
times there  is  a  similar  process  in  the  mesenteric  lymph  nodes.  Usually, 
however,  these  are  absent. 

The  symptoms  are  general  and  local.  So  far  as  the  intestinal  con- 
dition is  concerned,  diarrhea  is  the  most  frequent  and  serious  symp- 
tom. It  may  happen  that  the  same  child  will  suffer  for  a  long  time 
from  diarrhea  and  then  from  constipation,  but  the  constipation  is  usually 
the  result  of  dietetic  measures  directed  against  the  diarrhea, — i.  e.,  a 


FEEDING  IX  DIFFICULT  CASES  20.-, 

reduction  in  the  fat  or  the  carbohydrates,  or  both.  As  a  result,  the 
energy  value  of  the  food  is  reduced  to  a  point  at  or  below  the  main- 
tenance requirement.  When,  in  order  to  produce  gain  in  weight,  these 
substances  are  increased  in  the  food,  diarrhea  again  results.  There  may 
thus  be  over  long  periods,  alternating  constipation  and  diarrhea.  The 
stools  are  of  all  varieties,  depending  on  the  severity  of  the  symptoms  and 
the  character  of  the  food.  They  are  usually  more  frequent  than  normal 
and  generally  contain  undigested  food  and  mucus.  In  some  cases  the 
stools  contain  but  little  solid  matter,  the  character  being  that  of  yellow- 
isli-green  water.  The  stools  usually  have  a  sour,  unpleasant  odor,  but 
are  rarely  very  foul.  They  may  be  irritating  to  the  skin  and  cause 
troublesome  excoriations  and  intertrigo.  There  may  be  much  gas  and 
flatulence. 

If  there  is  constipation,  the  stools  are  usually  gray  or  white;  they 
are  smooth  and  pasty  like  hard  balls  and  passed  after  much  straining, 
often  coated  with  mucus  and  sometimes  streaked  with  blood.  Such 
stools  are  not  infrequently  seen  when  the  food  contains  a  large  amount 
of  fat.  "With  the  constipation,  there  may  be  much  flatulence  and  colic, 
the  attacks  of  which  may  be  severe. 

The  general  symptoms  are  those  -of  malnutrition.  These  are  more 
fully  described  elsewhere  and  need  only  be  mentioned  here.  The  most 
important  are :  stationary  or  falling  weight,  anemia,  poor  circulation, 
often  subnormal  temperature,  almost  constant  fretfulness  and  crying, 
with  very  little  quiet  sleep.  The  tongue  may  be  coated  but  more  often 
is  quite  clean.  The  appetite  is  frequently  good,  these  infants  taking 
food  whenever  given,  and  in  an  almost  unlimited  quantity.  There  are 
few  cases  in  which  occasional  vomiting  does  not  occur,  sometimes  it  is 
marked  and  persistent,  but  it  is  rare  for  it  to  be  so.  When  so  much  of 
the  food  is  regurgitated  by  vomiting,  as  in  the  cases  just  described,  the 
intestinal  tract,  even  with  highly  erroneous  methods  of  feeding,  is  thereby 
protected. 

The  duration  of  these  symptoms  is  indefinite.  Even  with  the  great- 
est care  there  is  little  or  no  tendency  to  spontaneous  improvement.  They 
may  drag  on  for  many  moiiths  with  frequent  exacerbations  and  remis- 
sions. The  symptoms  may  be  relieved,  but  at  the  same  time  to  insure 
growth  and  a  gain  in  weight  may  be,  for  the  time  being  at  least,  well 
nigh  impossible.  The  least  increase  in  the  food,  especially  the  carbo- 
hydrates or  fats,  may  be  sufficient  to  precipitate  an  attack  of  diarrhea 
with  further  loss  in  weight.  Thus,  there  may  alternate  slight  gains  and 
losses,  the  weight  for  months  being  nearly  stationary. 

A  danger  to  these  patients  is  that  of  intercurrent  infections.  To  a 
delicate  infant  an  attack  of  rhinopharyngitis  with  otitis  may  be  more 
serious  than  a  frank  pneumonia  to  a  vigorous  child.     Any  infection  is 


206  NUTRITION 

to  be  feared,  bronchitis  and  pneumonia  particularly  so.  Death  seldom 
results  from  the  severity  of  the  condition  itself.  With  appropriate  treat- 
ment a  gain  in  weight  usually  results,  although  this  may  be  delayed 
many  weeks  or  months.  With  infants  over  sis  months  of  age  the  prob- 
lem is  usually  an  easier  one  than  with  those  younger.  Especially  is 
there  difficulty  with  premature  infants  and  those  much  under  weight  at 
birth,  i.  e.,  five  pounds  or  less. 

Drugs  have  no  part  in  the  treatment  of  these  cases ;  in  nearly  every 
instance  they  had  best  be  omitted  altogether.  The  treatment  is  die- 
tetic. Prophylaxis  is  important.  Maternal  nursing  will  do  much  to 
prevent  the  development  of  such  cases.  It  is  necessary  to  obtain  a 
careful  and  minute  history  in  order  to  direct  matters  intelligently.  The 
previous  feeding  should  be  thoroughly  known,  the  different  changes  made 
and  their  effect  upon  the  intestinal  symptoms  and  the  infant's  weight. 
With  this  information  one  can  often  at  once  determine  where  mistakes 
have  been  made  and  in  many  instances  it  is  found  that  the  same  mistake 
has  been  repeated  with  each  change  of  food. 

Occasionally  diarrhea  develops  with  maternal  nursing  and  it  is  by 
no  means  infrequent  when,  on  account  of  a  tendency  to  attacks  of  diar- 
rhea, wet  nursing  is  resorted  to.  The  cause  of  this  is  the  large  amount 
of  fat  and  sugar  in  breast  milk,  both  of  which  readily  undergo  change 
in  the  intestines  with  the  production  of  irritating  lower  fatty  acids. 
Breast  feeding  should  not  be  interrupted  under  such  circumstances  but 
supplementary  feeding  with  a  food  low  in  fat  and  sugar  should  be  re- 
sorted to.  The  most  available  food  is  buttermilk.  This  may  be  given  at 
alternate  feedings  or  may  be  given  in  amounts  of  one  or  two  ounces 
just  before  the  nursing.  When  the  symptoms  have  been  overcome,  the 
buttermilk  may  gradually  be  withdrawn  from  the  dietary.  Breast 
feeding  is  altogether  the  safest  method  of  treating  such  conditions  in 
those  infants  under  three  months  of  age.  Many  of  those  older  may  be 
successfully  treated  by  artificial  feeding  but  progress,  in  order  to  be  sure, 
must  be  slow.  In  protracted  cases  minor  variations  in  the  composition 
of  the  food  or  in  the  plan  of  feeding  rarely  accomplish  much.  The 
most  brilliant  results  are  often  obtained  from  as  complete  a  change  in 
the  diet  as  possible.  Notwithstanding  the  fact  that  these  patients  are 
usually  much  below  the  normal  weight  and  often  losing  steadily,  the 
treatment  should  be  directed  first  of  all  to  allaying  the  most  marked  in- 
testinal symptoms.  Until  these  are  relieved,  no  permanent  improve- 
ment can  be  expected.  For  the  time  being,  the  weight  must  be  dis- 
regarded. 

So  far  as  the  elements  of  cow's  milk  are  concerned,  the  greatest 
difficulty  is  seen  when  l)otli  fat  and  sugar  are  given  in  considerable 
amount.     A  moderate  amount  of  fat  with  a  minimum  of  sugar  usually 


FEEDING  IN  DIFFICULT  CASES  207 

causes  no  diarrhea.  Sugar,  however,  even  in  the  absence  of  fat,  will 
produce  it.  For  this  reason,  the  use  of  skimmed  milk  and  even  fat-free 
milk  usually  causes  no  improvement  in  the  diarrhea,  there  being  too  much 
sugar  in  fresh  milk,  even  without  the  addition  of  any  extra  amount. 
Top-milk  or  milk  and  cream  mixtures  are  not  admissible.  If  fresh  milk 
mixtures  are  to  be  used,  dilutionjLDJLwhole  milk  or  of  partially  skimmed 
milk  should  be  given,  with  no  carbohydrates  added.  If,  upon  this  diet, 
the  stools  become  normal,  sugar  may  gradually  be  added,  but  this  must 
not  be  lactose  or  a  mixture  in  which  maltose  is  present  in  a  large  amount, 
such  as  malt  soup.  The  dry  preparations  of  maltose  or  cane  sugar 
should  be  at  first  tried  and  in  small  quantity,  not  over  one  teaspooiiful 
daily. 

If  fresh  milk  mixtures  are  not  well  borne,  buttermilk  and  other  fer- 
mented milks  may  be  tried.  These  succeed  in  a  certain  number  of  cases 
that  do  not  respond  to  skimmed  milk.  It  is  seldom  necessary  to  dilute 
them  more  than  with  an  equal  amount  of  water.  Additional  carbo- 
hydrates needed  may,  after  a  time,  be  supplied — best  by  adding  starchy 
food  with  smair  quantities  of  cane  sugar. 

Protein  milk  is  one  of  the  most  valuable  of  the  recent  additions  to 
our  resources  in  feeding  cases  of  this  type.  The  chief  advantages  here 
are  apparently  due  to  its  low  sugar  content, 'for- it  contains  a  consider- 
able amount  of  fat,  indicating  that  fat  in  the  absence  of  carbohydrates 
is  very  frequently  well  borne.  /  The  lai'ge  amount  of  protein  which 
readily  undergoes  putrefaction  inhibits  the  formation  of  the  lower  fatty 
acids  from  the  carbohydrates  and  fatsy  Only  for  very  young  infants 
need  it  be  diluted  and  it  is  seldom  neceffiary  to  reduce  the  fat  by  making 
it  from  skimmed  milk.  Not  much-  gain  in  weight  is  seen  when  protein 
milk  is  used  alone.  Carbohydrates  should  be  added  as  soon  as  possible, 
but  always  with  great  caution,  beginning  with  very  small  quantities. 
'Cane  sugar  should  first  be  tried,  then  one  of  the  dry  preparations  of  mal- 
tose beginning  with  not  more  than  a  half  tablespoonful  daily  and  slowly 
increasing. 

Either  of  these  sugars  may  be  used  in  conjunction  with  starchy  food 
which  may  be  wheat  or  barley  flour  from  one-quarter  to  one  ounce  daily, 
the  latter  amount  to  children  five  or  six  months  of  age.  Employed  in 
this  way  protein  milk  may  often  be  continued  for  two  or  three  months, 
but  without  the  addition  of  carbohydrates  it  is  seldom  advantageous 
for  more  than  two  or  three  weeks. 

Peptonized  milk  has  been  altogether  too  frequently  employed  and 
offers  no  aid  in  the  treatment  of  intestinal  conditions.  A  change  to  a 
diet  other  than  milk  should  be  made  very  slowly  and  with  great  care; 
one  relatively  rich  in  carbohydrates  is  usually  badly  borne.  Carbo- 
hydrates in  the  form  of  cooked  cereals  must  be  added  gradually.     Eggs 


208  NUTRITION 

are  sometimes  of  assistance  and  junket  is  frequently  of  value  in  pre- 
venting excessive  fermentation.  Solicitous  care  should  not  cease  with 
these  children  at  the  end  of  the  first  year,  they  must  be  closely  watched 
lintil  they  are  three  or  four  years  old. 

The  same  careful  hygiene  is  as  important  as  in  patients  with  gastric 
symptoms.    The  general  methods  employed  should  be  the  same. 

Cases  ivitli  Feeble  Digestion. — Infants  whose  digestion  is  very  feeble, 
although  they  have  neither  pronounced  gastric  or  intestinal  symptoms, 
are  very  dilBcult  patients  to  feed.  Gains  in  weight  are  very  slow  and 
one  must  be  content  if  any  regular  gain  takes  place.  In  case  of  failure 
by  the  usual  milk  modifications,  wet-nursing  is  altogether  the  most  suc- 
cessful form  of  feeding.  Sometimes  it  is  sufficient  if  only  partial  breast 
feeding  can  be  given,  i.  e.,  three  or  four  feedings  a  day.  This  is  a  plan 
of  much  value  in  institutions  and  saves  many  babies.  If  no  breast  feed- 
ing is  possible,  artificial  feeding  must  be  conducted  in  the  most  pains- 
taking manner  lest  serious  digestive  upsets  occur.  If  these  can  be 
avoided  it  usually  happens  that  as  the  child  grows  older  and  a  more 
varied  diet  can  be  given,  the  problem  grows  steadily  easier. 

With  some  infants,  in  the  event  of  failure  by  the  usual  methods,  the 
first  start,  which  is  really  the  most  difficult  one,  may  be  made  upon 
sweetened  condensed  milk  which  is  diluted  with  plain  water  or  barley 
water.  "Evaporated"  or  unsweetened  condensed  milk  has  at  times  suc- 
ceeded when  fresh  whole  milk  has  failed.  The  explanation  for  this  can- 
not be  given.  Unsweetened  condensed  milk  requires  the  same  addition 
of  sugar  and  starch  as  does  whole  milk. 

When  there  is  no  vomiting  and  no  tendency  to  diarrhea,  feeding  with 
considerably  higher  proportions  of  carbohydrates  than  are  usually  em- 
ployed is  also  sometimes  useful  for  a  short  time.  It  may  be  carried  out 
with  fresh  milk  as  in  the  various  malt-soup  mixtures,  or  with  sweetened 
condensed  milk  or  evaporated  milk  as  a  basis.  When  an  excess  of  carbo- 
hydrate is  given  the  percentages  of  fat  and  protein,  but  especially  the 
former,  should  be  lower  than  in  the  usual  formulas  for  the  age  and 
condition.  There  is  apparently  some  advantage  in  using  a  variety  of 
sugars;  a  combination  of  lactose,  maltose  and  cane  sugar  being  given 
rather  than  any  one  of  them  alone.  The  total  sugar  may  sometimes  be 
carried  above  7  per  cent  but  always  with  caution.  Starchy  food  is  added 
in  the  form  of  barley,  wheat  or  oat  flour,  cooked  for  ten  to  twenty  min- 
utes. The  daily  quantity  used  may  be  from  half  an  ounce  to  two  ounces 
according  to  age  and  condition.  The  larger  quantity  mentioned  may 
sometimes  be  given  to  an  infant  of  five  or  six  months.  With  infants 
over  six  months  of  age  thick  gruel  like  that  advised  for  normal  infants 
of  ten  or  twelve  months  may  be  of  great  assistance  in  causing  gain  in 
weiffht. 


HEALTHY  INFANTS  DURING  THE  SECOND  YEAR  200 

A  diet  containing  an  excessive  amount  of  carbohydrate  is  not  adapted 
to  prolonged  use  and  incautiously  used  may  be  followed  by  serious  upsets. 
For  a  time  all  may  go  well;  then  from  some  apparently  trivial  cause  a 
breakdown  occurs.  As  soon  as  possible  the  child  should  be  placed  upon 
a  more  rational  food,  i.  e.,  a  properly  "balanced  ration"  by  introducing 
at  first  one  and  then  other  feedings  from  whole  milk  modifications  in 
which  fat  and  protein  are  raised  and  carbohydrates  reduced. 

A  foodstuff'  occasionally  useful  is  olive  oil.  It  is  a  form  of  fat  which 
can  sometimes  be  tolerated  when  the  fat  of  cow's  milk  habitually  dis- 
agrees. The  amount  used  at  first  should  be  small,  not  more  than  one-half 
teaspoonful  twice  a  day.  The  maximum  amount  to  be  used  for  infants 
of  the  first  year  should  not  be  over  two  teaspoonfuls  daily. 

The  chief  means  by  which  weight  can  be  increased  in  children  suffer- 
ing from  malnutrition  is  therefore  through  the  addition  of  carboh^'drates, 
especially  maltose,  as  soon  as  these  can  be  tolerated ;  next  by  the  addition 
of  fat,  but  neither  of  these  is  to  be  employed  in  any  considerable  quantity 
until  the  marked  symptoms  of  indigestion  have  been  controlled. 


CHAPTER  IV 
FEEDING   AFTER    THE   FIRST    YEAR 

HEALTHY  INFANTS   DURING  THE   SECOND  YEAR 

The  physician  should  not  relax  his  vigilance  in  the  feeding  of  a 
child  after  the  first  year  has  passed.  The  ideas  of  the  laity  in  regard  to 
what  is  proper  for  a  child  after  he  has  outgrown  an  exclusive  milk  diet 
are  very  erroneous.  Most  of  the  disorders  of  digestion  of  early  childhood 
are  directly  traceable  to  dietetic  errors.  Among  the  poor  the  majority  of 
infants  are  given  solid  food  too  early,  in  too  large  quantities  and  improp- 
erly' prepared.  Among  many  of  the  intelligent  and  well-to-do  the  dis- 
position is  to  go  to  tlie  opposite  extreme  and  to  keep  the  infant  too  long 
upon  a  diet  composed  exclusively  or  almost  exclusively  of  milk. 

During  the  second  year  the  diet  of  a  healthy  child  should  consist 
chiefly  of  milk,  bread,  farinaceous  foods,  fruit  juices  or  cooked  fruit,  with 
a  small  amount  of  animal  food  in  the  form  of  beef  juice,  broths,  meat 
and  eggs.  By  the  middle  of  the  year  with  most  children,  with  some  even 
earlier,  potato  may  be  added,  also  green  vegetables,  at  first  in  small  quan- 
tities, thoroughly  cooked  and  pureed. 

Milk  should  be  the  largest  item  of  the  diet,  but  when  solid  food  in 
any  considerable  quantity  is  begun  it  should  be  reduced;  few  children 


210  XUTEITION 

require  more  than  a  pint  and  a  half  of  milk  a  da3^  The  popular  notion 
that  there  are  many  children  who  cannot  take  milk  is  an  erroneous  one; 
the  real  trouble  usually  is  that  too  rich  milk  is  given  or  that  the  quantity 
allowed  is  too  large.  It  is  often  drunk  like  water  with  a  hearty  meal  of 
other  food  and  the  child  is  simply  overfed.  On  the  other  hand,  to  permit 
a  child  to  give  up  milk  altogether  because  solid  food  pleases  the  palate 
better  is  a  mistake.  It  is  important,  however,  that  the  transition  from 
an  entirely  fluid  diet  to  one  of  solid  food  should  be  made  gradually,  and 
that  the  habit  of  taking  milk  should  not  cease  at  the  end  of  the  first,  or 
even  the  second  year. 

During  the  second  year  with  average  milk  and  average  infants  no 
modification  of  the  milk  is  required.  If  the  milk  is  very  rich,  such  as 
that  from  a  Jersey  herd,  it  should  be  partially  skimmed  or  diluted  with 
at  least  one-fourth  water.  In  hot  weather  especially  should  these  meas- 
ures be  insisted  on. 

Weanmg  from  the  Bottle. — This  should  always  be  begun  before  a 
child  is  a  year  old ;  by  tha  thirteenth  month  an  infant  should  take  all  his 
milk  from  a  cup,  except  possibly  the  10  p.  m.  feeding,  when  for  the  sake 
of  convenience  the  bottle  may  be  allowed.  Early  weaning  from  the  bottle 
is  a  matter  of  no  small  importance.  When  the  bottle  is  allowed  to  older 
children  the  temptation  to  overfeeding,  especially  during  the  summer, 
may  be  very  great.  Again  there  are  many  children  with  the  "bottle- 
habit"  so  firmly  developed  that  throughout  childhood,  although  at  any 
time  they  will  take  milk  from  the  bottle,  they  can  never  be  induced  to 
take  it  any  other  way,  and  sometimes  refuse  all  other  food  so  long  as  the 
bottle  is  allowed. 

From  Twelve  to  Fifteen  Months. — The  daily  schedule  at  this  period 
should  be  about  as  follows :  ^ 

6  to  7  A.M.     Milk,  six  ounces,  diluted  with  two  to  three  ounces  of  barley  or  oat 
gruel. 
9  A.M.    Orange  juice,  one  to  three  ounces. 

10  A.M.     Cerqal   (thoroughly  cooked  and  strained),  one  large  tabiespoonful. 
Milk,  six  ounces,  part  of  it  on  cereal. 
Crisp,  dry  toast,  one  piece. 
2  P.M.    Beef  juice,  one  to  two  ounces; 

or,  mutton  or  chicken  broth,  three  to  four  ounces; 
or,  one-half,  later  one  entire  soft  egg. 
Crisp,  dry  toast   or  unsweetened  zwieback,  one  piece. 
Milk  and  gruel  in  the  proportions  given  above,  four  to  six  ounces. 
6  P.M.    Same  as  at  10  a.m. 
10  P.M.    Same  as  at  6  a.m.,  but  given  from  a  bottle. 

In  preparing  the  food,  the  milk  and  the  gruel  are  simply  mixed 
together  while  the  latter  is  warm;  salt  and  at  first  a  very  small  quantity 


FEEDING  FROM  THE  THIRD  TO  THE  SIXTH  YEAR  211 

of  caue  sugar  are  added  to  make  it  palatal)le.  It  is  tlieii  divided  into  as 
many  feedings  as  are  required  for  the  day^  each  one  being  placed  in  a 
separate  bottle.  As  to  handling  the  bottles  and  pasteurizing  or  steriliz- 
ing, the  same  rules  apply  as  during  the  first  year. 

From  Fifteen  to  Twenty  Months. — The  diet  may  be  increased  by  the 
addition  of  more  solid  food.     The  average  child  will  require : 

6.30  A.M.    Milk,  warmed,  eight  ounces. 

9  A.M.     Orange  juice,  two  to  three  ounces. 

10  A.M.     Cereal,  two  good  tablespoonfuls,  oatmeal  or  hominy,  cooked  three 
hours,  not  strained,  with  one  ounce  of  thin  cream  or  top-milk. 
Milk,  six  ounces. 

Crisp  toast  or  zwieback,  one  or  two  pieces. 
2  P.M.    Beef  juice  and  two  teaspoonfuls  of  scraped  meat; 
or,  broth,  four  ounces,  and   one  egg. 
One-half  of  a  baked  potato; 

or,  one  tablespoonful  of  a  green  vegetable  (spinach,  carrots,  fresh 
peas,   string  beans,  asparagus  tips)    thoroughly  cooked  and  put 
through  a  fine  sieve. 
Stewed  prunes,  three   or  four; 

or,  one-half  a  baked  apple,  strained. 
Crisp  toast  or  dried  bread. 
6  P.M.    Cereal,  two  tablespoonfuls,  farina  or  cream  of  wheat,  cooked  one  hour, 
served  as  at  10  a.m. 
Milk,  eight  ounces. 
10  P.M.     Milk,  six  ounces  (omitted  at  eighteen  months  and  sometimes  earlier). 

From  Twenty  Months  to  Two  Years. — By  the  end  of  the  second  year 
the  amount  of  the  solid  food,  especially  the  quantity  of  meat  and  vege- 
tables, may  be  somewhat  increased.  The  meat  allowed  may  be  finely 
minced  or  scraped  beefsteak,  lamb  chop  or  chicken.  Only  four  meals 
should  be  given,  the  10  p.  m.  feeding  being  omitted,  and  nothing  but 
water  between  the  feedings ;  this,  however,  should  be  allowed  freely.  Eaw 
fruit  except  orange  juice  should  not  be  given.  It  is  usually  better  to  give 
the  fruit  and  milk  at  different  meals.  It  is  often  more  convenient  to 
transpose  the  morning  feedings,  giving  the  milk  at  10.30  and  the  prin- 
cipal meal  at  7.00  or  7.30  a.  m. 


FEEDING   FROM  THE  THIRD  TO  THE  SIXTH  YEAR 

Articles  Allowed. — From  the  following  list  the  diet  of  a  healthy  child 
may  be  arranged. 

Milk. — This  should  form  a  prominent  part  of  the  diet.  No  child 
requires  more  than  a  pint  and  a  half  (three  glasses)  daily.  Kich  Jersey 
milk  should  not  l)e  chosen.    The  milk  should  usually  be  given  warm. 


212 


NUTRITION 


Cream. — Not  more  than  three  or  four  ounces  of  thin  (16  or  20  per 
cent)  cream  should  be  given  daily.  It  should  not  be  used  upon  fruits, 
especially  sour  fruits.  It  may  be  used  upon  cereals,  upon  potato  and  in 
broths.  Cream  should  not  be  given  at  all  to  children  who  suffer  from 
so-called  bilious  attacks,  with  coated  tongue,  bad  breath,  etc. 

Eggs. — They  should  be  fresh,  soft-boiled,  poached,  coddled,  or  scram- 
])led,  but  not  fried.  Children  vary  greatly  as  regards  their  ability  to 
digest  eggs ;  many  children  will  take  two  eggs  a  day,  some  only  one,  and  a 
few  can  not  take  them  at  all. 

Meats. — Some  form  of  meat  should  be  given  once  a  day.  The  best 
are  beefsteak,  lamb  chop,  and  roast  beef  or  lamb  and  the  white  meat  of 
chicken ;  next  to  these  certain  of  the  more  delicate  kinds  of  fresh  fish, 
Avhich  should  be  boiled  or  broiled.  Beef  and  lamb  should  be  given  rare. 
All  meat  should  be  very  finely  divided.    Cold  meat  should  be  avoided. 

Vegetables. — Potato  may  be  given  once  a  day,  baked  or  mashed,  with 
the  addition  of  cream  or  beef  juice  rather  than  butter.  Of  the  vegetables 
the  best  are  asparagus  tips,  spinach,  stewed  celery,  string  beans,  carrots, 
and  fresh  peas.  One  of  these  vegetables  should  be  given  daily — always 
well  cooked  and  mashed. 

Cereals. — None  of  the  "dry"  or  ready-to-serve  cereals  should  be  given 


CALORIC   VALUES    OF    COMMON    FOODS 


Cereals  (cooked). 

Oatmeal 

Hominy 

Farina 

Rice 

Macaroni 

Vegetables. 

Lima  beans 

Peas 

String  beans 

Carrots 

Spinach 

Squash 

Mashed  potato 

Sweet  potato 

Butter 

Dry  cocoa 

Sugar  (cane) 

Lean  roast  beef,  lamb  or  chicken . 
Fish 


Ounce. 
18 
22 
16 
32 
26 


22 
33 
6 
17 
10 
14 
33 
58 


225 

146 

116 

50 

32 


Even 
Tablesp' 
10 
10 
7 
17 
15 


13 
16 

3 
10 
10 

9 
17 
30 


114 
38 
32 
22 
16 


Beef  juice 

Broth 

Cream  Soup 

Cu.stard 

Orange  juice 

Milk 

Cream  (20%) 

Condensed  milk 

Trotein  milk 

One  slice  of  bread,  4  x  4  x  J^  in 

One  large  roll 

One  soda  cracker 

One  egg  (yolk  60) 

One  medium  potato 

One  medium  apple 

One  fig 

Four  prunes 

One  large  banana 


Ounce. 

6 

5 

30 

40 

15 

20 

60 

100 

15 


80 

100 

25 

75 

100 

75 

50 

100 

100 


In  ordering  a  diet  for  children  a  knowledge  of  the  nutritive  or  caloric  value 
of  the  different  common  articles  of  diet  is  highly  desirable. 

As  estimated  in  the  table,  vegetables  are  finely  mashed,  meats  are  finely 
divided  and  even  tablespoonfuls  are  tightly  packed. 

Cereals  are  cooked  in  water  in  proportions  given  on  the  package,  i.  e.,  oat- 
meal one  cup  to  water  one  pint. 


FEEDING  FROM  THE  THIRD  TO  THE  SIXTH  YEAR  213 

to  young  children.  Tliey  are  the  cause  of  more  disturbances  of  digestion 
than  almost  any  other  common  article  of  diet.  Almost  any  cereal  which 
has  been  thoroughly  cooked  may  be  allowed — oatmeal,  wheaten  grits, 
hominy,  rice,  cornmeal,  farina,  and  arrowroot.  If  the  grains  are  used, 
cereals  should  be  cooked  from  three  to  six  hours,  after  having  been  pre- 
viously soaked.  The  partially  cooked  cereals  of  the  shops  should  always 
be  cooked  two  or  three  times  as  long  as  the  directions  upon  the  package. 
The  "tireless  cooker"  is  an  excellent  device  for  the  proper  cooking  of 
cereals  for  children.  Cereals  should,  always  be  well  salted,  and  given  with 
milk  or  cream,  but  with  little  or  no  sugar. 

Broths  and  Soups. — Both  meat  and  vegetable  soups  may  be  given  and 
nearly  all  varieties  of  the  latter  except  tomato  soup.  Plain  broths  are  not 
^'ery  nutritious,  but  when  thickened  with  arrowroot  or  cornstarch,  and 
when  milk  is  added,  they  are  very  palatable,  and  at  the  same  time  a  val- 
uable addition  to  the  diet.  Most  vegetable  purees  are  useful,  and  when 
properly  made  very  digestible.  Beef  juice  may  be  used  as  directed  for  the 
second  year. 

Bread  and  Biscuits  (Crackers) . — In  some  form  these  may  be  given 
with  nearly  every  meal,  better  without  butter  until  the  third  year.  All 
varieties  of  bread  may  be  allowed  wheff  stale — i.  e.,  two  or  three  days  old ; 
also  dried  bread,  zwieback,  and  oatmeal  or  gluten  crackers. 

Desserts. — ^The  only  ones  besides  cooked  fruits  that  should  be  allowed 
up  to  the  sixth  year  are  junket,  plain  custard,  rice  pudding  without 
raisins,  and,  not  oftener  than  once  a  week,  ice  cream.  Of  the  last  three, 
the  quantity  given  should  be  very  moderate. 

Fruits. — Some  fruit  should  be  given  to  most  healthy  children  every 
day.  Oranges,  baked  apples,  and  stewed  prunes  are  the  most  to  be 
depended  upon.  Eaw  apples  shojild  not  be  given  in  most  cases.  Peaches, 
pears,  and  grapes  (with  seeds  removed)  may  be  given  when  thoroughly 
ripe  and  fresh,  but  only  in  moderate  quantity.  The  piilpy  fruits  should 
be  given  to  young  children  only  when  cooked.  Much  indigestion  is  pro- 
duced by  too  much  fruit  or  improper  fruits.  Special  care  should  be 
exercised  in  the  use  of  fruits  in  very  hot  weather,  and  in  cities  where 
they  may  not  always  be  fresh.  The  juice  of  fresh  berries  may  be  given 
in  the  second  year ;  but  the  whole  fruit  should  be  very  sparingly  given  to 
all  young  children,  and  always  without  cream. 

Articles  Forbidden. — The  following  articles  should  not  be  allowed 
children  under  four  years  of  age,  and  with  few  exceptions  they  may  be 
withheld  with  advantage  up  to  the  seventh  year : 

Meats. — Ham,  sausage,  pork  in  all  forms,  salt  fish,  corned  beef,  dried 
beef,  goose,  duck,  game,  kidney,  liver,  meat  stews,  meat  dressings  and 
cold  meats. 

Vegetables. — Fried  vegetables  of  all  varieties,  cabbage,  raw  or  fried 


214  NUTRITION 

onions,  raw  celery,  radishes,  lettuce,  cucumbers,  tomatoes  (raw  or 
cooked),  beets  (unless  they  are  very  small  and  quite  fresh),  egg-plant, 
and  green  corn. 

Bread  and  Cahe. — All  hot  bread  and  rolls;  buckwheat  and  all  other 
griddle  cakes;  all  fresh  sweet  cakes,  particularly  those  containing  dried 
fruits  and  those  heavily  iced. 

Desserts. — All  nuts,  candies,  pies,  tarts,  and  pastry  of  every  descrip- 
tion; also  all  salads,  jellies,  syrups,  and  preserves. 

Drink's. — Tea,  coffee,  wine,  beer,  cider,  and  soda  water. 

Fruits. — All  dried  fruits;  bananas,  unless  baked;  all  fruits  out  of 
season  and  stale  fruits,  particularly  in  summer. 

From  the  third  to  the  sixth  year  four  meals  sliould  usually  be  given 
daily  and  at  regular  intervals — e.  g.,  7  and  10.30  a.m.  ;  1.30  and  6  p.m. 
The  second  meal  should  be  a  small  one. 

There  are  a  few  simple  rules  in  feeding  which  should  always  be  fol- 
lowed :  A  child  should  be  taught  to  eat  slowly  and  thoroughly  masticate 
his  food.  The  food  must  always  be  very  finely  divided,  for  mastication 
is  very  imperfect  even  up  to  the  sixth  or  seventh  year.  It  is  unwise 
continually  to  urge  children  to  eat  when  they  are  disinclined  to  do  so 
at  the  regular  hours  of  meals,  or  when  tlie  appetite  is  habitually  poor, 
and  in  no  circumstances  should  children  be  forced  to  eat.  Indigesti- 
ble articles  of  food  should  not  be  given  to  tempt  the  appetite  when  ordi- 
nary simple  food  is  refused.  Food  should  not  be  allowed  between  meals 
when  it  is  habitually  declined  at  meal-time.  If  a  child  refuses  to  eat, 
and  examination  reveals  no  fault  with  the  food  prepared,  it  should  sel- 
dom be  offered  again  until  the  next  feeding  time.  In  all  cases  of  tem- 
porary indisposition,  no  matter  of  what  nature,  and  during  periods  of 
excessive  heat  in  summer,  the  amount  of  solid  food  should  be  reduced 
and  more  water  given.    If  milk  is  the  food,  it  should  be  diluted. 


FEEDING   DURING   ACUTE   ILLNESS 

Infants. — Feeding  is  an  important  part  of  the  treatment  of  every 
acute  disease  in  childhood,  but  especially  so  in  infancy.  Unless  the  ill- 
ness is  due  to  disease  of  the  digestive  tract,  all  cases  must  be  fed  in  about 
the  same  way.  It  is  much  easier  by  proper  feeding  to  prevent  disturb- 
ances of  digestion  than  to  allay  them.  In  infancy  this  complication  often 
turns  the  scale  against  the  patient.  In  every  severe  acute  illness,  espe- 
cially if  it  is  of  a  febrile  character,  the  power  of  digestion  is  much  dimin- 
ished. One  evidence  of  this  is  the  onset  with  vomiting;  another  is  the 
anorexia  which  accompanies  the  early  stage  of  nearly  all  -acute  diseases. 
We  should  respect  this  disinclination  and  make  it  our  guide  in  the  treat- 


FEEDING  DURTNG  ACUTE  ILLNESS  215 

ment.  But  water  is  needed;  withholding  this  will  often  cause  the  teni- 
perature  to  rise  even  higher  than  before. 

In  all  acute  febrile  diseases  the  general  rule  should  be,  less  food  and 
more  water  than  in  health.  For  bottle-fed  infants  this  is  easily  accom- 
plished by  simply  increasing  the  dilution  of  the  food ;  for  nursing  infants 
by  making  the  nursing  time  shorter  and  giving  water  freely  between 
feedings  either  from  a  spoon  or  bottle.  During  febrile  conditions,  fat, 
especially,  is  badly  borne,  and  this  should  therefore  be  reduced  more  than 
the  other  elements  of  the  food.  The  diet  should  consist  largely  of  carbo- 
hydrates. 

Eegularity  in  feeding  is  too  often  entirely  ignored.  While  it  is  true 
that  with  some  capricious  children  all  rules  must  be  disregarded,  it  is 
with  the  great  majority  a  decided  advantage  to  adhere  to  proper  food 
and  regular  intervals.  Food  should  never  be  given  at  less  than  three- 
hour  intervals,  although  there  is  no  limit  to  the  frequency  with  which 
water  may  be  given,  and  unless  the  stomach  is  irritable,  almost  no  limit 
as  to  quantity.  Stimulants,  when  required,  are  often  best  given  hi  a 
very  dilute  form  with  the  water. 

Forced  Feeding — Gavage. — Not  a  few  cases,  however,  are  seen  in 
which,  after  a  child  has  been  several  days  sick,  in  consequence  of  delirium, 
stupor,  sepsis,  or  some  other  serious  condition,  he  may  refuse  all  food  or 
take  so  little  that  he  is  in  danger  of  death  from  inanition.  At  this  junc- 
ture forced  feeding  or  gavage  serves  an  excellent  purpose.  Both  food 
and  stimulants  can  thus  be  introduced  at  regular  intervals  with  slight 
disturbance,  and  lives  saved  which  would  otherwise  be  lost.  If  gavage 
is  employed,  the  stomach  should  be  washed  at  least  twice  a  day.  The 
intervals  of  feeding  should  be  made  at  least  one  hour  longer  than  is  cus- 
tomary in  health.    Forced  feeding  is  not  applieal)]e  to  chronic  conditions. 

Older  Children. — The  same  conditions  with  reference  to  digestion 
exist  as  in  the  case  of  infants.  Older  patients,  however,  are  not  so  easily 
disturbed,  and  the  disturbance  of  digestion  is  not  so  likely  to  be  serious 
as  in  the  case  of  infants.  Even  here  the  physician  should  direct  the  food 
to  be  given  at  regular  intervals,  not  oftener  than  every  three  hours, 
and  should  never — as  is  so  often  done — order  that  milk  be  given  the 
child  every  time  he  asks  for  a  drink.  In  most  cases,  for  children  under 
five  years  old,  milk  should  be  somewhat  diluted.  Children  who  do 
not  take  milk  readily  may  be  given  beef  tea,  broth,  gruel,  thin  custard, 
or  kumyss,  and  occasionally  plain  ice  cream,  but  this,  if  given  in  any 
considerable  quantity  or  very  often,  is  likely  to  disturb  the  stomach  and 
take  away  what  little  desire  for  food  the  child  may  have.  Eaw  eggs  are 
palatable  when  beaten  up  with  a  little  sherry,  sugar,  and  cracked  ice. 
Fruits,  especially  orange  and  grape  juice,  may  be  allowed  in  almost  every 
febrile  disease,  but  not  given  within  two  hours  of  a  milk  feeding. 


216  NUTRITIO?^ 

The  water  given  may  be  plain  boiled  water,  but  often  better,  are  some 
of  the  carbonated  waters,  Vichy,  Seltzer,  or  i^pollinaris,  these  being  less 
likely  to  disturb  the  stomach. 

It  is  certainly  a  mistake  to  force  food  upon  older  children  in  any 
disease  in  which  their  condition  is  not  dangerous.  But  when  there  is 
sepsis,  delirium,  or  coma  associated  with  other  dangerous  symptoms, 
gavage  may  be  resorted  to  with  but  little  more  difficulty,  and  with  no  less 
satisfactory  results,  than  in  infants. 


IDIOSYNCRASIES  TO   FOODSTUFFS 

It  is  only  in  recent  years  that  there  has  been  demonstrated  an  idiosyn- 
crasy on  the  part  of  some  children  to  certain  foodstuffs,  in  all  probability 
to  the  protein  of  the  foodstuffs  and  to  this  alone. 

The  most  conspicuous  example  is  the  proteins  of  egg.  Some  children 
are  so  sensitive  to  egg  proteins  that  the  most  minute  quantity  taken  inter- 
nally or  even  applied  locally  to  an  abraded  skin  will  produce  the  most 
marked  symptoms.  The  local  symptoms,  if  taken  by  mouth,  are  a  burn- 
ing sensation  of  the  mucous  membranes  followed  ]jy  marked  congestion 
and  swelling,  which  is  sometimes  so  severe  as  to  suggest  that  an  irritant 
poison  has  been  swallowed.  The  general  symptoms  which  follow  almost 
immediately  include  persistent  vomiting,  profuse  diarrhea  and  marked 
prostration.  These  are  often  threatening  and  may  be  serious,  although 
they  usually  last  but  a  few  hours.  With  these  severe  cases  a  marked 
eosinophil ia  is  often  present.  Xot  only  may  there  be  symptoms  referable 
to  the  gastro-intestinal  tract  but  sometimes  dyspnea  which  resembles  an 
attack  of  spasmodic  asthma.  The  above  symptoms  represent  the  more 
severe  form  of  this  susceptibility.  There  is  a  much  larger  number  of  chil- 
dren who  show  this  sensitiveness  in  a  milder  form,  often  only  by  repeated 
attacks  of  vomiting  after  the  ingestion  of  egg.  Such  a  susceptibility  is 
frequently  lost  during  childhood  but  may  persist  to  adult  life  to  such  a 
degree  that  the  most  minute  quantity  of  egg  taken  in  any  form  whatever 
is  immediately  followed  by  a  disturbance. 

Very  much  less  frequently  similar  symptoms  may  follow  the  ingestion 
of  cow's  milk.  We  have  seen  two  infants  in  whom  less  than  ten  drops  of 
fresh  cow's  milk  produced  symptoms  of  a  severe  form.  Such  a  con- 
dition, however,  is  extremely  rare,  and  to  attribute  to  milk  idiosyncrasy 
the  common  disturbances  incident  to  artificial  feeding  is  quite  improper. 

In  older  children  a  similar  sensitiveness  is  seen  to  certain  cereals, 
particularly  to  oatmeal  and  buckwheat,  and  also  to  certain  nuts,  especially 
almonds  and  walnuts.  In  still  others  an  extraordinary  sensitiveness  to 
fruits,  usually  raw  fruits,  is  seen.     The  most  frequent  example  is  the 


ACIDOSIS  217 

familiar  susceptibility  to  strawberries,  less  often  it  may  be  to  raw  apples. 
Ill  most  cases  the  disturbance  amounts  only  to  an  attack  of  urticaria. 
Occasionally  in  the  more  susceptible  the  digestive  disturbances  above 
noted  are  also  present.  Similarly,  but  less  frequently,  other  raw  fruits, 
grape  fruit,  oranges  and  bananas,  may  cause  symptoms.  Certain  shell 
fish,  such  as  crabs,  oysters,  etc.,  may  produce  similar  symptoms. 

From  clinical  observation  alone  many  erroneous  conclusions  are  apt 
to  be  drawn.  The  absolute  proof  of  such  sensitiveness,  as  has  been  indi- 
cated, is  afforded  by  the  cutaneous  reaction  which  follows  the  application 
of  the  protein  of  any  of  the  substances  mentioned.  The  application  of 
such  tests  is  a  matter  of  somewhat  difficult  technic  and  its  use  is  only 
possible  in  the  hands  of  a  trained  observer. 

ACIDOSIS 

For  the  preservation  of  health  it  is  necessary  that  the  body  should 
always  contain  an  excess  of  bases,  in  order  to  maintain  that  degree  of 
alkalinity  in  the  fluids  of  the  body  with  which  the  various  functions  are 
carried  on  to  the  best  advantage.  This  degree  of  alkalinity  is  maintained 
under  normal  conditions  with  wonderful  constancy  even  though  there  is 
a  continuous  elaboration  of  acids  such  as  sulphuric,  phosphoric  and  car- 
bonic in  the  organism.  The  acids  are  neutralized  and  removed  from  the 
body  by  a  three-fold  mechanism : 

1.  Carbon  dioxid  is  given  off  from  the  lungs. 

2.  The  kidneys  are  able  to  excrete  an  acid  urine  from  a  slightly 
alkaline  blood.  The  alkali  spared  is  available  to  neutralize  more  acid 
or  to  assist  in  the  renewal  of  the  alkali  reserve  of  the  body. 

3.  Ammonia  is  formed  which  is  capable  of  neutralizing  acid.  The 
ammonia  is  formed  at  the  expense  of  urea,  a  neutral  substance,  and  thus 
represents  a  clear  gain  of  alkali  for  the  body. 

There  is  a  normal  preponderance  of  alkali  over  acid  in  the  fluids  of 
the  organism.  This  depends  upon  the  maintenance  of  an  alkaline  reserve, 
very  largely  bicarbonates,  which  is  found  in  the  blood,  tissue  juices  and 
cells  of  the  body.  So  long  as  the  eliminating  mechanism  for  the  excre- 
tion of  acids  is  preserved  the  alkaline  reserve  is  not  affected,  even  though 
the  production  of  acids  may  be  greatly  increased.  When  acids  are  pro- 
duced in  excess  or  their  elimination  is  interfered  with,  the  normal  pre- 
ponderance of  liases  over  acids  is  disturbed  and  acidosis  results. 

It  is  apparent  that  acids  such  as  those  of  the  acetone  series  may  be 
formed  in  the  body  in  considerable  amount  and  yet  be  excreted  without 
affecting  the  alkaline  reserve.  The  acids  are  neutralized  by  alkalies  that 
can  be  replaced  by  those  of  the  food  or  by  ammonia.  Under  such  condi- 
tions there  is  no  acidosis.    When  the  production  of  acids  is  so  great  that 


218  NUTRITION 

they  cannot  be  neutralized  without  diminishing  the  reserve  of  alkali, 
acidosis  may  be  said  to  be  present.  The  dividing  line  between  the  two 
conditions  is  a  very  narrow  one. 

Acidosis  may  result  from  the  production  in  excess  of  acids  that  are 
present  in  small  amount  in  normal  metabolism,  such  as  aceto-acetic  and 
/3  oxybutyric  acids.  These  acids  are  not  directly  poisonous  but  produce 
their  injurious  effect  by  depriving  the  body  of  alkali.  They  are  present 
chiefly  in  diabetes  and  cyclic  vomiting. 

Acidosis  presumably  may  result  from  the  failure  to  excrete  acids 
formed  only  in  normal  amount.  It  is  conceivable,  but  not  yet  proven, 
that  acidosis  may  result  from  the  abnormal  loss  of  bases. 

The  means  for  the  detection  of  acidosis  are  chiefly  those  that  deter- 
mine a  diminution  in  the  bicarbonate  or  in  the  total  alkaline  reserve  of 
the  blood,  among  which  may  be  included  the  determination  of  the  carbon 
dioxid  in  the  alveolar  air,  a  change  in  the  reaction  of  the  blood,  the 
presence  of  acids  (such  as  those  of  the  acetone  series)  in  excess  in  the 
blood  or  urine,  an  increased  tolerance  for  alkalies,  or  an  increased  am- 
monia in  the  urine  which  is  evidence  of  the  attempt  to  neutralize  an 
excess  of  acids. 

The  methods  of  treatment  are  discussed  under  those  diseases  in  which 
acidosis  is  found. 


CHAPTEE  V 

THE  DERANGEMENTS   OF   NUTRITION 

Inanition — Marasmus — Malnutrition 

The  derangements  of  nutrition,  especially  those  accompanied  by  a 
loss  of  weight,  form  a  distinct  and  a  very  large  class  in  the  ailments  of 
infancy,  particularly  during  the  first  year.  The  symptoms  are  often 
definite  and  characteristic,  and  for  this  reason  have  frequently  been  con- 
sidered and  discussed  as  separate  diseases.  They  are  rather  the  result 
of  several  different  factors  and  usually  represent  terminal  stages  of  func- 
tional or  organic  disease.  In  adults  such  symptoms  are  usually  seen 
in  connection  with  organic  disease.  These  cases  are  often  very  puz- 
zling, and  in  a  large  number  of  them  a  diagnosis  of  some  constitu- 
tional disease,  such  as  hereditary  syphilis,  or  tuberculosis,  or  organic 
disease  of  the  stomach  or  intestines,  is  erroneously  made.  The  essential 
condition  in  all  these  cases  is  the  inability  of  the  infant  to  get  from  his 
food  what  his  system  needs.  He  can  not  digest  or  assimilate  enough  to 
support  life.     He  is  unable  to  replace  from  his  food  the  daily  waste  of 


ACUTE  INANITION  219 

his  tissues.     The  constructive  metaholism  is  iuiperfecl  ;  tlie  process  is, 
therefore,  essentially  one  of  starvation,  which   may   be   rapid  or  slow, 
according  to  circumstances. 

The  fault  in  these  cases  may  be  with  the  constitution  of  the  child, 
with  the  organs  of  digestion,  or,  what  is  more  generally  the  case,  with 
the  food.  The  pToblem  is  to  adapt  the  food  to  the  individual  child 
under  consideration.  The  solution  is  often  very  easy  at  first,  but  the 
difficulties  multiply  rapidly  the  longer  the  condition  has  lasted.  It  is 
therefore  essential  that  the  true  explanation  of  the  symptoms  should  be 
recognized  at  the  earliest  possible  moment.  Changes  occur  so  rapidly  in 
very  young  infants  that  a  mistake  in  diagnosis  and  a  consequent  delay 
of  a  few  days  may  be  sufficient  to  determine  a  fatal  result.  The  outcome 
in  cases  of  imperfect  nutrition  depends  almost  entirely  upon  their  man- 
agement. The  condition  is  not  one  which  tends  to  right  itself.  Spon- 
taneous improvement  or  recovery  rarely  takes  place.  JSTot  only  is  careful 
observation  of  the  child  and  his  symptoms  important  but  also  close  atten- 
tion to  the  body  weight.  A  child  whose  nutrition  is  a  matter  of  diffi- 
culty should  be  weighed  regularly,  in  the  early  months  at  least  twice  a 
week,  and  once  a  week  throughout  the  first  year.  If  this  is  done,  the  first 
signs  of  failing  nutrition  are  unerringly  ^detected.  If  an  infant  does  not 
gain  in  weight  something  is  wrong ;  a  steady  loss  in  weight  is  a  warning 
which  should  never  pass  unheeded ;  for,  unless  the  conditions  are  changed, 
it  is  practically  certain  to  continue,  and  generally  with  increasing  rapid- 
ity until  the  vitality  has  been  reduced  to  such  a  point  that  no  means 
of  treatment  can  restore  it.  The  younger  the  child  the  more  rapid  the 
loss,  and  the  longer  it  has  continued  the  greater  is  the  danger. 

Acute  Inanition. — Eapid  loss  of  weight,  frequently  spoken  of  as  acute 
inanition,  is  common  in  early  infancy,  when  it  often  simulates  serious 
organic  disease.  In  older  children  it  is  not  frequent,  and  usually  is 
dependent  upon  some  obvious  cause.  In  all  the  acute  diseases  of  the 
digestive  tract  many  of  the  symptoms  are  due  to  inanition.  The  obscure 
cases  are  those  in  which  the  digestive  symptoms,  strictly  speaking,  are 
not  prominent. 

The  rapid  loss  of  weight  usually  takes  place  under  one  of  the  follow- 
ing conditions:  (1)  When  a  child  refuses  all  food,  whether  from  the 
breast  or  the  bottle,  or  can  be  made  to  take  only  an  insignificant  amount. 
The  cause  of  this  it  is  often  impossible  to  discover.  Symptoms  of  inani- 
tion are  sometimes  seen  at  weaning,  when  a  child  persistently  refuses  to 
take  food  from  a  bottle  or  spoon.  (2)  When  the  food  given  is  entirely 
inadequate,  as  when  an  infant  is  nursing  upon  a  dry  breast,  or  one  in 
which  the  milk  supply  is  so  scanty  that  the  child  gets  practically  nothing. 
It  is  occasionally  seen  later,  when  the  breast-milk,  for  some  unexplained 
reason,  suddenly  fails.     {?>)  When  tlie  character  of  the  food  is  improper. 


V 


220  NUTRITION 

On  account  of  extreme  poverty,  the  infant  may  be  getting  only  tea  or 
toast  soaked  in  water  or  albumin  water.  It  may  occur  in  young  infants 
who  are  fed  entirely  on  starchy  foods.  (4)  When  the  infant  at  birth 
has  such  feeble  powers  of  digestion,  because  premature  or  delicate,  that 
he  is  imable  to  take  or  to  digest  sufficient  food  to  maintain  life.  (5) 
\^Tien  a  sudden  change  of  food  is  made  to  one  so  difficult  of  dige.stion 
that  the  child  is  unable  to  assimilate  it.  This  may  happen  after  sudden 
weaning.  In  such  cases  the  symptoms  of  inanition  are  mingled  witli 
those  of  acute  indigestion,  but  the  former  usually  predominate. 

The  mode  of  development  depends  upon  the  antecedent  condition. 
In  young  infants  acute  inanition  often  follows  malnutrition,  when  per- 
haps there  has  been  nothing  noticeable  except  a  gradual  loss  in  weight; 
or,  if  the  weight  has  not  been  watched,  it  may  be  observed  only  that  the 
infant  has  not  been  doing  well.  Severe  symptoms  may  come  on  quite 
suddenly,  and  if  the  nature  and  the  gravity  of  the  condition  are  not 
appreciated  the  case  may  terminate  fatally  in  two  or  three  days.  The 
loss  in  weight  is  rapid,  amounting  often  to  three  or  four  ounces  a  day. 
The  temperature  in  the  newly-born  may  be  high,  but  it  is  more  often 
subnormal.  The  pulse  is  weak  and  may  be  rapid,  but  is  at  times  very 
slow.  The  heart  sounds  are  feeble.  The  urine  is  scanty.  The  extrem- 
ities are  cold,  and  the  peripheral  circulation  poor.  There  is  usually  com- 
plete muscular  relaxation.  This  is  especially  marked  in  the  abdomen 
where  the  muscles  almost  entirely  lose  their  tone.  The  skin  may  be  dry 
or  covered  with  a  clammy  perspiration.  There  is  extreme  pallor,  and 
often  a  peculiar  bluish-gray  color  to  the  face.  This  is  always  a  grave 
symptom.  Cyanosis  may  be  present  in  children  who  have  previously 
cried  well  and  in  whom  there  is  no  suspicion  of  atelectasis.  The  respira- 
tions are  rapid  and  may  be  irregular.  There  may  be  constant  worrying 
and  fretfulness,  or  a  condition  of  semi-stupor,  in  Avhich  the  child  makes 
no  sign  of  wanting  food.  The  fontanel  is  sunken  and  the  pupils  are 
contracted.  The  bowels  usually  move  frequently,  although  there  may  be 
constipation,  due  to  the  small  amount  of  food  taken.  When  no  food  is 
taken  for  two  or  three  days  the  stools  may  resemble  meconium. 

The  progress  depends  much  upon  the  age  of  the  infants.  Those  under 
one  month  usually  succumb  quickly.  In  them  the  symptoms  sometimes 
last  but  a  few  days,  seldom  more  than  a  week  or  two.  The  development 
of  such  symptoms  in  a  young  infant  is  a  very  serious  sign.  In  older 
infants  the  progress  downward  is  usually  less  rapid. 

The  outcome  of  such  cases  is,  however,  always  uncertain,  but  with 
proper  treatment  many  may  be  saved.  It  is  hard  for  one  who  is  not 
familiar  with  the  condition  to  appreciate  the  great  and  even  the  immedi- 
ate danger  in  which  a  young  infant  may  be  from  inanition,  notwithstand- 
ins:  the  absence  of  both  vomiting  and  diarrhea.     The  treatment  must  be 


MARASMUS  221 

immediate  and  energetic.  Breast  milk  is  essential.  There  is  no  oppor- 
tunity to  experiment  with  artificial,  feeding.  No  food  can  be  given  if 
there  is  vomiting  or  severe  diarrhea,  but  in  the  absence  of  these  breast 
milk  may  be  given  by  gavage  if  necessary.  The  intervals  should  be 
long — at  least  four  hours.  In  the  event  of  no  vomiting  but  diarrhea,  but- 
termilk may  be  given,  alternating  with  the  breast  milk.  If  it  is  impossi- 
ble to  obtain  breast  milk,  buttermilk  is  probably  the  best  form  of  diet 
unless  the  child  is  over  three  months  of  age,  when  feeding  with  protein 
milk  may  be  attempted.  Eectal  feeding  is  of  no  avail.  Often  the  symp- 
toms are  largely  due  to  a  lack  of  water.  Injections  of  a  normal  salt  solu- 
tion should  be  given  per  rectum  or  under  the  skin.  Hypodermoclysis  is 
often  of  great  value.  Absorption  is  usually  prompt.  The  rapidity  with 
which  shrivelled  tissues  will  drink  up  water  is  astonishing.  ISTormal  saline 
solution  should  be  employed  in  amounts  from  150  to  240  c.c.  once  or  twice 
a  day.  This  may  be  repeated  for  several  days.  While  the  improvement 
following  hypodermoclysis  is  frequently  marked,  it  must  be  remembered 
that  the  effect  is  only  temporary.  Unless  proper  food  is  retained  and 
absorbed  or  the  digestion  improves,  the  conditions  are  soon  as  bad  as 
ever  and  subsequent  injections  produce  less  and  less  effect.  Saline  solu- 
tion may  be  given  by  the  drop  method  into  the  rectum.  This  method  is 
seldom  satisfactory.  Transfusion,  by  the  direct  or  indirect  method,  may 
be  life-saving.  Energetic  stimulation  by  caffein  or  camphor,  hypoder- 
mically,  is  indicated.  Except  for  the  stimulants,  drugs  are  of  no  use 
whatever. 

Marasmus. — Gradual  and  progressive  loss  of  weight,  wasting,  is  a 
symptom  of  many  conditions  in  infancy.  It  occurs  in  tuberculosis,  in 
infantile  syphilis,  and  also. as  a  result  of  obvious  disturbance  of  the  gastro- 
intestinal tract.  At  times,  however,  it  appears  to  be  a  vice  of  nutrition 
only  and  develops,  so  far  as  can  be  made  out,  without  general  or  local 
organic  disease.  To  this  type  the  names  of  Marasmus,  Infantile  Atropliy 
and  8im/ple  Wasting  have  been  applied. 

This  condition  is  not  very  often  seen,  in  the  country  or  in  private 
practice;  but  it  is  frequent  in  dispensary  practice  in  all  large  cities,  a.nd 
is  especially  common  in  institutions  for  young  infants.  In  such  institu- 
tions, fully  half  the  deaths  under  one  year  are  directly  or  indirectly  from 
this  cause.  It  is  a  very  large  factor  in  the  immense  infant  mortality  of 
large  cities  in  summer.  Although  the  cause  of  death  is  usually  reported 
under  some  other  name,  the  determining  factor  in  the  fatal  result  is  the 
previous  marantic  condition  of  the  patient.  The  primary  cause  may  be 
a  congenital  weakness  of  constitution  which  may  depend  upon  heredity. 
It  is  often  seen  in  premature  children.  In  the  vast  majority  of  cases,  how- 
ever, it  depends  upon  two  factors — the  food  and  the  surroundings. 
Among  the  poor  who  live  in  tenements,  many  artificially-fed  infants  do 
9 


222  jSTuTPvITION 

very  badly.  This  is  clue  to  neglect,  to  ignorance  in  regard  to  proper 
infant  feeding  and  inability  to  procure  what  the  child  reqviires,  especially 
pure  cow's  milk.  A  country  infant  may  be  neglected  in  many  respects, 
and  is  often  badly  fed ;  but  he  has  plenty  of  pure  air,  and  usually  thrives. 
In  the  city,  as  long  as  an  infant  has  a  plentiful  supply  of  good  breast-milk 
he  continues  to  do  well  in  most  instances,  in  spite  of  the  fact  that  his 
surroundings  are  bad.  When  there  are  not  only  bad  feeding  and  un- 
healthful  surroundings,  but  also  an  inherited  constitutional  vice,  we  have 
all  the  factors  required  to  produce  marasmus  in  its  most  marked  form. 
The  odds  are  so  against  the  infant  that  the  feeble  spark  of  vitality  flickers 
for  a  few  months  only  and  gradually  goes  out. 

Another  prominent  factor  in  the  production  of  marasmus  is  the  over- 
crowding and  lack  of  individual  care  of  infants  in  institutions.  Even 
though  artificially  fed  in  an  intelligent  manner,  many  infants  who  are 
plump  and  healthy  on  admission,  lose  little  by  little,  until  at  the  end  of 
three  or  four  months  they  become  wasted  to  skeletons,  dying  of  some 
mild  acute  illness,  such  as  an  attack  of  bronchitis,  the  essential  cause, 
however,  being  marasmus.  The  common  mistake  is  that  of  placing  too 
many  children  in  one  ward  with  no  chance  of  obtaining  a  proper  amount 
of  fresh  air  and  with  too  little  individual  attention.  No  house-plant  is 
more  delicate  or  sensitive  to  its  surroundings  than  is  an  infant  during  the 
first  few  months  of  life. 

The  post-mortem  findings  in  such  cases  are  exceedingly  unsatisfac- 
tory, and  throw  little  if  any  light  upon  the  cause  of  death.  Every  now 
and  then  general  tuberculosis  is  discovered  in  patients  dying  apparently 
of  marasmus,  the  existence  of  which  was  not  previously  suspected.  An 
occasional  lesion  is  fatty  liver.  This  may  lead  to  such  enlargement  of 
the  organ  that  its  weight  is  increased  by  one-half.  Both  to  the  naked  eye 
and  under  the  microscope  the  usual  changes  of  fatty  infiltration  are  pres- 
ent, often  to  an  extrieme  degree.  In  the  past  too  much  has  doubtless  been 
made  of  this  condition  of  the  liver  in  marasmus.  From  figures  given 
elsewhere  (see  article  on  Fatty  Liver),  it  will  be  observed  that  the  lesion 
is  not  more  frequent  in  this  condition  than  in  infants  dying  from  other 
diseases.  Its  exact  relation  to  the  condition  of  wasting  has  not  yet  been 
determined. 

With  these  exceptions  the  autopsies  show  nothing  striking.  In  the 
stomach  and  intestines  there  is  nothing  of  pathological  importance.  The 
theory  advanced,  that  atrophy  of  the  intestinal  tubules  is  tlie  explanation 
of  marasmus,  has  found  little  support. 

The  condition  seems  rather  to  be  a  failure  of  assimilation,  owing  to 
imperfect  digestion,  improper  food,  unhygienic  surroundings,  or  feeble 
constitution.  As  a  result,  there  is  a  progressive  loss  in  weight,  feeble 
circulation,  imperfect  lung  expansion,  lowered  body  temperatnre,  and. 


MARASMUS 


223 


filially,   a   condition  incompatible  with  life,  for   resistance  becomes  so 
feeble  that  the  slightest  functional  disturbance  proves  fatal. 

The  general  history  of  these  cases  is  strikingly  uniform.  The  follow- 
ing is  the  story  most  frequently  told  at  the  hospital :  "At  birth  the  baby 
was  plump  and  well  nourished,  and  continued  to  thrive  for  a  mouth  or 
six  weeks  while  the  mother  was  nursing  him ;  at  the  end  of  that  period 


Fig.  18.- 


-Marasmtjs;  a  Patient  in  the  Babies'  Hospital,  Ten  Months  Old,  Weight 
Six  Pounds.     Weight  at  birth  reported  to  have  been  nine  pounds. 


circumstauces  made  weaning  necessary.  From  that  time  the  child  ceased 
to  thrive.  He  began  to  lose  weight  and  strength,  at  first  slowly,  then 
rapidly,  in  spite  of  the  fact  that  every  known  form  of  infant-food  was 
tried."  As  a  last  resort  the  child,  wasted  to  a  skeleton,  is  brought  to  the 
hospital. 

The  most  constant  symptom  is  a  steady  loss  in  weight  until  a  condi- 
tion of  extreme  wasting  is  reached,  at  which  point  these  patients  may 


224  NUT^RITION 

remain  for  many  weeks.  Their  general  appearance  is  characteristic. 
They  have  an  old  look ;  the  skin  is  wrinkled,  has  lost  its  tone,  and  hangs 
in  folds  upon  the  extremities  (Fig.  18).  The  legs  are  like  drumsticks; 
the  abdomen  is  prominent;  the  temples  are  hollow;  the  fontanel  is 
sunken ;  the  eyes  large ;  the  features  sharp ;  and  the  hands  resemble  bird- 
claws.  Often  the  children  are  reduced  literally  to  skin  and  bones. 
Anemia  is  a  very  marked  and  almost  constant  symptom.  Accidental  heart- 
murmurs  are  frequently  heard.  The  body  temperature  is  usually  sub- 
normal unless  artificial  heat  is  employed.  A  rectal  temperature  of  95° 
or  96°  F.  is  very  common,  and  one  of  93°  or  94°  F.  is  occasionally  seen. 
In  addition  to  the  pallor  of  the  face,  there  may  be  a  leaden  hue. 

A  not  infrequent  symptom  is  general  edema.  The  first  thing  which 
calls  attention  to  this  is  often. an  unexpected  gain  in  weight  which  may 
amount  to  several  ounces  a  day.  The  edema  may  increase  until  the 
cellular  tissue  of  the  entire  body  is  water-logged.  There  are  not,  how- 
ever, effusions  into  the  large  serous  cavities.  The  exact  pathology  of  this 
nutritional  edema  is  not  clear.  It  is  of  quite  frequent  occurrence  in  cases 
of  marasmus,  esj)ecially  in  infants  under  six  months  of  age.  It  seems 
impossible  to  connect  it  with  any  definite  form  of  feeding.  Thus,  we 
have  seen  it  in  infants  kept  for  a  long  time  upon  barley  water,  in  others 
who  were  receiving  nothing  but  condensed  milk,  in  still  others  who  were 
taking  a  milk  formula  apparently  of  suitable  proportions.  The  urine  in 
the  marked  cases  shows  neither  albumin,  nor  casts,  but  usually  an  almost 
complete  absence  of  chlorids.  Coincidentally  with  the  disappearance  of 
the  edema  the  chlorids  appear  in  the  urine,  showing  a  close  association 
between  the  retention  of  chlorids  and  the  retention  of  water  in  the  tissues. 
Thus,  in  one  case  at  the  height  of  the  edema  the  child  was  eliminating 
but  .008  gram  of  sodium  chlorid  daily ;  three  days  afterwards,  while  the 
dropsy  was  rapidly  disappearing,  the  amount  exceeded  .5  gram.  In  the 
treatment  of  this  condition  the  most  satisfactory  food  in  our  experience 
has  been  protein  milk.  Whether  this  is  due  to  its  low  sodium  chlorid 
content  or  not  it  is  impossible  to  say.  The  administration. by  mouth  of 
digitalis  has  seemed  also  advantageous.  An  infant  of  three  or  four 
months  can  take  half  a  dram  of  the  infusion  three  or  four  times  daily. 

The  stools  are  sometimes  normal,  but  usually  contain  undigested  food- 
with  mucus.    Xo  matter  how  carefully  fed,  these  patients  are  easily  upset. 
Vomiting  is  readily  excited.     The  appetite  in  many  is  almost  entirely 
lost;  others  take  their  food  quite  well  and  have  fairly  good  stools  but 
steadily  lose  weight. 

Frequent  complications  are  thrush  and  bedsores  which  are  sometimes 
seen  over  the  sacrum  or  heels,  but  most  frequently  upon  the  occiput. 
Occasionally  there  is  seen  a  reflex  spasm  of  the  muscles  of  the  neck,  pro- 
ducing a  marked  opisthotonus,  which  may  last  for  several  days  or  weeks. 


MARASMUS  225 

In  hospital  wards  these  infants  are  very  susceptible  to  all  infections,  par- 
ticularly to  those  of  the  respiratory  tract.  Otitis,  rhinopharyngitis,  bron- 
chitis and  pneumonia  are  especially  common. 

The  progress  in  most  cases  is  steadily  downward ;  but  it  may  be  cut 
short  at  any  time  by  acute  disease.  Frequently  these  infants  die  suddenly 
when  apparently  they  are  as  well  as  they  have  been  for  several  weeks.  In 
summer  they  wilt  with  the  first  days  of  very  hot  weather,  and  die  often 
in  a  few  hours  from  a  slight  functional  derangement  of  the  stomach  and 
bowels. 

The  symptoms  shown  by  some  infants  that  have  been  fed  for  a  long 
time  upon  a  diet  almost  exclusively  of  carbohydrates  merit  special  con- 
sideration. They  suffer  from  what  the  Germans  call  Melilndlirschaden. 
The  infants  may  have  received  proprietary  foods  or  cereal  decoctions 
in  order  to  overcome  diarrhea  or  because  milk  is  impossible  to  obtain, 
and  it  is  a  restriction  to  carbohydrates  for  a  long  time  that  causes  the 
characteristic  symptoms  to  develop.  For  a  while  they  may  hold  their 
weight  or  may  even  gain ;  before  long,  however,  they  begin  to  lose  weight 
and  the  loss  may  be  extreme.  There  is  in  some  instances  a  marked 
tendency  to  edema  which  may  mask  the  loss.    Pallor  is  striking. 

Of  especial  importance,  however,  are  a  peculiar  rigidity  of  the  mus- 
culature and  a  great  lessening  of  immunity  to  infection.  The  rigidity  is 
especially  marked  in  the  legs.  The  muscles  are  contracted  and  hard.  It 
is  difficult  to  extend  the  extremities.  In  severe  cases  opisthotonus  may 
develop.  The  diminution  in  the  resistance  to  infection  allows  of  the 
development  of  furuncles,  otitis,  bronchitis  and  infections  of  the  eyes. 
Especially  characteristic  is  keratomalacia  with  perforation  of  the  cornea 
and  destruction  of  one  or  both  eyes. 

The  condition  is  a  severe  one  and  is  frequently  fatal.  The  longer  it 
has  existed  the  worse  the  prognosis.  Infants  with  keratomalacia  seldom 
recover.  The  severity  of  the  condition  is  in  large  part  due  not  only  to 
the  insufficiency  of  the  food  as  a  whole,  but  to  the  almost  complete  absence 
of  fat,  protein  and  salts.  It  is  not  unlikely  that  vitamines  are  also  lack- 
ing. 

With  loss  of  weight  from  any  cause  the  older  the  child  the  better  the 
chances  of  recovery.  Very  young  infants  are  always  difficult  subjects  to 
deal  with.  They  go  down  more  rapidly  and  build  up  more  slowly  than 
those  who  are  older.  Much  depends  upon  whether  everything  possible 
can  be  done  for  the  child :  whether  a  wet-nurse  can  be  secured  and  whether 
the  patient  can  have  the  benefit  of  the  best  surroundings,  in  the  country 
in  summer  and  in  winter  a  warm  climate  where  he  can  be  kept  out  of 
doors  the  greater  part  of  the  time.  In  institutions  cases  in  infants  under 
four  months  old  are  usually  hopeless.  Of  those  over  eight  months  quite  a 
proportion  can  be  saved  by  proper  treatment,  even  though  the  body-weight 


226  NUTRITION 

is  reduced  to  eight  or  nine  pounds.  When  recovery  occurs  it  may  be 
complete,  and  the  child  at  two  or  three  years  may  be  as  vigoroijs  as  any 
child  of  his  age. 

The  most  important  treatment  is  that  whieli  relates  to  prophylaxis. 
Maternal  nursing  should  be  encouraged  by  every  possible  means  especially 
among  the  poor.  For  those  who  must  be  artificially  fed  the  important 
things  are  a  pure  milk  supply  together  with  proper  instruction  as  to  how 
it  is  to  be  used  in  infant  feeding.  At  the  same  time  opportunities  for 
fresh  air  should  be  secured.  This  is  a  large  part  of  the  difficulty  in 
institutions. 

As  far  as  possible,  wet-nurses  should  be  obtained  if  the  infants  are 
under  four  months  old.  For  these  very  young  patients  success  by  artifi- 
cial feeding  is  generally  impossible.  With  those  of  six  months  or  over, 
intelligent  artificial  feeding  is  very  frequently  successful.  In  iiistitutions 
we  seldom  succeed  without  at  least  partial  breast  feeding. 

For  very  young  infants,  with  a  temperature  which  is  habitually  sub- 
normal, some  means  of  maintaining  the  body  heat  must  be  emploA^ed. 
The  simplest  and  usually  an  effective  means  is  to  oil  the  body  and  envelop 
it  completely  in  a  cotton  jacket  and  then  surround  it  with  hot-water  bags 
or  bottles.  The  room  should  be  kept  warm.  In  institutions  it  is  con- 
venient to  have  a  warm  room  for  such  infants,  the  temperature  of  which 
is  kept  about  80°  F.  These  infants  require  no  drugs  but  a  great  deal 
of  careful  nursing. 

Malnutrition. — Failure  to  gain  properly  is  exceedingly  common 
among  young  children,  and  such  cases  occu])y  a  large  part  of  the  time  and 
attention  of  one  engaged  in  pediatric  practice.  The  term  malnutrition 
perhaps  characterizes  them  better  than  any  other.  Altliough  tbese  chil- 
dren can  not  be  said  to  be  actually  ill,  they  are  very  far  from  Avell,  and 
their  condition  is  often  the  cause  of  the  greatest  solicitude  on  tlie  part  of 
parents,  ]iot  only  from  the  existing  state  of  healtli,  but  from  tlie  appre- 
hension of  the  development  of  some  serious  organic  or  constitutional  dis- 
ease, especially  tuberculosis. 

Certain  children  are  delicate  from  birth,  possessing  only  feeble  vital- 
ity, though  without  giving  evidence  of  any  actual  disease.  They  are 
often  the  offspring  of  parents  of  delicate  constitution  and  poor  physical 
development,  or  of  those  with  tuberculosis,  gout,  or  syphilis.  Very  many 
city  children  are  included  in  this  group.  Among  the  poor  the  condition 
is  the  result  of  bad  hygiene,  insufficient  or  improper  food,  overcrowding, 
etc.  Among  the  well-to-do  it  is  seen  in  those  Avho  inherit  a  too  highly 
developed  nervous  organization  with  a  corresponding  amount  of  physical 
deterioration.  Another  group  includes  those  children  who  were  prema- 
ture or  very  small  at  birth,  weighing  perhaps  only  three  or  four  pounds. 
Many  cases  are  traceable  to  improper  feeding  or  equally  pool'  nursing 


MALNUTRITION  227 

during  the  first  few  months.  These  children  get  a  poor  start  in  life,  and 
on  that  account  are  handicapped  throughout  infancy.  A  frequent  cause 
of  malnutrition  in  infants  is  the  pernicious  custom  of  keeping  them  in 
close  apartments  where  the  thermometer  ranges  from  73°  to  75°  F.,  and 
where  the  greatest  anxiety  is  constantly  felt  lest  they  take  cold.  Such 
infants  may  lose  in  wieight,  become  anemic,  and  exhibit  all  the  signs  of 
malnutrition  when  nothing  else  is  wrong  except  tlie  conditions  men- 
tioned. Malnutrition  often  depends  upon  some  previous  acute  disease, 
especially  of  the  stomach  and  intestines. 

In  children  who  are  over  two  years  old  the  condition  of  malnutrition 
may  be  due  to  any  of  the  factors  above  mentioned — inherited  feebleness 
of  constitution,  bad  feeding  and  its  resulting  indigestion,  too  little  fresh 
air,  and  close  confinement  indoors.  It  is,  however,  at  this  period,  much 
more  frequently  than  in  infancy,  dependent  upon  some  previous  acute 
disease.  As  a  result,  an  impression  is  left  upon  the  child's  constitution 
which  lasts  for  months,  often  for  years,  and  which  manifests  itself  not 
by  any  special  local  symptoms,  but  by  a  general  condition  of  debility. 
Faulty  methods  in  education,  especially  overpressure  in  schools  may  have 
a  deleterious  effect  upon  the  health  of  older  children. 

Not  only  the  weight  but  the  genefal  physical  development  is  much 
below  the  normal.  At  one  year  the  body  length  may  be  three  or  four 
inches  less  than  the  average.  Dentition  may  not  be  materially  delayed. 
Muscular  development  is  backward;  many  of  these  children  do  not  sit 
alone  until  a  year  old,  and  barely  walk  at  two  and  a  half  or  three  years. 
The  muscles  are  soft  and  flabby,  and  the  ligaments  so  weak  that  paralysis 
is  often  suspected.  The  body  is  so  small  that  the  head  seems  unnaturally 
large,  and  a  diagnosis  of  incipient  hydrocephalus  is  frequently  made. 
Mentally  these  infants  are  somewhat  backward  but  the  mental  develop- 
ment is  often  strikingly  in  advance  of  the  physical.  Some  symptoms  of 
rickets  are  usually  present. 

The  examination  of  the  blood  reveals  the  usual  changes  of  a  moderate 
secondary  anemia.  The  circulation  is  poor,  the  hands  and  feet  are  fre- 
quently cold.  In  many  children  the  skin  is  unnaturally  dry;  in  others 
there  is  a  disposition  to  excessive  perspiration,  particularly  about  the 
head.  Nervous  symptoms  are  frequently  present.  These  children  are 
restless,  fretful,  and  irritable ;  they  sleep  badly.  Enlargement  of  the 
lymph  glands,  especially  those  of  the  neck,  is  common. 

One  of  the  most  characteristic  things  about  these  patients  is  their 
feeble  power  of  digestion  and  assimilation.  Unremitting  care  and  con- 
stant watclifulness  are  required  to  keep  them  u])  to  even  a  moderate 
standard  of  health.  The  most  trivial  clianges  in  food  niiiy  u])set  lliem. 
xA.ttacks  of  acute  indigestion  are  usually  brought  on  by  overfeeding — the 
mistake  which  is  almost  invariably  made  by  mothers  who  are  discouraged 


X 


228  NUTRITION 

with  the  slow  progr.ess  made,  and  are  anxious  to  make  their  children  grow 
fat  and  strong.  The  balance  is  so  delicately  adjusted  that  the  slightest 
deviation  from  proper  rules  of  feeding,  either  as  to  the  quality  of  the 
food  or  the  quantity  given,  is  immediately  followed  by  an  attack  of  acute 
indigestion,  often  by  severe  diarrhea.  As  a  result,  the  child  may  lose  as 
much  in  two  or  three  days  as  he  has  gained  in  a  month  or  more.  These 
acute  attacks,  if  in  summer,  not  infrequently  prove  fatal.  Not  only  do 
these  patients  have  but  little  resistance  to  acute  disturbances  of  the 
stomach  and  intestines,  but  any  acute  disease  is  serious — measles,  whoop- 
ing-cough, and  pneumonia  being  especially  fatal. 

If  under  six  months  of  age,  among  the  poor  or  in  institutions,  such 
infants  are  almost  certain  to  go  on  from  bad  to  worse.  In  private 
practice,  where  it  is  possible  to  have  the  best  care  and  surroundings, 
with  the  cooperation  of  an  intelligent  mother  or  nurse,  a  very  large 
number  of  these  infants  can  be  reared.  After  the  second  year  has  passed 
the  problem  becomes  a  much  simpler  one,  and  if  infectious  diseases 
and  other  forms  of  acute  illness  can  be  avoided,  the  probabilities  are 
in  favor  of  the  child's  becoming  stronger  each  year  and  growing  to 
maturity. 

"Inkier  children  are  thin,  pale,  and  undersized,  particularly  if  the  con- 
dition is  constitutional  or  hereditary.  Sometimes  they  are  taller  than 
the  average  for  their  age,  and  their  symptoms  are  often  attributed  to 
too  rapid  growth.  One  of  the  most  striking  things  about  children  suffer- 
ing from  malnutrition  is  their  .vulnerability.  They  "take"  everything. 
Catarrhal  processes  in  the  nose,  pharynx,  and  bronchi  are  readily  excited, 
and,  once  begun,  tend  to  run  a  protracted  course.  There  is  but  little 
resistance  to  any  acute  infectious  disease  which  the  child  may  contract. 
Often  one  illness  quickly  follows  another,  so  that  these  children  are  not 
infrequently  sick  for  almost  an  entire  season.  Their  muscular  develop- 
ment is  poor;  they  tire  readily;  are  able  to  take  but  little  exercise,  and 
their  circulation  is  sluggish.  Mentally  they  are  usually  bright,  often  pre- 
cocious. They  are  cross,  fretful,  and  any  unusual  excitement  produces 
an;  effect  which  lasts  for  some  time.  Their  sleep  is  usually  disturbed  and 
restless;  they  "waken  frequently,  and  occasionally  suffer  from  night- 
terrors. 

Digestive  symptoms,  if  not  constant,  are  very  easily  excited.  Chil- 
dren of  five  or  six  years  have  to  be  fed  as  carefully  as  infants.  The  appe- 
tite is  usually  poor,  and  mothers  are  distressed  because  their  children  eat 
so  little,  yet,  when  food  is  urged  upon  them,  attacks  of  indigestion  follow 
with  singular  regularity.  The  tongue  is  slightly  coated  the  greater  part 
of  the  time.  The  bowels  are  apt  to  be  constipated,  apparently  more  from 
lack  of  muscular  tone  than  from  anything  else.  From  time  to  time  there 
may  be  large  quantities  of  mucus  in  the  stools  for  two  or  three  days.    A 


MALNUTRITION  229 

moderate  amount  of  anemia  is  always  present,  and  tliis  may  be  the  most 
striking  feature. 

The  duration  of  the  condition  depends  very  much  upon  the  cause.  If 
the  cause  is  constitutional  or  inherited,  it  is  likely  to  last  throughout 
childhood,  but  it  often  greatly  improves  about  the  time  of  puberty.  When 
it  follows  some  acute  illness  it  commonly  lasts  for  a  few  months  only. 
The  longer  the  condition  has  lasted  and  the  greater  the  general  disturb- 
ance the  slower  will  be  the  improvement.  The  great  danger  is  the  super- 
vention of  some  acute  disease. 

It  is  oftentimes  difficult  to  find  out  to  what  the  failure  properly  to 
develop  is  due.  Much  regarding  inherited  constitutional  tendencies  can 
be  learned  from  the  family  history  and  from  the  condition  of  other  chil- 
dren in  the  family.     Tuberculosis  must  be  carefully  excluded. 

Other  things  to  be  considered  are  syphilis,  rickets,  diseases  of  the 
blood,  intestinal  parasites  and,  of  course,  organic  diseases  of  the  lungs, 
heart,  stomach,  intestines,  liver  and  kidneys.  Even  malignant  disease, 
though  rare,  should  not  be  overlooked.  It  may  take  careful  observation 
for  several  days,  and  sometimes  for  weeks,  with  repeated  physical  exam- 
inations, before  all  these  conditions  can  be  positively  excluded. 

In  private  practice  a  large  proportion  of  cases  are  due  to  improper 
feeding  or  nursing;  next  in  importance  are  improper  surroundings,  and 
last  come  inherited  constitutional  conditions.  In  other  words,  most  of 
these  children  are  born  healthy,  but  become  ill  or  delicate  in  consequence 
of  improper  management. 

In  older  children,  after  excluding  constitutional  and  local  diseases, 
the  whole  life  of  the  child  must  be  investigated  to  discover  the  funda- 
mental condition  which  is  at  fault.  A  carefully  obtained  history  from 
infancy  is  of  the  greatest  assistance.  It  is  often  difficult,  and  sometimes 
impossible,  to  get  at  the  primary  factor,  for  in  cases  of  long  standing 
there  may  be  symptoms  connected  with  almost  every  function  of  the  body. 
One  should  scrutinize  closely  the  quality  and  quantity  of  food  given,  the 
amount  of  sleep,  the  hours  of  study  and  recreation,  the  amount  of  exer- 
cise in  the  open  air,  and  the  physical  conditions  surrounding  the  child. 
Usually  the  most  important  factor  in  the  case  can  be  discovered. 

The  problem  of  nutrition  is  to  be  solved  by  diet  and  general  manage- 
ment ;  drugs  occupy  a  very  small  place  in  treatment.  With  infants  when- 
ever possible  breast  feeding  should  be  employed.  Next  in  importance  to 
diet  is  fresh  air.  The  natural  tendency  of  a  mother  who  has  a  delicate 
infant  is  to  house  him  closely  and  never  allow  him  a  breath  of  fresh  air. 
It  is  of  the  greatest  assistance  if  these  children  can  be  sent  to  a  warm 
climate  for  the  winter.  If  this  is  not  possible,  fresh  air  may  be  obtained 
l)y  changing  apartments,  or  by  an  airing  in  the  room  with  tlie  windows 
open. 


230  NUTRITION 

Cold  sponging  is  a  valuable  tonic  that  can  only  be  employed,  however, 
with  fairly  vigorous  infants  that  react  promptly.  If  the  child  remains 
blue  and  cold  for  some  time  afterward,  the  cold  sponging  should  not  be 
repeated. 

Friction  and  massage  are  useful  in  many  cases.  The  child  should  be 
laid  upon  the  lap  of  the  nurse,  if  possible,  before  an  open  fire,  and  should 
always  be  covered  with  a  blanket.  The  entire  body  should  then  be  rubbed 
for  ten  or  twenty  minutes  with  the  bare  hand,  or,  better,  with  cocoa 
butter.  Professional  operators  are  inclined  to  be  too  energetic  for  little 
children. 

The  only  tonics  of  much  value  are  iron,  preparations  of  malt,  nux 
vomica,  and  cod-liver  oil.  Cod-liver  oil  is  too  much  used  in  these  cases, 
and  in  too  large  doses.  Many  of  these  infants  can  not  take  it  at  all.  It 
should  not  be  given  when  the  tongue  is  coated  and  the  appetite  poor. 
The  dose  should  always  be  small,  e.  g.,  ten  to  twenty  drops  of  the  pure  oil 
tliree  times  a  day,  or  twice  as  much  of  an  emulsion. 

Experiments  in  treatment  are  nearly  always  unfortunate.  The  phy- 
sician should  indicate  in  writing,  for  the  guidance  of  the  mother,  specific 
rules  with  regard  to  the  amount  of  food,  the  time  at  which  it  is  to  be 
given,  the  hours  for  bathing,  sleep  and  airing.  He  should  see  the  patient 
at  regular  intervals  and  often  enough  to  be  sure  that  his  orders  are  being- 
enforced.     Good  results  are  obtained  only  by  constant  watchfulness. 

The  same  general  principles  are  to  be  applied  to  older  children  as  to 
infants.  The  diet  is  of  the  first  importance.  Only  the  simplest  and  most 
easily  digested  articles  of  food  should  be  given.  Milk,  beef,  eggs,  the 
lighter  and  more  easily  digested  cereals  and  vegetables,  bread,  and  fruit 
should  form  the  diet.  All  sweets,  pastry,  highly  seasoned  food,  candy, 
nuts,  tea,  and  coffee  should  be  absolutely  prohibited,  and,  in  fact,  all  the 
articles  mentioned  as  "forbidden"  in  the  Chapter  on  the  Feeding  of  Older 
Children.  When  the  appetite  is  poor  and  simple  food  not  well  taken,  the 
child  should  not  be  allowed  to  take  indigestible  articles  for  the  sake  of 
eating  something.  Nothing  should  be  given  between  meals,  and  regular 
hours  of  feeding  must  be  followed.  Three  meals  a  day,  for  children  over 
three  years  old,  are  better  than  the  practice  of  giving  more  frequent  feed- 
ings. Under  no  circumstances  should  children  be  coaxed,  urged,  or  hired 
to  eat ;  much  less  should  they  be  forced  to  do  so.  There  is  a  popular  mis- 
apprehension in  regard  to  the  variety  in  diet  which  children  need.  Most 
children  do  better  when  a  very  simple  and  fairly  imiforra  diet  is  con- 
tinued. 

The  nervous  factor  is  a  very  large  and  a  very  important  one.  Many 
of  these  children  are  essentially  cases  of  neurasthenia  at  as  early  an  age 
as  four  or  five  years.  Excitement  and  activity  are  M'hat  they  crave  and 
what  must  be  most  carefully  avoided. 


SCORBUTUS  231 

The  general  habits  of  children  should  be  directed;  there  should  bo 
regular  and  early  hours  for  retiring,  freedom  from  undue  excitement, 
ajid  interest  should  be  awakened  in  outdoor  amusements.  Children 
should  be  kept  as  much  as  possible  in  the  open  air,  but  the  amount  of 
active  exercise  should  be  strictly  limited.  Usually  they  do  much  better 
if  they  can  be  in  the  country  during  the  entire  year.  Only  a  limited 
amount  of  reading  and  study  should  be  allowed;  and  if  children  are  at 
school,  care  should  be  taken  that  overpressure  is  not  the  cause  of  the 
symptoms,  particularly  in  an  ambitious  child.  Cold  sponging  given  in 
the  morning,  as  described  in  the  introductory  Chapter  on  General  Thera- 
peutics, is  extremely  beneficial  to  children  who  take  cold  readily.  In 
general,  these  children  require  early  hours,  a  simple  diet,  a  quiet,  regular 
life,  and  very  little  medicine. 

In  recent  years  there  has  been  a  disposition  to  attril)utc  many  of  the 
symptoms  included  in  the  foregoing  pages  to  insufficiency  in  the  secretion 
of  the  ductless  glands.  Extracts  from  tliese  glands  have  been  widely 
employed  in  treatment.  There  is  no  satisfactory  evidence  that  such  au 
etiology  is  correct  or  such  a  treatment  beneficial. 


CHAPTEE  VI 
DISEASES  DUE    TO  FAULTY  NUTRITION 

The  diseases  due  to  faulty  nutrition  are  numerous.  There  are  two, 
]K)wever,  Avhicli  have  been  so  clearly  shown  to  originate  in  this  way  that 
llicy  may  be  put  in  a  class  by  themselves.  These  are  scorbutus  and  rickets. 
Tlie  purpose  of  considering  them  in  connection  with  the  disturbances  of 
nutrition  is  to  emphasize  this  relationship. 

SCORBUTUS    (Scurvy) 

Scor])utus  is  a  constitutional  disease  due  to  some  prolonged  error  in 
diet,  it  is  characterized  by  spongy,  bleeding  gums,  swellings  and  eccliy- 
nioses  about  the  joints,  especially  the  knee  and  ankle,  hemorrhages  from 
(lie  nose,  and  occasionally  from  other  mucous  membranes,  extreme  hyper- 
esthesia, and  often  pseudo-paralysis  of  the  lower  extremities.  Added  to 
these  local  symptoms  there  is  in  advanced  cases  a  general  cachexia  with 
marked  anemia.  While  scorbutus  and  rickets  are  very  frequently  asso- 
ciated, they  can  not  be  considered  as  different  forms  of  the  same  disease. 


232  NUTRITION 

Cases  of  scorbutus  were,  however,  described  in  older  writings  under  the 
title  of  Acute  Eickets. 

Scurvy  was  well  recognized  and  grajDhically  described  by  Glisson  as 
long  ago  as  the  middle  of  the  seventeenth  century.  For  our  earliest  mod- 
ern knowledge  of  the  pathology  of  this  disease  we  are  indebted  to  the 
observations  of  Barlow  and  Cheadle.  On  the  continent  of  Europe  scurvy 
is  most  frequently  kno^ni  as  Barlow's  disease. 

Scurvy  is  not  a  rare  disease.  In  active  hospital  and  private  practice 
many  cases  are  seen  each  year. 

EtiologX- — ^S^  is  an  important  factor;  more  than  four-fifths  of  the 

cases  occur  between  the  sixth  and  the  fifteenth  months,  and  half  of 

them  between  the  seventh  and  the  tenth  months.     Scurvy  has  been  seen 

in  infants  under  a  month  old.     The  majority  of  the  cases  reported  have 

>v     been  observed  in  private  practice,  often  in  the  best  surroundings.     Pre- 

.  \f    vious  disease  is  not  a  factor  of  much  importance.     Most  of  the  children 

k  ^  /  attacked  have  been  in  good  health  up  to  the  development  of  scurvy. 

)  //  In  about  one-fourth  of  the  number  some  previous  derangement  of  the 

'^    digestive  tract  has  existed. 

The  only  etiological  factor  yet  known  to  bear  any  constant  relation 
to  the  jjroduction  of  scurvy  is  diet.  The  important  facts  regarding  the 
previous  diet  have  been  well  brought  out  by  an  investigation  of  the  Amer- 
ican Pediatric  Society.     They  were  as  follows : 

Breast-milk in    12  cases;  alone  in  10. 

Raw  cow's  milk 

Pasteurized  milk 

Condensed  milk 

Sterilized  milk 

Proprietary  infant-food 


Previous  food- 


"       5 

u 

u 

"     4 

"     20 

u 

u 

«  16 

"     60 

(( 

" 

"  32 

«  107 

li 

« 

«  68 

"  214 

l< 

This  table  shows  that  while  scurvy  may  occasionally  develop  with 
almost  any  variety  of  food,  three  stand  out  prominently — viz.,  proprie- 
tary infant  foods,  condensed  milk,  and  sterilized  milk.  In  all  of  these 
it  would  appear  that  something  needed  for  normal  healthy  nutrition  is 
wanting.  Scurvy  is  not  likely  to  follow  unless  an  improper  diet  is  con- 
tinued for  a  long  period,  usually  several  months.  In  some  instances 
when  it  developed  in  nursing  infants,  the  nurse's  milk  has  been  examined 
and  found  totally  inadequate  to  the  needs  of  nutrition,  many  of  the  chil- 
dren having  exhibited  serious  disturbances  of  nutrition  before  any  signs 
of  scurvy  appeared. 

Several  cases  have  come  under  our  observation  where  scurvy  has 
developed  in  children  who  have  been  kept  for  four  or  five  months  upon 
raw  milk,  very  greatly  diluted.  Scurvy  may  result  from  taking  milk 
which  has  been  pasteurized,  usually  when  the  temperature  has  been  high 


SCORBUTUS  233 

(16.7°  F.),  and  the  time  prolonged  (30  minutes).  With  the  lower  tem- 
perature now  more  generally  employed  (155°  F.),  it  is  less  likely  to 
develop.  We  do  not  believe  scurvy  to  be  a  frequent  result  of  the  pasteur- 
ization of  milk,  and  not  io  1)C  weighed  against  the  advantages  of  pasteur- 
ization; but  still  a  danger  to  be  reckoned  with.  Since  the  general  use  of 
])asteurized  milk  the  numl)er  of  cases  of  scurvy  is  certainly  on  the  in- 
crease. The  number  of  cases  which  develop  while  on  a  diet  of  boiled  or 
sterilized  milk  is  so  large  that  we  are  driven  to  the  conclusion  that  the 
heating  alone  is  the  cause,  especially  since  prompt  recovery  has  often  fol- 
lowed when  no  other  change  is  made  than  to  discontinue  the  heating. 
These  facts  show  that  the  sterilization  of  milk  is  attended  with  some 
disadvantages,  and  shoulii  not— be  continued  as  the  sole  diet  for  Ion"; 
periods.^ 

The  addition  of  carbohydrates  to  the  food  affords  no  protection,  but 
rather  increases  the  danger  of  scurvy. 

Scurvy  frequently  develops  after  the  prolonged  use  of  condensed  milk 
or  proprietary  foods  as  the  sole  diet. 

There  is  certainly  a  predisposition  to  this  disease  on  the  part  of  some 
infants,  for  with  the  same  diet  one  child  may  develop  the  disease  while 
another  remains  free.  We  have  seen  twins  fed  in  exactl}^  the  same  way, 
one  of  whom  developed  scurvy  while  the  other  did  not. 

While  it  may  be  regarded  as  established  that  the  cause  of  scurvy  is  die-  , 

tetic,  no  single  dietetic  error  can  be  held  responsilde  for  the  disease.  It  UaCl\  O. 
has  been  recently  shown  that  there  are  substances  in  foods  vitally  neces- 
sary for  health,  the  vitamins.  It  is  quite  clear  that  scurvy  depends 
upon  the  absence  of  some  of  these.  Either  they  are  lacking  in  the  food 
or  have  been  destroyed  by  prolonged  heating.  Typical  scurvy  can  be 
produced  in  some  animals  by  giving  a  diet  chiefly  of  grain  with  no 
fresh  vegetables  or  fruit.  The  addition  of  these  latter  articles  immedi- 
ately cures  the  disease.  So  it  is  with  children  who  are  at  once  relieved 
by  orange  or  lemon  .juice,  or  as  Freise  has  shown,  b^  the  driecLalmliQliii 
extracts_of_jegetables. 

Lesions. — The  most  marked  effects  of  scurvy  are  seen  in  the  bones, 
blood-vessels,  and  the  blood.  The  number  of  recorded  autopsies  in  this 
disease  is  not  large.  We  have  had  the  opportunity  of  making  examina- 
tions in  seven  cases.  The  findings  are  remarkably  uniform,  but  repre- 
sent, of  course,  the  extreme  results  of  the  disease.  The  most  striking; 
lesion  is  subperiosteal  hemorrhage,  which  is  practically  constant  and  may 
occur  almost  anywhere  in  the  body,  but  affects  chiefly  the  bones  of  the 
lower  extremities;  it  is  often  very  extensive,  and  may  reach  from  the 
knee  to  the  great  trochanter,  or  from  the  ankle  nearly  to  the  knee. 
Extravasations  may  also  be  found  between  the  muscles,  and  blood  may 
infiltrate  the  cellular  tissue  in  the  neighborhood  of  the  joints.     Besides 


\)iV^iA'lt 


234  XUTRITIOX 

these  lesions  resulting  from  hemorrhagic  periostitis  the  bone  itself  may 
be  affected.  Separation  of  the  epiphysis  from  the  shaft  of  some  of  the 
long  bones,  generally  at  the  shoulder,  lower  end  of  the  femnr  or  lower 
end  of  the  tibia,  is  fonnd  in  most  of  the  fatal  cases.  Xotwithstandin2L 
the  serious  lesions  near  the  large  ;ioints,jLhe  joints  t]iemsel\es  are  usually, 
normal. 

The  microscopical  changes  in  the  bones,  due  to  scurvy  are  quite  char- 
acteristic. They  consist  in  l\emorrhages  within  the  marrow  as  well  as 
beneath  the  periosteum.  There  is  a  diminution  of  osteoblastic  activity; 
the  osteoblasts  are  relatively  few  in  number  and  the  formation  of  new 
l)one  is  decreased  or  has  altogether  ceased.  WTiat  bone  has  been  formed, 
however,  is  well  calcified.  The  absorption  of  bone  is  not  increased.  For 
tliis  reason  the  shaft  of  the  bone  is  firm  but  there  is  a  place  of  least 
resistance  in  the  subepiphYseal  zone  owing  to  the  lack  of  bone  formation- 
It  is  through  this  weakened  zone  that  separation  occurs  as  tlie  result  of 
very  slight  traimiatism. 

•* — - — c : ■    «» 

The  marrow  undergoes  extensive  changes.  The  marrow  cells  in  areas, 
especially  in  the  neighborhood  of  the  epiphyses,  have  largelv  disappeared^ 
leaving  only  the  supporting  cells.  In  addition  there  are  almost  always 
found  some  of  the  changes  characteristic  of  rickets. 

The  visceral  lesions  are  inconstant.  Those  most  frequently  found  are 
small  hemorrhages  beneath  the  pleura,  pericardium,  and  peritoneum, 
sometimes  into  the  various  organs,  also  bronchopneumonia  and  nephritis, 
which  occasionally  occur  as  complications. 

There  may  be  small  extravasations  foimd  upon  the  surface  of  any  of 
the  mucous  membranes.  Alterations  in  the  blood-vessels  are  undoubtedly 
an  important  factor  in  bringing  about  the  disposition  to  hemorrhage. 
The  changes  in  the  blood,  in  the  gums,  and  the  lesipns  of  the  skip,  will  be 
considered  with  the  symptoms. 

Symptoms. — In  many  cases  a  period  of  indisposition,  fretfulness, 
pallor,  and  failing  nutrition  precedes  the  local  symptoms,  but  usually 
1  tenderness  of  the  legs  is  the  first  symptom  noticed.  In  the  beginning 
this  is  occasional  and  so  slight  as  to  cause  the  infant  to  cry  only  upon 
being  handled.  Later  it  becomes  almost  constant  and  is  very  acute.  At 
first  this  soreness  is  not  very  definitely  localized,  but  is  generally  more 
marked  about  the  knees  and  ankles.  Some  swelling  may  be  noticed,  often 
just  above  the  ankle  joints.  Coincident  with  these  may  be  seen  the 
'3^)  changes  in  the  mouth.  The  gums  are  of  a  deep  purplish  color,  swollen, 
particularly  about  the  upper  central  incisors,  and  may  quite  cover  the 
teeth.  They  bleed  from  the  slightest  irritation,  and  sometimes  spon- 
taneously. The  child  now  becomes  fretful  and  cross,  sleeps  badly,  loses 
color,  weight,  and  appetite.  lie  may  become  quite  cachectic  in  appear- 
ance.   All  those  symptoms  come  on  very  gradually,  ofteii  with  periods  of 


SCORBUTUS 


235 


a  few  days  in  which  apparent  improvement  is  seen.  Sometimes  they  may 
continue  for  several  weeks  without  making  any  perceptible  impression 
upon  the  child's  previously  good  condition. 

If  the  disease  is  recognized,  and  proper  treatment  instituted,  rapid 
improvement  follows,  with  complete  and  permanent  recovery.  If  not 
recognized,  and  the  faulty  diet  is  continued,  the  disease  advances  to  the 
more  severe  form.  The  tenderness  of  the  legs  becomes  exquisite,  so  that 
any  movement  or  even  the  slightest  touch  causes  the  child  to  scream  with 
pain  or  apprehension.  Tlie  posture  is  very  characteiistic^  There 
semiflexion  of  thighs  and  legs  and  outward  rotationat  thejiijj.     (See  Fig. 


IS 


Fig.  19. — Scurvy  Showing  Characteristic  Swellings  and  Posture.  Patient  8^ 
months  old,  fed  exclusively  upon  malted  milk  after  the  age  of  3  months.  Epiphyseal 
separation  at  the  upper  extremity  of  both  humeri,  lower  extremity  of  both  femora  and 
lower  extremity  of  left  tibia.     Prompt  and  complete  recovery. 


19.)  In  this  position  the  child  often  lies  motionless  and  voluntary  move- 
ments of  the  extremities  can  not  be  excited.  Paralysis  is  often  susnected. 
The  disability  is  chiefly  owing  to  the  extreme  pain  which  motion  pro- 
vokes, but  may  depend  upon  epiphyseal  separation.  Small  ecchymoses 
are  frequently  seen  about  any  of  the  large  joints,  resembling  the  ordinary 
"black-and-blue"  spots,  and  these  often  confirm  the  opinion  previously 
formed  that  the  child  has  met  with  some,  accident.  The  swelling  near 
the  joints,  particularly  the  knee,  may  be  so  great  that  the  limb  is  nearly 
twice  the  size  of  its  fellow.  The  buccal  symptoms  are  usually  striking. 
In  addition  to  spongy,  swollen,  bleeding  gums,  dark  purplish  bags  may 
he  seen  over  teeth  not  yet  through.  There  may  be  bleeding  from  the 
roof  of  the  mouth  or  from  the  pharynx.  The  pain  is  sometimes  so  severe 
as  seriously  to  interfere  with  taking  food  ;  there  is  moderate  though  rarely 
extreme  salivation.  Blood  may  be  vomited  or  passed  with  the  feces  or 
the  urine.  In  the  severe  cases  the  stools  are  rarely  normal,  more  or  less 
catarrhal  colitis  usually  being  present.  The  general  condition  is  one  of, 
grave  anemia,  ac^mpanied_by_ji  marked  cachexia  and  progressive  wastj 
iug.     The  child  cries  almost  constantly,  sleeps  little,  and  is  truly  a  pit- 


236  NUTRITION 

iable  object.  Slight  fever  is  usually  present;  and  in  some  of  the  more 
rapidly  progressing  cases  with  extensive  lesions  a  temperature  of  102°  or 
103°  F.  is  common.  Unless  recognized  and  the  cause  removed,  the  con- 
dition grows  steadily  worse,  the  symptoms  continuing  until  death  occurs 
either  by  slow  asthenia,  or  suddenly  from  heart  failure,  or  from  some 
intercurrent  disease,  such  as  bronchopneumonia  or  acute  gastro-enteritis. 
The  duration  of  the  illness  in  the  fatal  cases  is  from  two  to  four  months^ 

The  onset  is  gradual  in  the  great  majority  of  the  cases,  the  earliest 
symptoms  noticed  in  the  order  of  frequency  being  pain  and  tenderness 
^tiie__leg{S,  soreness  and  sponginess  of  the  gums,  di^abilitx,  anemiaj 
cutaneous  hemorrhages^  aurl  ver}^  Tarely  hematuriiji. 

Pain  and  tenderness  are  very  prominent,  being  noted  in  about  95  per 
cent  of  the  cases;  in  the  majority  they  are  present  only  on  motion  or 
handling.  The  location  of  the  pain  and  tenderness  in  181  cases  was  as 
folloAvs  :  Lower  extremities  alone,  133 ;  upper  extremities  alone,  2  ;  lower 
and  upper,  12 ;  lower  and  trunk,  7.  In  all  but  two  cases,  therefore,  the 
lower  extremities  were  affected,  the  lower  part  of  the  thigh  and  the  leg 
just  above  the  ankle  being  the  usual  seat. 

Disability,  or  pseudo-paralysis,  is  a  very  common  symptom,  and  in  all 
severe  cases  a  constant  one.  It  exists  in  varying  degrees  from  a  slight 
disinclination  to  use  the  limb  to  complete  helplessness.  In  many  cases 
it  is  more  marked  than  the  pain,  and  has  led  to  a  diagnosis  of  polio- 
myelitis. 

SAvellings  are  associated  with  pain  and  tenderness  in  most  of  the 
severe  cases.  They  are  most  marked  near  the  joints,  but  may  extend 
for  some  distance  along  the  shafts  of  the  bones.  In  nearly  all  cases  the 
location  is  the  lower  part  of  the  thigh  or  the  lower  part  of  the  leg,  and 
usually  of  both  sides.  Swellings  are  occasionally  seen  at  the  shoulders  or 
wrists;  in  rare  cases  there  may  be  swelling  about  the  elbows  or  hips  or 
over  the  ribs,  scapula,  or  ilium.  Eedness  is  not  generally  present,  but  the 
parts  may  have  a  dark  purplish  color.  It  is  to  the  hemorrhages  that  both 
the  swellings  and  the  discoloration  are  chieily  due.  There  is  often  marked 
edema  of  the  affected  limbs. 

Protrusion  of  the  eyeball  is  present  in  a  small  proportion  of  the 
cases;  an  extreme  exophthalmus  is  sometimes  seen,  and  is  due  to  orbital 
hemorrhage. 

The^gums  are  affected  in  nearly  all  cases,  the  exceptions  being  those 
recognized  and  treated  early.  Hemorrhage  occurs  in  about  one-half  the 
cases,  and  frequently  there  is  ulceration  not  unlike  that  of  a  mercurial 
stomatitis.  It  is  rather  curious  that,  though  the  lower  teeth  are  cut  first, 
the  upper  gum  is  almost  always  most  affected,  and  in  the  milder  cases 
usually  alone  involved.  Of  45  cases  in  which  no  teeth  had  been  cut,  the 
gums  were  affected  in  21  and  normal  in  21.    This  is  sufficient  to  disprove 


SCORBUTUS  237 

the  old  opiuion  that  the  gums  are  affected  only  when  teeth  have  appeared. 
'  The  severe  inflammation  and  ulceration  sometimes  seen  seem  to  be  the 
result  of  secondary  infection. 

Hemorrhages  beneath  the  skin  are  present  in  about  half  the  cases. 
They  are  rarely  extensive,  usually  multiple,  and  their  location  is  no 
doubt  often  determined  by  a  slight  traumatism.  Hemorrhages  from  the 
mucous  membranes  are  not  quite  so  frequent.  There  may  be  bleeding 
from  the  gums,  nose,  bowels,  and  rarely  from  the  stomach.  Hemorrhages 
in  most  cases  are  frequently  repeated,  but  seldom  profuse. 

Epiphyseal  sej)aration  is  seen  in  most  of  the  very  severe  cases.  It  is 
most  frequently  either  of  the  lower  epiphysis  of  the  femur  or  the  tibia,  or 
the  upper  e^^iphysis  of  the  humerus,  and  is  often  bilateral.  The  actual 
separation  may  be  caused  by  some  slight  injury,  the  condition  of  the  bone 
predisposing  to  this  occurrence.  In  several  cases  of  our  own  with  sep- 
aration which  recovered,  rapid  union  occurred  under  anti-scorbutic  treat- 
ment. 

Early  in  the  disease,  even  thougii  marked  swelling  of  the  limbs  may 
be  present,  an  X-ray  examination  may  shoM^  little  or  nothing.  The  sub- 
periosteal hemorrhages  can  not  usually  be  made  out  until  there  is  a  deposi- 
tion in  the  effusion  of  the  salts  of  calcium.  Then  they  appear  with  great 
clearness  as  spindle-shaped  thickenings  of  the  bones,  sometimes  running 
the  whole  length  of  the  diaphyses.  These  are  absorbed  very  slowly  and 
require  weeks  or  mouths  to  disappear.  Changes  at  the  epiphyses  are 
also  found.  They  consist  in  distortions  and  irregularities  of  the  normal 
line.  Sej)aration  of  the  epiphysis  can  be  occasionally  made  out.  Some 
rachitic  changes  also  can  usually  be  recognized. 

Anemia  is  slight  in  the  early  stage,  but  increases  as  the  disease 
progresses.  Blood  examinations  may  show  marked  reduction  of  the 
hemoglobin,  sometimes  to  thirty-five  or  forty  per  cent;  also  in  nearly 
all  cases  a  proportionate  reduction  of  the  red  cells.  The  changes  are 
those  of  an  ordinary  secondary  anemia. 

The  urine  contains  albumin  in  about . one-fourth  of  the  cases;  in 
nearly  half  of  those  containing  albumin  casts  also  are  found.  In  rare 
cases  hematuria  is  an  early  symptom.  Blood  cells  usually  in  moderate 
numbers  are  found  in  practically  all  but  the  mildest  cases,  and  are  of 
some  diagnostic  importance. 

Evidences  of  general  malnutrition  are  present  in  all  advanced  cases, 
varying,  of  course,  greatly  in  degree.  In  a  few  infants  under  o'ur  own 
observation  the  weight,  color,  and  general  appearance  of  health  have 
continued  in  spite  of  very  decided  local  symptoms.  In  most  of  them  the 
impaired  nutrition  is  shown  l)y  loss  of  appetite,  occasional  attacks  of 
vomiting,  and  ■  still  more  frequently  by  derangements  of  the  bowels, 
which  vary  from  slight  indigestion  to  a  serious  catarrhal  condition  of 


238  Jp  NUTRITION 

both  small  and  large  intestine.    It  is  with  the  latter  that  the  discharge 
of  hlood  is  usually  seen. 

Association  with  Rickets. — In  the  American  Pediatric  Society's  in- 
vestigation great  pains  were  taken  to  obtain  definite  and  accurate  data 
regarding  this.  Of  the  cases,  340  in  number,  in  which  this  point  was 
noted,  vsymptonis  of  rickets  were  present  in  152,  or  45  per  cent.  Mild 
grades  of  rickets  are,  of  course,  impossible  for  us  to  recognize.  Post 
mortem,  rickets  is  almost  invariably  found  associated  with  scurvy,  for 
the  reason  that  during  the  age  at  which  scurvy  may  develop  rickets  is, 
in  hospital  patients,  a  well  nigh  universal  disease.  There  is  no  reason 
for  believing  rickets  and  scurvy  to  be  different  forms  of  the  same  dis- 
ease. 'niPtw<]L  i''i«^>'"^f  striking  charaftpristif-s  of  sr-n^yy.  viz..  tpiiflpncy 
to  hemorrhages  and  prompt  curability  by  fresh  food  and  fruit  juices, 
bave  no  counterpart  in  rickets. 

Diagnosis. — The  disease  with  whicli  infantile  scurvy  is  most  fre- 
quently confounded  is  rlieumatisni^  In  fully  four-fifths  of  the  cases 
which  have  come  to  our  notice  this  has  been  the  previous  diagnosis.  Tlie^ 
extreme  rarity  of  rheumatism  under  one  year  should  always  make  one  Nk- 
cautious;  pain  and  tenderness  of  the  legs  only,  should,  in  an  infant^ 
invariably  suggest  scurvy  rather  than  rheumatism.  The  extreme  disabil- 
ity has  often  led  to  a  diagnosis  of  poliomyelitis,  but  here  again  the  acute 
tenderness  should  set  one  rigjit.  Many  cases  of  scurvy  come  into  the 
hands  of  the  orthopedic  surgeon  with  a  diagnosis  of  joint  or  spinal  dis- 
ease. Where  the  swelling  was  mainly  of  one  limb  we  have  twice  known 
a  diagnosis  of  malignant  disease  to  be  made,  from  the  cachexia,  the 
shape  of  the  swelling,  the  discoloration,  and  the  pain.  We  havevknown 
two  cases  to  be  operated  upon  by  eminent  surgeons,  once  with  a  diag- 
nosis of  sarcoma  and  once  of  ostitis  of  both  tibiae.  ISTot  until  t^e  sub- 
periosteal hemorrhages  and  epiphyseal  separation  were  discoverfed  was 
the  nature  of  the  trouble  suspected.  ; 

The  diagnosis  of  scurvy  seldom  presents  any  difficulties  to  ojie  who.^*^ 
has  once  seen  a  case.  ISTo  one  need  err  if  the  essential  features  of  the  i||| 
disease  are  kept  in  mind:  the  extreme  soreness  of  the  legs,  spongy, 
swollen  gums,  swelling  near  the  large  joints,  a  tendency  to  he) •-(  irrhages, 
and  usually  a  history  of  the  prolonged  use  of  some  proprietai^ infant 
food,  or  sterilized  or  condensed  milk.  The  epiphysitis  of  h#(.'ditary 
syphilis  has  many  symp<  oms  in  com^iypUrMth  scurvy,  "fcftiT  it  usuall 
occurs  at  an  earlier, ^ge^ before  the  fifth  montli)  and  other  evidence^ 
s;^fih,ilj«  are  usually  present.  If  any  doubt  exists,  this  will  be  rer" 
by  the  prompt  improvement  and  generally  rapid  cure  following  at 
scorbutic  diet. 

Prognosis. — This  is  invariably  good  if  the  di|;tiifiPW^l|!H^ early. 
jSTo  patients  with  symptoms  so  serious   impft)j|^   witliJuch^marvelous 


SCORBUTUS  2:>.<.) 

rapidity  as  do  the  great  majority  of  those  with  scurvy,  under  proper 
management.  The  figures  of  the  American  Pediatric  Society's  report  on 
this  point  are  interestijig.  The  average  duration  of  the  disease  before 
treatment  was  Ix'gun  in  over  tliree  liundred  cases  was  somewliat  ovei- 
three  weeks.  In  eighty  per  cent  strilcing  improvement  was  noticed  dur- 
ing the  first  week  of  treatmcjit,  ajid  in  forty  per  cent  witiiin  tliree  days. 
Over  two-thirds  of  these  cases  were  well  within  three  weeks,  and  nearly 
one-third  Mdthin  one  week,  after  the  beginning  of  treatment. 

It  is  only  when  the  disease  is  of  long  standing,  when  the  malnutrition 
is  severe,  or  when  serious  complications,  usually  involving  the  digestive 
tract,  are  present  that  the  symptoms  persist  and  the  issue  becomes  doubt- 
ful. It  is  difficult  to  tell  what  the  exact  mortality  of  scurvy  is.  Any  case 
allowed  to  go  on  may  result  fatally.  The  younger  the  infant  the  more 
likely  is  this  to  occur.  We  have  seen  five  fatal  cases.  ^.  In  one  of  our 
])atients  death  resulted  from  hemorrhage  which  followed  an  incision  into 
an  epiphyseal  swelling  at  the  lower  end  of  the  femur,  made  before  the 
patient  was  seen  and  which  persisted  despite  all  treatment. »  Barlow's 
early  article  included  thirty-one  cases  with  seven  deaths.  It  is  rare  that 
scurvy  leaves  any  permanent  effects.  Eecovery  is  not  only  rapid  but 
complete.  Belapses  are  extremely  rare  and  have  been  observed  only  in 
one  or  two  cases,  where  chronic  indigestion  existed  of  so  extreme  a 
character  that  proper  feeding  was  impossible.  The  after-effects  are 
usually  the  result  of  prolonged  malnutrition,  of  which  the  attack  of 
s(-urvy  was  only  one  manifestation. 

Treatment. — Prevention  requires  that  all  infants  reared  on  sterilized 
or  pasteurized  milk  should  be  given  other  food  much  earlier  than  was 
formerly  thought  necessary.  It  is  not  enough  to  add  gruel  or  farinaceous 
foods.  Fruit  juices  should  be  begun  as  early  as  the  fifth  or  sixth  month. 
Beginning  with  two  teaspoonfuls  the  amount  may  gradually  be  increased 
to  two  or  three  tablespoonfuls  daily  and  continued  as  a  regular  part  of 
the  diet.  The  early  use  of  broth  in  which  green  vegetables  have  been 
cooked  ].s  also  of  value,  or  the  grated  vegetahle  may  be  given  to  the  infant 
as  a  puree..  The  treatment  of  scurvy  is  usually  very  simple — viz.,  to  dis- 
conthiMilmf^  proprietary  foods,  condensed  milk  or  sterilized  milk,  and  to 
substit;  ^  a  diet  of  fresh  cow's  milk,  modified  to  suit  the  child's  digestion. 
WTT"\''tnj  'hange  alone  improvement  will  soon  begin  and  gradual  recov- 
er;"^ take  place.  However,  ntien  fi?sb  fruit  juice  is  added  improvement 
is  ;nud^  more  rapid.  It  should  always  be  combined  with  the  change 
;;;  diet.  Orange  juice  is  to  be  preferred,Haut  jhe  juice  of  any  fresli  ripo 
fruii  will  answer  the  purpose.  Oranges  should  be  sweet  and  fresh.  From 
two  t(;  t^our  ounces  of  the  juice  a  day  are  required,  best  given  iiT'divided 
doses,  abouL  oae  houi  before  the  milk-feeding.  It  may  be  given  plain 
or  diluted  with  water.     In  some  cases  when  not  well  tolerated  by  the 


r- 


240  NUTRITION 

stomach,  it  is  better  given  at  niglit  when  no  food  is  taken.  Potato 
also  has  marked  anti-scorbutic  properties,  and  may  be  given  in  the 
form  of  a  puree  to  infants  as  yomig  as  eight  or  ten  months.  The  only 
really  difficult  cases  to  manage  are  those  in  which  the  general  condition 
approaches  one  of  marasmus,  or  Avhen  scurvy  is  accompanied  by  marked 
gastric  or  intestinal  disturbance.  When  an  intestinal  catarrh  is  present, 
with  the  bowels  moving  five  or  six  times  a  day,  one  may  hesitate  to  give 
the  fruit  juice  for  fear  of  increasing  these  symptoms.  In  a  number  of 
instances  we  have  seen  intestinal  symptoms,  which  had  resisted  ordinary 
measures,  immediately  improved  by  the  fruit  juice,  thus  establishing 
their  intimate  connection  with  the  scorbutic  condition. 

Other  things  of  value  are  fresh  beef  jiiice,  and  for  older  children  all 
fresh  vegetables,  especially  potato.  The  anemia  and  malnutrition  call 
for  iron,  cod-liver  oil,  and  other  tonics,  which  should  be  given  after  active 
symptoms  of  the  disease  have  disappeared.  Infants  with  scurvy  should 
be  handled  as  little  as  possible,  and  should  be  particularly  protected 
against  exposure  in  their  extremely  susceptible  condition.  To  relieve 
pain  and  prevent  deformity  the  affected  limbs  should  be  immobilized  by 
splints  during  the  period  of  marked  symptoms  if  epiphyseal  separation 
lias  taken  place,  and  in  many  other  severe  cases. 


RICKETS   (Rachitis) 

Eickets  is  a  chronic  disease  of  nutrition.  While  the  only  important 
anatomical  changes  are  found  in  the  bones,  it  is  not  to  l^e  regarded  as  a 
disease  of  bone,  but  as  a  very  complex  pathological  process,  the  result  of 
disturbed  metabolism,  which  affects  chiefly  the  bones,  but  also  the  mus- 
cles, ligaments,  mucous  membranes,  and  nearly  all  the  organs  of  the  body, 
including  the  nervous  system.  It  occurs  especially  between  the  ages  of 
six  and  eighteen  months.  While  not  a  fatal  disease  /jer  se,  rickets  adds 
very  greatly  to  the  danger  from  all  acute  diseases  in  infancy,  and  even 
to  some  degree  also  to  those  of  later  life. 

The  great  frequency  of  rickets  has  only  recently  been  recognized.  It 
is  probably,  at  least  in  cities,  the  disease  from  which  infants  most  fre- 
quently suffer.  It  has  been  possible  to  determine  this  only  since  the 
pathology  has  been  firmly  established,  for  many  cases  give  no  I'linical 
evidence  and  the  disease  can  be  recognized  only  post  mortem.  The  symp- 
toms by  which  we  recognize  rickets  are  chiefly  due  to  bone  changes,  and 
these  must  be  quite  well  marked  before  they  are  discovered  clinically. 
For  this  reason  rickets  may  run  its  course  without  any  suspicion  having 
been  aroused  as  to  its  presence.  Schmorl  found  in  3S6  consecutive 
autopsies  upon  children  dying  between  the  second  month  and  the  fourth 


RICKETS  241 

year,  evidence  of  rickets  in  90  per  cent,  while  96.6  per  cent  of  infants 
between  the  fourth  and  eighth  month  were  rachitic.  There  can  be  no 
doubt  that  among  the  poor  in  cities^  rickets  is  an  ahnost  universal  disease. 

Etiology. — Certain  facts  in  the  causation  of  rickets  are  well  known.' 
It  is  closely  related  to  improper  feeding  and  bad  hygienic  surroundings. 
Artificially-fed  children  are  much  more  prone  to  the  disease,  especially 
those  who  are  badly  fed.  Breast  feeding  does  not  entirely  protect  against 
the  disease,  though  it  greatly  modifies  its  character.  Severe  forms  of 
rickets  are  not  common  in  nursing  children  unless  lactation  is  unduly 
prolonged,  as,  for  example,  when  nursing  is  continued  for  fifteen  to 
eighteen  months  without  other  food.  There  is  a  predisposition  on  the 
2)art  of  certain  children  to  acquire  rickets  quite  independent  of  the  food. 
Of  two  children  that  are  nursing  the  same  woman,  one  may  develo}) 
rickets  perhaps  in  a  severe  form  and  the  other  may  escape  it;  and 
allowing  a  rachitic  infant  Avho  has  been  l)reast  fed  to  nurse  a  woman 
Mdiose  own  child  is  not  rachitic,  brings  no  assurance  that  the  rickets  will 
be  cured. 

The  diet  of  children  who  develop  rickets  upon  artificial  feeding  is 
most  frequently  deficient  in  fat  and  often  at  the  same  time  in  protein, 
Avhile  it  is  apt  to  contain  an  excess  of  earbflhydrates.  It  has  been  believed 
that  the  most  important  factor  is  the  deficiency  of  fat.  Eickets  is  exceed- 
ingly common  in  children  reared  upon  the  proprietary  foods,  nearly  all 
of  which  are  very  low  in  fat  and  contain  an  excess  of  carbohydrates.  It 
is  also  common  in  children  who  are  reared  upon  sweetened  condensed 
milk. 

According  to  Feer,  infants  in  the  mountainous  parts  of  Switzer- 
land seldom  develop  rickets  although  they  may  have  been  breast-fed 
for  only  a  short  time  and  thereafter  are  given  a  diet  almost  exclu- 
sively of  carbohydrates.  It  is  doubtful  if  diet  has  the  importance  that 
has  been  ascribed  to  it  in  the  past. 

Though  animals  under  domestication  suffer  from  rickets,  it  is  impos- 
sible to  produce  the  disease  by  even  the  most  abnormal  diet.  Certain 
experiments  have  been  made  which  show  that  a  condition  of  the  bones 
resembling  rickets  may  be  produced  in  ^imals^by  a  diet  deficient  in 
calcium  salts,  and  furthermore  that  this  "i^ay  be  cured  simply  by  the 
addition  of  these  salts  to  the  food.  The  conclusion  can  not,  however,  be 
drawn  that  rickets  in  children  is  produced  in  this  manner.  In  the  first 
place  the  bony  condition  in  the  artificial  disease  is  not  histologically  the 
same  as  that  seen  in  rickets ;  again,  rickets  in  the  child  is  not  cured 
simply  by  the  administration  of  calcium  salts;  and,  finally,  rickets 
develops  when  these  elements  have  not  been  deficient  in  the  food. 

Eickets  is  essentially  a  disease  of  cities,  being  most  often  seen  in 
children  living  in  crowded  tenements  where,   in  addition  to  improper 


242  NUTEITION 

food,  the  liyg.ieuic  suiTOimdin^s  are  the  .poorest.  For  this  reason  poor 
ventilation,  tilth  and  lack  of  sunlight  have  been  regarded  as  potent  fac- 
tors in  producing  the  disease.  Their  exact  influence  is  difficult  to  deter- 
mine. 

Distribution  of  Rickets. — It  was  formerly  held  that  rickets  was  almost 
unknown  in  many  parts  of  the  world.  It  is  now  apparent  that  prac- 
tically no  region  escapes.  The  greatest  frequency  of  the  disease,  however, 
is  in  the  teinp£rate,.Zifltte.  Tropical  and  semi-tropical  countries  are  rela- 
tively free  from  rickets.  But  the  inhabitants  of  these  countries,  partic- 
ularly the  negro  and  the  Italian,  when  removed  to  cities  of  the  temperate 
zone,  suffer  most  frequently  and  severely.  In  the  cities  of  America  no 
race  is  exempt  from  the  disease.  In  Xew  York  the  greatest  suscepiibiliiy 
is  aminig  the  jiegrocs  and  ItaliaJis.  The  extreme  cases  of  rickets  seen  are 
almost  invariably  in  one  of  these  natioualitics.  It  is  exceptional  to  see  in 
a  dispensary  or  hospital  a  child  of  cither  of  these  races  who  does  not 
show,  to  a  greater  or  less  degree,  the  signs  of  rickets.  These  two  southern 
races  seem  to  bear  very  badly  the  climate  and  the  confined  life  of  the 
northern  cities.  So  far  as  our  observations  are  concerned,  there  is  no 
peculiarity  in  the  food  of  these  people  which  explains  the  prevalence  of 
rickets  among  them,  and  it  must  be  attributed  to  a  race  peculiarity.  In 
the  country,  the  immunity  from  rickets  may  be  partly  due  to  the  more 
prevalent  custom  of  maternal  nursing,  and  partly  to  the  better  surround- 
ings, the  increased  resistance  of  the  children  rendering  them  much  less 
susceptible  to  unwholesome  influences  than  children  in  the  cities. 
Among  dispensary  and  hospital  patients  of  our  large  cities  rickets  is 
exceedingly  common,  and  is  seen  chiefly  in  the  foreign  elements  of  the 
population. 

Season. — This  apparently  has  an  important  influence  upon  tlie  devel- 
opment of  the  disease.  The  figures  from  four  large  outpatient  clinics 
show  that  from  January  to  June  there  were  treated  more  than  twice  as 
many  rachitic  patients  as  from  July  to  December.  Schmorl  has  reported 
that  he  found  early  cases  at  autopsy  rather  more  commonly  in  the  cold 
months  than  in  tlie  warm,  that  the  most  active  cases  were  considerably 
more  frequent  in  the  mid  monUis.  and  that  the  vast  majority  of  cases 
with  evidences  of  healing  were  seen  in  the  summer  and  early  fall.  The 
active  symptoms  of  rickets  are  more  frequently  seen  and  are  more  severe 
in  the  winter  and  spring.  What  it  is  that  determines  this  we  are  as 
yet  quite  unable  to  say. 

Heredity. — The  influence  of  heredity  is  difficult  to  determine.  It  is 
believed  by  some  excellent  authorities  to  be  a  factor  in  the  production 
of  the  disease.  Siegert  has  reported  numerous  instances  where  children 
with  rachitic  parents  developed  rickets  while  other  children  of  non- 
rachitic parents  living  in  the  same  environment  and  receiving  the  same 


rJCKETS  243 

food  did  not  develop  rickets.  Elgood  has  given  the  history  of  a  woman 
who  was  married  three  times.  By  her  first  and  third  husbands,  who  had 
not  had  rickets,  she  bore  children  who  remained  free  from  the  disease, 
while  by  her  second  husband,  who  had  suffered  from  rickets,  she  bore 
five  children,  all  of  whom  developed  rickets.  There  seems  to  be  no 
greater  reason  for  denying  the  influence  of  heredity  in  rickets  than 
there  is  in  arteriosclerosis  or  tuberculosis. 

Previous  Disease. — Eickets  not  infrequently  develops  in  syphilitic 
children;  the  connection,  however,  seems  to  be  no  closer  than  with  any 
other  cachexia.  Chronic  disorders  of  the  digestive  tract  sometimes  pre- 
cede and  often  follow  the  development  of  rickets.  It  appears  to  develop 
quite  independently  of  previous  disease. 

Eickets  affects  both  sexes  with  equal  frequency.  The  symptoms 
usually  manifest  themselves  betw^een  the  sixth  and  eighteenth  months. 
Congenital  and  late  rickets  will  be  considered  separately. 

Experimental  Rickets. — Eickets  is  never  found  in  wild  animals;  in 
those  under  domestication,  especially  with  in-breeding,  it  is  by  no  means 
unusual.  In  zoological  gardens  it  is  quite  prevalent.  It  would  appear 
easy,  therefore,  to  produce  rickets,  but  the  attempts  have  been  almost 
always  unsuccessful.  By  depriving  animals  of  calcium  and  phosphorus 
severe  lesions  of  the  bones  have  been  produced,  enlarged  epiphyses,  bend- 
ing of  the  bones  and  even  fractures,  but  the  condition  is  an  osteoporosis 
and  not  rickets. 

By  bacterial  inoculation  Morpurgo  produced  true  rickets  in  white 
rats.  Findlay  restricted  the  activity  of  puppies  and  saw  rickets  develop. 
Klose  and  Matti  claim  that  true  rickets  results  in  dogs  from  early 
thymus  extirpation.  It  is  undoubtedly  true  that  rickets  did  follow  some 
of  their  operations,  but  that  it  was  due  to  the  removal  of  the  tliymus 
seems  open  to  question. 

Pathology. — Eickets  is  a  disorder  of  nutrition,  the  result  of  some 
disturbance  of  metabolism  in  which  calcium  plays  a  very  important  role. 
The  exact  nature  of  this  disturbance  is  not  yet  understood.  Three  theories 
have  been  advanced  in  explanation  of  the  deficiency  of  calcium  in  the 
bones,  which  is  the  most  striking  characteristic  of  the  disease.  The  first 
one,  that  rickets  is  due  to  a  lack  of  calcium  in  the  food,  is  not  supported 
cither  by  clinical  or  experimental  evidence.  T^he  ,^eco7id  tkemrv  is  that 
tlie  disease  is  due  to  an  increased  excretion  of  calcium  as  a  result  of 
disturbances  of  digestion.  It  is  very  likely  that  the  increased  excre- 
tion of  calcium  occurs  only  in  rachitic  children.  Diet  alone  or  dis- 
turbed chemical  processes  are  not  sufficient  to  account  for  it.  Tlio  tliLi-d 
JJieojy  advanced  is  that  although  sufficient  calcium  is  fnrnishod  in  tlio 
food,  it  is  excreted  in  excess  because  the  bones  are  iiica]ia1)le  of 'absorbing 
it.     This  is  the  tlioory  that  has  the  most  clinical  and  cxperiuuMilnl  evi- 


244  NUTRITION 

(lence  in  its  favor;  though  what  produces  the  incapacity  of  the  bone  to 
retain  calcinm  is  quite  unknown. 

Lesions. — The  only  constant  and  characteristic  lesions  of  rickets  are 
found  in  the  bones;  these  changes  are  sufficiently  definite  to  give  it  a 
place  as  an  essential  disease.  One  of  the  most  striking  features  of 
rachitic  bones  is  tli,eir  unnatural  flexibililY-  This  is  due  to  the  lack.-of 
mineral  salts  in  the  bones  and  especially  to  the  lack  of  calcium.  ISTpr- 
mally  bone  contains  abotit  one-third  organic  and  two-thirds  inorganic 
matter.  "  In  marked' rickets  the  proportions  are  reversed,  the  bones  often 
containing  twice  as  much  organic  as  inorganic  matter.  While  all  the 
inorganic  elements  are  actually  diminished 'the  phosphorus  and  mag- 
nesium may  be  relatively  increased.     The  chief  loss  is'  in  the  calcium. 

Thcr^han^es  in  thC' shafts  and  flat  bones  are  imiyersal.  Those  at.  the 
epiphyses  show  a  marked  parallelism  with  the  activity  of  growth.  Where 
growth  is  most  rapid  the  lesions  are  most  .advanced.  The  middle  ribs  are 
earliest  and  chiefly -aflectedy.  then  the  other  ribs  and  the  lower  femoral 
epiphyses,  the  lower  extremities  of  the  radius  and  tibia,  and  eventually 
in  some  cases  all  the  long  bones,  including  the  metacarpal  and  the 
phalanges.  There  are  characteristic  changes  in  form.  The  most  con- 
stant is  enlargement  at  the  epiphyses,  which  is  most  strikingly  seen  at 
the  lower  extremities  of  the  radius  and  tibia  and  at  the  costochondral 
junction  of  the  middle  ribs.  All  the  sharp  angles,  borders  and  prom- 
inences of  the  bones  are  effaced.  The  curvatures  of  rachitic  bones  are 
allowed  by  the  increased  flexibility  due  to  the  loss  of  mineral  salts.  They 
may  be  due  to'  a  variety  of  causes.  Some  are  simply  an  exaggeration  of 
the  normal  curves  much  increased  by  the  swelling  of  the  epiphyses; 
others  are  cliie  to.  muscular  action,  to  atmospheric  pressure,  to  some 
unn0.tural  posture,,  such; as  the  cross-legged, position,  to  the  weight  of  the 
limbs  or  the -.^weight  of  the  body.  Marked  deformity  is  usually  due  to 
displacement  of  the  epiphysis  jor  to  fracture.  Displacement  of  the  epi- 
physes is  rare  except  inthe^ribs,  Avliere  it  occurs  to  a  certain  extent  in 
every '.axl-vanced  case.  ,  Fractures  of  the  long  bones  are  very  common. 
The  bones  most  frequently  broken  are  the  radius  and  ulna;  next  in  order 
the  ribs,  humerus,  femur,  fibula  and  clavicle.  The  fractures  are  usually 
ofTFie  green-stick  variety  with  more  or  less  impaction  and  are  generally 
follqAved  by _  the.  production  of  considerable  callus,  though  subperiosteal 
solution  of- continuity  is  occasionally  found  with  no  deformity  and  little 
if  any;  callus.  When  bending  occurs  there  is  a  production  of  new  tissue 
ljeneai}li  the.  .periosteum  to  compensate  for  the  mechanical  disadvantage 
of  position  in  which  the  new  bone  is  placed.  The  sluifts  are  frequently 
greatly  thickened.  The  principal,  change  in  the  form  of  the  flat  l)ones 
consists  in  the  production  of  large -bosses  or  prominences  upon  the 
parietal  and  frontal  bones,  due  to  an  increase  of  vascular,   immature 


PLATE  II 


CQ 


RICKETS  245 

l)oiie  beneath  the  periosteum.  Bosses  are  found  where  the  norma' 
bending  produces  the  greatest  stress  upon  the  bone.  The  deficiency  in 
calcium  over  areas  in  the  occipital  bone  that  are  thin  even  under  normal 
conditions,  allows  them  to  indent  under  the  finger.     This  is  craniotabeg. 

In  a  longitudinal  section  of  one  of  the  long  bones  the  principal 
change  seen  at  the  extremity  is  that  the  cartilaginous  layer  which  unites 
the  epiphysis  and  the  shaft  is  very  much  enlarged  both  in  width  and 
thickness,  the  latter  being  sometimes  four  or  five  times  the  normal.  The 
transitional  zone  is  a  whitish  or  bluish-white  color,  rather  softer  tliaii 
normal  cartilage.  On  one  side  it  blends  with  the  cartilage  of  the  epipliy- 
sis,  on  the  other  it  presents  an  irregular  dentated  border.  The  nor- 
mal red  marrow  may  cease  a  quarter  or  half  an  inch  from  the  epiphysis, 
its  place  being  taken  by  a  light  gray  or  whitish  layer  that  microscopically 
is  seen  to  be  fibrous  tissue.  The  replacement  of  so  much  marrow  is 
perhaps  the  reason  for  some  of  the  anemia  that  is  prominent  in  severe 
rickets.  The  epiphyseal  centers  of  ossification  are  but  slightly  affected. 
-  In  the  process  of  healing  the  epiphyseal  swellings  slowly  diminish  in 
size  and  may  quite  disappear;  the  slight  curvatures  may  be  entirely  over- 
come and  the  greater  ones  much  lessened.  Some  of  the  long  bones  remain 
more  or  less  permanently  thickened  and  with  a  denser  and  thicker  cor- 
tical layer.  The  beading  of  the  ribs  becomes  almost  imperceptible;  the 
bosses  upon  the  skull  shrink  very  markedly  and  may  leave  scarcely  a 
trace  of  their  existence.  In  most  cases  except  in  Italians  and  negroes  the 
active  process  in  rickets  comes  to  an  end  by  the  time  the  child  is  two  and 
a  half  years  old,  often  at  two  years. 

Microscopical  Appearances. — When  normal  conditions  obtain  at  the 
epiphyses,  the  cartilaginous  intercellular  substance  between  the  lowest  of 
the  four  layers  of  cartilage  cells  becomes  infiltrated  with  calcium,  form- 
ing rigid  columns.  These  direct  the  vessels  budding  up  from  the  marrow 
against  the  cartilage  cells  which  are  then  destroyed  by  erosion.  The  col- 
umns themselves  are  partly  consumed  by  osteoblasts  but  the  remains  of 
them  act  as  the  centers  around  which  l)one  is  formed  by  osteoblastic  activ- 
ity. The  new  bone  is  first  formed  as  osteoid  tissue,  which  differs  from 
mature  bone  only  in  its  containing  no  calcium..  When  it  absorbs  calcium 
it  becomes  true  bone.  It  absorbs  calcium  so  soon  after  its  formation  that 
only  a  narrow  layer  of  osteoid  tissue  is  ever  found  in  health.  Marrow 
cells  accompany  the  capillary  loops.  The  cartilage  itself  is  nourished  by 
vessels  that  spring  from  the  perichondrium  and  run  transversely  in  the 
so-called  cartilage  canals.  Throughout  the  whole  skeleton  all  tlie  bone  is 
well  calcified  with  the  exception  of  the  narrow  zone  of  osteoid  (issue. 

In  rickets  the  most  striking  feature  is  the  presence  of  large  amounts 
of  limeless  bone,  or  osteoid,  throughout  the  whole  skeleton.  It  is  more 
marked  in  some  situations  than  others  but  it  is  a  universal  process.     At 


246  NUTKITION 

the  epiphyses  the  calcium  is  also  absent  from  the  intercellular  ground 
substance.  The  marrow  vessels  are  not  directed  against  the  cells  but 
they  grow  in  all  directions,  breaking  up  the  normal  contour  of  the  epi- 
physeal line.  Some  of  the  cartilage  grows  down  undisturbed,  or  islands 
of  cartilage  cells  are  formed  and  not  destroyed.  The  cartilage  is  not 
formed  in  excess.  It  is  found  in  excess  because  it  is  allowed  to  remain. 
The  transitional  zone,  or  ''metaiDhysis,"  is  weakened  and  nature  attempts 
to  remedy  this  by  the  production  of  fibrous  tissue  and  osteoid  tissue.  In 
this  way  the  metaphysis  is  increased  greatly  in  diameter  and  also  in. 
thickness;  for,  on  account  of  its  inelasticity,  it  expands  laterally  as  the 
result  of  muscular  action  or  weight  and  does  not  return  to  its  former 
position.  Vascularization  of  the  metaphysis  is  accomplished  by  a  per- 
sistence of  the  cartilage  canals. 

When  healing  takes  place  the  osteoid  tissue  in  the  flat  l)ones  and  the 
shafts  of  the  long  bones  absorbs  calcium,  and  the  transformation  into 
normal  bone  is  rapidly  completed.  At  the  epiphysis  the  first  step  is  the 
deposition  of  calcium  in  the  cartilage  on  the  epiphyseal  side  of  the  la.st 
cartilage  canals  persisting  in  the  metaphysis.  Vessels  from  these  bud 
back  and  destroy  the  cartilage.  The  metaphysis  is  thus  protected  from 
a  further  production  of  cartilage.  That  which  remains  is  gradually  dis- 
integrated and  normal  bone  takes  the  place  of  the  osteoid  tissue  and 
connective  tissue.  There  is  no  anatomical  explanation  of  the  deficient 
growth  which  is  occasionally  encountered.  It  must  r^esult  from  perma- 
nent damage  to  the  function  of  the  proliferating  zone  of  cartilage  cells. 

Healing  is  not  always  a  continuous  process.  Eelapses  of  the  disease 
occur.  As  proof  of  this  lines  of  calcification  may  be  foimd  buried  in  the 
rachitic  zone.  Two  and  occasionally  three  of  these  are  encountered. 
They  represent  abortive  attempts  at  healing. 

Visceral  Lesions. — These  are  not  infrequent,  but  are  not  essential  to 
rickets.  In  the  lungs  they  are  due  to  deformities  of  the  chest  wall  and 
to  complications.  Beneath  the  deep  lateral  furrows  which  are  so  com- 
mon, there  is  found  a  part  of  the  lung  in  a  state  of  more  or  less  complete 
collapse.  This  is  accompanied  by  emphysema  of  the  portion  just  ante- 
rior to  it.  Acute  and  chronic  bronchitis  and  bronchopneumonia  are 
exceedingly  frequent.  A  low  grade  of  chronic  catarrhal  inflammation 
of  the  stomach  and  intestines  is  common,  and  is  often  associated  with 
dilatation  of  these  organs.  The  spleen  is  enlarged  in  most  cases  during 
the  period  of  active  symptoms.  This  is  usually  moderate  in  degree. 
The  swelling  of  the  spleen  is  chiefly  due  to  simple  hyperplasia.  Enlarge- 
ment of  the  liver  is  less  frequent,  and  may  occur  with  or  without  that  of 
the  spleen.  There  are  no  constant  changes  in  tlie  structure  of  these 
organs.  The  lymph  nodes  are  frequently  enlarged.  This  is  due  to 
simple  hyperplasia,  and  has  no  close  connection  with  rickets.     Cerebral 


RICKETS 


247 


changes  are  rare,  and  those  described  are  rather  of  accidental  occurrence 
than  dependent  upon  the  rachitic  process.  As  stated  under  Symptoms, 
enlargement  of  tlie  head  is  usually  due  to  thickening  of  the  cranial  bones. 
Although  hydrocephalus  is  occasionally  seen,  it  is  extremely  doubtful 
whether  it  is  more  frecpieiit  than  in  ])atients  not  racliitic.  Hypertrophy 
of  the  brain  has  been  described  in  connection  with  rickets,  but  as  yet 
this  does  not  seem  to  be  established  by  sufficient  pathological  evidence. 
The  muscles  are  flabby  from  imperfect  nutrition,  and  sometimes  atrophied 


Fig.  20. — Costochondral  Junction  in  Marked  Rickets.  (A)  cartilage,  CB)  rib,  (C) 
mas.se.4  of  cartilage  cells,  (D)  metaphysis  or  transitional  zone,  composed  of  masses  of 
cartilage  cells,  osteoid  tissue,  blood  vessels  and  fibrous  tissue.  Normal  marrow  in 
this  zone  is  absent. — Note  that  the  epiphyseal  line  no  longer  exists. 


from  disuse,  but  no  essential  anatomical  changes  have  Ijeen  demonstrated 
in  them. 

Symptoms. — The  symptoms  upon  which  a  diagnosis  of  rickets  can  be 
based  are  chiefly  bony  symptoms.  Lesions  of  the  bones  must  exist  some 
weeks  before  they  reach  a  degree  that  can  be  recognized  clinically. 
Schmorl  has  found  microscopical  evidences  of  rickets  as  early  as  the 
end  of  the  second  montli.  In  the  clinic  we  seldom  .see  uinnistakal)le 
rickets  before  the  fourth  or  fiflh  month.  A  well-niark(!d  case  of  rickets 
makes    a  striking   picture    ( IMnte    111),   and    one   not   c;t^ilv    mistaken. 


248  NUTRITION 

There  are  seen  the  large  head,  beaded  ribs,  narrow  chest,  prominent  abdo- 
men, symmetrical  swellings  of  the.  epiphyses  of  the  wrists  and  ankles, 
and  curvatures  of  the  extremities.  The  beginning  of  symptoms  is  nearly 
always  insidious,  and  the  patient  does  not  usually  come  nnder  observation 
until  they  have  existed  for  -several  weeks,  often  several  months. 

Eaelt  Symptoms. — The  most  constant  early  symptoms  are  sweating 
of  the  head,  extreme  restlessness  at  night,  constipation-,  beading  of  the 
ribs,  and  craniotabes.  The  head-sweating  is  rarely  absent,  and  may  con- 
tinue for  several  months.  It  is  especially  profuse  during  sleep,  the  per- 
spiration standing  out  in  large  drops  upon  the  forehead,  often  being 
sufficient  to  wet  the  pillow.  This  is  one  of  the  causes  of  the  nasal  and 
lironchial  catarrhs  so  common  in  rachitic  infants.  There  is  marked  rest- 
lessness during  sleep :  the  children  tossing  about  their  cribs,  kicking  off 
the  clothes,  and  never  having  the  quiet,  natural  slumber  of  healthy  in- 
fants. This'  may  be  due  to  many  causes,  but  when  persistent  and  asso- 
ciated with  marked  perspiration  of  the  head,  rickets  should  be  suspected. 
In  many  rachitic  infants  serious  nervous  symptoms  may  be  seen  due  to 
associated  tetany,  such  as  laryngismus  stridulus,  and  general  convulsions. 
Constipati&n  is  frequently  seen  as  an  early  symptom,  although  it  is  more 
marked  in^tfie  later  stages  of  the  disease. 

The  beading  of  the  ril)s  is  almost  invariably  the  first  appreciable 
change  "ill  the  bones,  and  it  is  well-nigh  constant.  This  forms  the  so- 
called  "rachitic  rosary,"  consisting  of  nodules  at  the  line  of  jinu-tion  of 
the  costal  cartilages  and  the  ribs.  It  may  be  slight,  or  there  may  be  a 
row  of  knobs  as  large  as  small  marbles.  In  many  cases  with  marked 
thoracic  deformity', "  little  _or  no  beading  of  the  ribs  is  seen  externally, 
although  at  autopsy  it  is  found  to  be  very  marked  upon  the  internal 
surface  of  the  chest.  The  costochondral  junctions  of  newly-born  infants, 
especially  the  more  vigorous  ones,  are  readily  palpable.  Care  should  be 
taken  not  to  confound  these  \\  ith  the  rachitic  rosary  which  appears  only 
after  several  months.  In  infants  under  six  months  there  may  be  found 
soft  spots  in  the  cranium,  usually  over  the  occipital  or  posterior  portions 
of  the  parietal  bones.  These  are  from  one-fourth  to  one  inch  in  diam- 
eter, and  there  are  usually  several  of  them  present.  By  pressure  with  the 
finger  they  give  a  sort  of  parchment-crackling  sensation.  This  condjtion 
is  known  as.  craniotabes.  Craniotabes  is  a  rachitic  manifestation  and 
depends  in  no  wise  upon  syphilis.  A  rachitic  cachexia  is  not  usually 
present  until  the  symptoms  have  existed  for  several  months,  and  in  many 
cases  it  is  not  seen  at  all. 

Deformities. — The  deformities  of  rickets  are  almost  invariably  sym- 
metrical in  character,  and  usually  numerous.  In  extreme  cases  almost 
every  bone  in  the  body  is  affected. 

Head. — This  usually  appears  to  be  too  large,  and  although  it  may  not 


PLATE  III 


Typical  Rickets 

Showing  the  large  head,  narrow  chest,  prominent  abdomen,  marked  enlargement 
of  the  epiphyses  at  the  wrists  and  ankles.  There  are  also  curvatures  of  the  forearms  and 
legs  which  are  not  so  well  shown. 

The  patient  a  child  two  and  a  half  years  old. 


RICKETS  -240 

be  greater  in  circumference  than  that  of  a  healthy  child  of  the  same  age, 
it  is  out  of  proportion  to  the  rest  of  the  body.  Jn  marked  cases  the 
increase  in' circumference  may  be  one  or  two  inches.  The  enlargement  is 
chiefly  due  to  thickening  of  the  cranial  bones.  In  one  case  with  marked 
deformity,  we  found  the  skull  over  the  parietal  bones  half  an  inch  in 
thickness  (Fig.  21).  This  thickening  diminishes  with  recover}',  but  in 
most  cases  the  head  remains  throughout  life  larger  than  it  should  be. 


Fig.  21. — Rachitic  Skull.     From  colored  child  two  years  old,  horizontal  section,  inner 
surface;   showing  thickening  of  the  bones,  especially  the  frontal,  and  open  fontanel. 

The  shape  of  the  rachitic  head  is  somewhat  square  (Fig.  22),  owing  to 
the  formation  of  large  bosses  over  the  parietal  and  frontal  eminences. 
It  is  flattened  at  the  occiput  from  pressure,  and  flattened  also  at  the 
vertex.  In  extreme  cases,  the  prominences  upon  the  frontal  and  parietal 
bones  may  be  so  great  as  to  produce  quite  a  marked  furrow  along  the  line 
of  the  sagittal  and  frontal  sutures,  and  one  at  right  angles  to  this  along 
the  coronal  suture  (Fig.  23).  This  condition  gives  unusual  prominence 
to  the  forehead.  Marked  deformity  of  the  head  has  been  observed  in 
about  one-third  of  our  cases.     The  sutures  may  remain  open  for  an 


NUTRITION 


iiiijiatiiral  time,  occasionally  until  the  end  of  the  first  year.    The  fontanel 
is  late  in  closing,  being  frequently  found  open  at  two  and  a  half,  and 

sometimes  even  at  three  years. 
"'^  Often  at  eighteen  or  twenty 
I  months  the  fontanel  is  two 
inches  in  diameter.  The  veins 
of  the  scalp  are  often  promi- 
nent, and  the  hair  is  frequent!}' 
worn  from  the  occiput,  owing  to 
restlessness  during  sleep.  Oc- 
casionally rickets  and  hydro- 
co})haliis  are  associated,  but  the 
association   is  accidental. 

(.'lu'st. — Beading  of  the  ribs 
lias  already  been  mentioned. 
This  is  the  most  characteristic 
feature,  but  in  the  majority  of 
cases  there  are,  in  addition, 
lateral  depressions  over  the 
lower  third  of  the  chest,  at  the 
line  of  junction  of  the  carti- 
lages with  the  ribs,  with  ever- 
sion  of  the  lower  border  of  the 
ribs,      ill  severe   cases   these   depressions   or   furrows    are   so    great   as 


'MJ: 


.  22. — Rachitic  Head.  Italian  child  two 
years  old;  square,  prominent  forehead  and 
flat  vertex. 


Fig.  23.— Rachitic  Skull  from  a  Child  One  Year  Old.     Showing  frontal  and  parietal 

bosses  and  wide  fontanel. 


RICKETS 


251 


to  cause  serious  deformity  (Plate  IV).  Usually  there  is  a  great 
diminution  in  the  transverse,  and  an  increase  in  the  autercjposterior, 
diameter  of  the  chest.  Fig.  24  shows  the  outline  of  the  chest  of  a  rachitic 
child  of  two  years,  compared  with  that  of  a  healthy  child  of  the  same  age. 
Another  frequent  deformity  is  the  "rachitic  girdle,"  which  consists  in  a 
transverse  depression  al)out  two  inches  broad,  extending  from  one  .side  of 
the  chest  to  the  other,  a  short  distance  above  its  lower  border.  The  chest 
wall  yields  at  the  attachment  of  the  diaphragm  which  becomes  more 
nearly  horizontal.  As  a  result  of  this  the  liver  becomes  somewhat  dis- 
placed downward.  Marked  thoracic  deformity  was  seen  in  about  twenty 
per  cent  of  our  cases,  but  in  only  a  small  proportion  was  the  chest  nor- 
mal. 

The  factors  in  the  production  of  the  thoracic  deformity  are  the  con- 


A  B 

Fig.  24.^A,  Horizontal  Section  of  a  Rachitic  Chest,  child  two  years  old,  showing 
lateral  furrows;    B,  Section  of  Chest  of  Healthy  Child  of  the  Same  Aoe. 


traction  of  the  diaphragm,  atmospheric  pressure,  and  soft  chest  walls, 
these  yielding  at  the  point  where  they  have  least  resistance,  viz.,  at  the 
junction  of  the  costal  cartilages  and  the  ribs.  The  swelling  of  the  costo- 
chondrai  junction,  which  is  much  accentuated  by  the  displacement  of  the 
cartilages  on  the  ribs,  limits  to  a  marked,  degree  the  capacity  of  the 
thorax.  When  there  exists  any  obstruction  to  the  entrance  of  air,  as  with 
bronchitis,  hypertrophied  tonsils,  or  adenoid  growths  of  the  pharynx,  the 
thoracic  deformities  are  exaggerated.  Irregular  chest  deformities  depend 
upon  the  co-existence  of  pathological  conditions  in  the  lungs.  Pigeon- 
breast  is  occasionally  seen,  but  it  is  doubtful  if  this  depends  upon  rickets 
alone.  • 

Spine. — In  very  many  of  the  milder  cases  this  is  normal.  I'he  most 
characteristic  deformity  consists  in  a  posterior  curve  (kyphosis),  which 
is  a  general  one,  usually  extending  from  the  mid-dorsal  to  the  sacral 
region  (Fig,  25).  'Hiis  existed  in  nearly  half  of  our  cases.  In  11k' 
early   part   of    the    disease    it    disappears    entirely    on    suspending    lln' 


252 


NUTEITION 


cliild,  or  making  extension  upon  the  extremities;  but  in  cases  of  long 
standing  it  may  not  disapi)ear  entirely  hy  these  tests.  Very  much  less 
frequently  there  is  seen  a  rotary  curvature.  This^,  in  our  experience^  has 
been  more  frequently  with  the  convexity  to  the  left  side -than  to  the 
right— the  opposite  of  th'e  common  form  of  lateral  curvature  -aeen  in 
young  girls.  Marked  lateral  curvature  in  ohiklren  under  three  years  is 
usually  rachitic. 

The  clavicle  is  affected  only  in  severe  cases.     The  usual  deformity 
consists  in  an  exaggeration  of  the  anterior  curve  at  the  inner  third  of 

the  bone,  which  is  somewhat  shortened  and 
its  extremities  enlarged.  It  is  not  infre- 
quently the  seat  of  green-stick  fracture;  . 

Deformities  of  the  pelvis  belong  -to';. ob- 
stetrics rather  than  to  pediatrics.  The  most 
common  rachitic  change  is  a  diminution  of 
the  anteroposterior  diameter  and  a  narrow- 
ing of  the  subpubic  arch. 

Extremities. — -Deformities  of  the  upper 
extremities  are  usually  symmetrical.  '  The 
humerus  is  aftected  only  in  severe  cases.-  It 
has  a  forward  and  ontward  curve,  altliougli 
rarely  a  very  marked  one.  Both  the  epiphy- 
ses are  enlarged,  although  the  upper  one  can 
not  well  be  made  out  unless  the  child  is  very 
thin.  The  radius  and  ulna  are  frequently 
"  ■       •  ■-  ^'      '•  affected.      They    present    a    convexity   uj)on 

their  extensor  surfaces,  which  in  some  cases  is  very  marked,  partic- 
ularly in  children  who  have  •  been  creeping.  Green-stick  fractures 
are  quite  frequent  here  as  they  are  also  in  the  femora. ,  They  are  fre- 
quently.multiple  and  occur  from  very  slight  causes,  sometimes  appar- 
ently from  muscular  contraction.  Multiple  fractures  -may  he  fouiidvwith 
no  separation,  the  periosteum  apparently  still  remaining  intact.  They 
are  frequently  found  in  the  fibula.  Eachitic  changes  at  the  epiphyses 
are  more  common  than  in  the  shaft,  enlargement  of  the  epiphyses  at  the 
Avrist  being-  one  of  the  most  constant  bony  deformities  of  rickets,  (Plate 
III).  Less  frequently  similar  swellings  are  seen  at  the  elbow.  Enlarge- 
ment of  the  ends  of  the  metacarpal  bones  or  the  phalanges  .'we -liave  seen 
but  seldom  and  only  in  extreme  cases. 

The  lower  extremities  are  rather  more  frequently  affected  than  the 
upper,  but  in  a  similar  way.  The  femur  is  involved  only  in  severe 
cases;  it  commonly  presents  a  general  forward  and  outward  curve, 
■wdiich  is  mainly  due  to  the  weight  of  the  legs  as  the  child  sits.  Occa- 
sionally there  is  also  an  outward  rotation  of  the  femur,  when  children 


Fig.     25. — Rachitic     Curva 

,    ;TURE  OF  THE  SpINE; 


PLATE  lY 


Deformity  of  the  Chest  in  Severe  Rickets 
In  the  upper  picture,  giving  the  external  view,  is  shown  a  deep  oblique  furrow  at  the 

junction  of  the  ribs  and  costal  cartilages,  these  meeting  at  an  acute  angle. 

In  the  lower  picture  the  ribs  have  been  separated  from  the  spine  and  spread  open, 

showing  the  same  deformity  as  it  appears  from  within,  looking  forwards. 
From  a  colored  child  ten  months  old. 


RICKETS 


253 


have  been  allowed  to  sit  much  in  a  cross-legged  posture.  When  such 
children  begin  to  walk,  the  toes  are  turned  very  far  outward.  The 
principal  deformities  of  the  lower  extremity  are  bow-legs  and  knock- 
knees.  Knock-knees  are  more  common  in  females,  and  are  believed  to 
be  due  to  an  overgrowth  of  the  iinier  condyle  of  the  femur.  Enlarge- 
ment of  both  condyles  can  be  demonstrated  in  most  of  the  marked  cases 
of  rickets.  The  cases  of  slight  bow-legs  may  be  due  simply  to  swelling 
of  the  epii^hyses,  the  shaft  of  the  bone  being  quite  normal.  This  point 
we  have  verified  by  post-mortem  observations.  Such  are  probably  most 
of  the  deformities  which  disappear  spontaneously.  The  most  severe 
cases  of  bow-legs  are  often  associated  with  some  degree  of  antero- 
posterior  curvature,   and   the   latter   may   be   the   principal   deformity. 


Fig.  26. — Multiple  Fractures  in  Rickets.     Showing  both  arms  of  the  same  patient; 
fractures  also  of  both  femora. 


Enlargement  of  the  epiphyses  at  the  ankles  is  usually  present  when  it  is 
seen  at  the  wrists,  and  nearly  to  the  sam.e  degree.  Enlargement  of 
the  upper  epiphyses  of  the  tibia  and  the  fibula  is  seen  only  in  severe 
cases.  The  cause  of  the  deformities  of  the  leg  is  not,  primarily,  at  least, 
walking  too  early,  since  they  are  common  in  children  who  have  never 
walked;  slight  deformities,  however,  may  be  aggravated  by  early  walk- 
ing. A  change  which  has  not  been  sufficiently  emphasized  is  the  arrested 
growth  of  the  long  bones ;  this  is  one  of  the  most  characteristic  features 
of  riclvets.  A  rachitic  child  of  three  years  often  measures  in  height  four 
or  five  inches  less  than  a  healthy  child  of  the  same  age,  the  difference 
being  almost  entirely  in  the  lower  extremities. 

All  the  ligaments,  but  particularly  those  about  the  large  joints,  are 

lax  and  frequently  elongated.    This  may  lead  to  the  deformity  known  as 

weak  ankles,  or  to  an  over-extension  at  the  knee   (genu  recurvatum) ; 

also  to  unnatural  mobility  at  the  hips,  shoulders,  elbows,  or  wrists.     The 

10 


254  NUTRITION 

condition  of  the  ligaments  plays  an  important  part  in  the  production  of 
spinal  deformities. 

Muscles. — The  muscular  symptoms  of  rickets  are  almost  as  constant 
and  as  characteristic  as  those  of  the  bones.  The  muscles  are  small,  very 
flabby,  and  poorly  d(?ve1o^d;  hence  rachitic  children  are  unable  to  sit 
erect,  or  to  stand  or  walk  at  the  usual  age.  Of  one  hundred  and  fifty- 
one  cases  in  which  the"  date  of  walking  alone  was  investigated,  only 
twenty-seven,  or  eighteen  per  cent,  walked  before  the  fifteenth  month; 
forty-seven  per  cent  were  not  walking  at  the  eighteenth  month;  twenty 
per  cent,  not  at  two  years ;  and  ten  per  cent,  not  at  two  and  a  half  years. 
Late  walking  is  one  of  the  most  common  symptoms  for  which  advice 
is  sought  by  parents  with  rachitic  children.  The  muscular  power  in  the 
extremities  is  sometimes  so  feeble  as  to  suggest  paralysis.  We  have  seen 
a  number  of  cases  in  which  the  symptoms  so  resembled  paralysis,  that 
even  expert  diagnosticians  were  unable  to  differentiate  rickets  from  pol- 
iomyelitis except  l)y  the  electrical  reactions,  those  in  rickets  being  usually 
normal  or  exaggerated.  In  other  cases  the  symptoms  may  suggest 
cerebral  palsy  of  the  flaccid  type.  The  muscular  symptoms  may  be 
marked  when  the  bony  changes  are  slight,  and  conversely.  As  no  lesions 
of  the  muscles  have  been  demonstrated,  the  symptoms  are  probably  due 
to  imperfect  nutrition.  Two  other  symptoms  depend  chiefly  upon  the 
condition  of  the  muscles,  viz.,  pot-belly  and  constipation. 

Pot-belly  is  quite  an  early  symptom,  and  in  most  cases  a  very  marked 
one  (Plate  III).  It  was  noted  in  sixty  per  cent  of  our  cases.  The  en- 
largement of  the  abdomen  is  uniform.  It  is  everywhere  tympanitic,  and 
it  may  be  as  tense  as  a  drumhead.  It  is  due  to  a  loss  of  tone  in  the 
abdominal  muscles,  and  in  the  muscular  walls  of  the  stomach  and  in- 
testine. It  is  aggravated  by  chronic  indigestion  and  excessive  intestinal 
fermentation.  The  enlargement  is  thus  mainly  from  tympanites.  There 
may  be  a  marked  degree  of  dilatation  both  of  the  stomach  and  the  colon. 
To  a  very  small  degree  only,  does  the  large  abdomen  depend  upon  swell- 
ing of  the  liver  or  spleen. 

The  constipation  of  rickets,  as  already  suggested,  depends  upon  the 
loss  of  tone  in  the  muscular  walls  of  the  intestines.  It  may  alternate 
with  diarrhea.  It  rarely  happens  that  a  rachitic  child  has  habitually 
normal  evacuations  from  the  bowels.  Hard,  dry,  constipated  stools  fre- 
quently set  up  a  condition  of  chronic  catarrh  of  the  colon  in  which  large 
masses  of  mucus  are  discharged. 

Fever. — Accordinf";  to  some  observers  there  is  a  febrile  movement 
which  belongs  to  the  active  stage  of  rickets,  but  Ave  have  never  been  able 
to  satisfy  ourselves  of  the  truth  of  this  observation. 

Dentition. — As  a  rule,  dentition  is  late  and  apt  to  be  difficult,  i.  e., 
it  is  associated  with  attacks  of  indigestion  or  other  disturbances  which 


RICKETS  255 

may  be  serious.  Individual  cases,  however,  present  great  variation  in 
regard  to  this  symptom.  A  study  of  the  progress  of  dentition  in  one 
hundred  and  fifty  rachitic  children  gave  the  following  results :  in  fifty 
per  cent  the  first  teeth  were  cut  on  or  before  the  eighth  month;  twenty 
per  cent  of  the  cases  had  no  teeth  at  twelve  months,  and  in  eight  per 
cent  none,  had  appeared  at  fifteen  months.  Even  though  the  first  teeth 
come  at  the  usual  time,  the  progress  of  dentition  is  usually  retarded  by 
the  development  of  rickets.  The  character  of  the  teeth  in  rickets  is 
usually  good.  This  is  in  striking  contrast  to  hereditary  syphilis,  where 
the  tendency  to  early  decay  is  constantly  seen. 

General  Appearance. — Children  suffering  from  marked  rickets 
are  almost  always  anemic.  The  majority  are  fat  and  flabljy.  The  tissues 
are  soft  and  have  but  little  resistance.  Earely,  they  may  be  thin,  like 
patients  suffering  from  marasmus. 

Eachitic  patients  are  very  prone  to  suffer  from  hypertrophied  tonsils, 
adenoid  growths  of  the  pharynx,  and  enlargements  of  the  lymph  nodes 
of  the  neck.  In  all  forms  of  acute  illness  the  feeble  resistance  of  these 
patients  is  very  evident.  This  is  especially  true  in  acute  disease  of  the 
lungs. 

The  mucous  membranes  are  very  vulnerable  in  all  rachitic  patients. 
From  the  slightest  indiscretion  in  diet  an  attack  of  acute  indigestion  or 
diarrhea  may  be  brought  on,  and  from  a  very  insignificant  exposure, 
catarrhal  inflammation  of  the  upper  or  lower  air  passages  is  excited. 
In  rachitic  patients  all  such  attacks  are  prone  to  run  a  protracted  course. 
Inflammation  of  the  trachea  and  larger  bronchi  is  likely  to  extend  to  the 
smaller  bronchi  and  the  lungs. 

The  downward  displacement  of  the  liver  and  spleen  from  contraction 
of  the  chest  should  not  be  mistaken  for  enlargement  of  these  organs. 
Moderate  enlargement  of  the  spleen  is  very  common  during  the  stage 
of  most  active  symptoms,  i.  e.,  from  the  sixth  to  the  twelfth  month. 
Great  enlargement  of  either  liver  or  spleen  is  infrequent. 

Blood. — Anemia  is  present  in  most  of  the  marked  cases,  its  intensity 
varying  with  the  severity  of  the  rachitic  process.  The  blood  picture  is 
usually  that  of  an  ordinary  secondary  anemia.  Leucocytosis  is  often 
present;  it  is  more  marked  in  cases  accompanied  by  an  enlarged  spleen. 

Nervous  Symptoms. — These  are  among  the  most  frequent  mani- 
festations of  rickets.  Eestlessness  at  night  has  already  been  men- 
tioned as  a  prominent  early  symptom.  Pain  and  tenderness  are  rare. 
A  disposition  to  muscular  spasm  is  seen  in  many  cases.  There  may 
be  laryngismus  stridulus,  general  convulsions  or  other  manifestations 
of  tetany.  It  was  formerly  believed  that  rickets  was  the  cause  of  the 
convulsions.  It  seems  now  apparent  that  it  is  the  associated  tetany 
which  is  intimately   dependent  upon  rickets.     The  clinical  evidences 


256  NUTRITION 

of  rickets  may  be  very  slight  yet  the  nervous  symptoms  be  very  marked. 
Calcium  Metabolism. — Owing  to  the  remissions  and  relapses  that 
occur  in  rickets  and  the  impossibility  of  determining  whether  the 
disease  is  active  or  not,  it  has  been  a  difficult  matter  to  study  the 
calcium  metabolism  of  rickets.  The  experiments  of  Schabad  show 
plainly  that  in  early  cases  either  the  retention  of  calcium  is  very  low 
or  there  is  an  actual  loss.  In  older  cases  there  may  still  be  a  diminished 
retention  or  it  may  be  nearly  normal,  depending  upon  the  stage  of  the 
disease.    In  convalescence  the  retention  is  two  or  three  times  the  normal. 

Course  and  Termination. — Eickets  is  essentially  a  chronic  disease,  and 
its  course  is  measured  by  months.  The  active  symptoms  in  most  cases 
continue  from  three  to  fifteen  months,  being  interrupted  from  time  to 
time  by  remissions,  but  these  are  seldom  appreciated   clinically. 

The  earliest  symptoms  of  improvement  are  a  diminution  in  the 
nervous  symptoms,  especially  in  the  restlessness  at  night;  increased 
muscular  power,  as  shown  by  a  disposition  to  stand  or  walk;  diminution 
in  the  head-sweats;  disappearance  of  the  craniotabes;  and  improve- 
ment in  the  anemia.  The  changes  in  the  deformities  are  very  slow,  and 
from  month  to  month  almost  imperceptible.  When  improvement  once 
begins,  however,  it  usually  goes  steadily  forward. 

Congenital  Bickets. — In  the  middle  of  the  last  century,  all  bone 
abnormalities  apparent  at  birth  were  believed  to  be  due  to  fetal  rickets. 
Further  investigation  has  shown  that  most  of  them  were  examples  of 
chondrodystrophy  or  osteogenesis  imperfecta.  Ivassowitz  and  more 
recently  others  have  maintained  that  rickets  is  usually,  if  not  always, 
congenital  in  origin.  More  careful  clinical  observation  and  especially 
pathological  studies  have  shown,  however,  that  evidences  of  rickets  are 
not  to  be  found  at  birth.  There  is  probably  no  such  condition  as  fetal 
rickets. 

Late  Rickets. — Eare  instances  have  been  reported  of  bony  deformi- 
ties in  all  respects  like  those  of  rickets,  developing  in  children  from 
six  to  twelve  years  old.  The  course  is  slow  and  the  deformity  fre- 
quently extreme.  A  number  of  cases  studied  microscopically  by  such 
authorities  as  Schmorl  and  Schmidt  leave  no  room  for  doubt  as  to  the 
existence  of  the  condition.  It  is  very  imusual  in  this  country.  We  have 
never  seen  a  case. 

Acute  Rickets. — Although  from  time  to  time  cases  have  been  reported 
with  this  title,  from  a  study  of  the  histories  it  is  clear  that  the  great 
majority,  if  not  all  of  them,  were  cases  of  infantile  scurvy.  It  is  doubt- 
ful whether,  strictly  speaking,  there  is  such  a  thing  as  acute  rickets. 

Diagnosis. — The  diagnosis  of  rickets  is  not  usually  difficult.  The 
most  important  early  symptoms  for  diagnosis  are  sweating  of  the  head, 
craniotabes,  great  restlessness  at  night,  delayed  dentition,  and  enlarged 


RICKETS  257 

fontanel.  Each  of  these,  taken  separately,  may  mean  something  else,  but 
collectively  they  can  mean  nothing  but  rickets.  In  the  later  stages  some 
of  the  characteristic  deformities  are  usually  present;  the  most  constant 
are  beading  of  the  ribs,  enlargement  of  the  epiphyses  of  the  wrists  and 
ankles,  and  bow-legs. 

Special  symptoms,  when  unusually  prominent,  may  give  rise  to  diffi- 
culty in  diagnosis.  The  enlargement  of  the  head  may  be  mistaken  for 
hydrocephalus.  The  delayed  dentition  and  large  fontanel  of  the  cretin 
may  be  mistaken  for  rickets.  Muscular  weakness  may  be  so  great,  espe- 
cially when  affecting  the  legs,  as  to  make  it  easy  to  mistake  a  rachitic 
pseudo-paralysis  for  actual  paralysis  due  to  a  cerebral  or  spinal  lesion. 
When  walking  is  much  delayed,  rickets  may  be  passed  over  as  simple 
backwardness.  In  nearly  all  of  the  last-mentioned  group  of  cases  the 
diagnosis  may  be  established  by  a  careful  search  for  the  bony  changes, 
and  by  the  fact  that  in  rickets  there  is  only  a  general  weakness  of  all 
the  muscles,  and  not  actual  paralysis  of  any  limb  or  group  of  muscles. 
The  greatest  difficulty  is  usually  found  when  the  muscular  symptoms 
are  marked  and  the  bony  changes  slight,  as  is  not  infrequently  the  case. 
Here  the  question  is,  whether  rickets  is  sufficient  to  explain  all  the  symp- 
toms, or  whether  in  addition  some  other  condition  is  present.  The 
electrical  reactions  will  usually  decide  the  question  of  poliomyelitis,  while 
the  presence  of  cerebral  syinptoms,  exaggerated  knee-jerks,  and  rigidity 
of  the  J^gs,  will  usually  mark  jnf ant ile'^ cerebral  paralysis.  The  bony 
enlargements  of  syphilis  may  be  confounded  with  those  of  rickets.  The 
bony  changes  of  early  syphilis,  although  affecting  the  epiphyses  are 
seen  at  an  earlier  age  and  are  generally  accompanied  by  pain  and  ten- 
derness, sometimes  by  epiphyseal  separation,  none  of  which  are  seen  in 
rickets.  The  bony  changes  of  late  syphilis  affect  the  shaft  rather  than 
the  extremities  of  the  long  bones;  when  the  bone  is  enlarged  near  the 
joint  it  IS  usually  upon  one  side  only.  In  syphilis  there  may  be  necrosis, 
while  in  rickets  breaking  down  of  bone  is  never  seen.  From  scurvy, 
rickets  is  differentiated  by  the  absence  of  marked  hyperesthesia,  ecchy- 
moses,  and  other  hemorrhages,  the  changes  in  the  gums,  and  most  of  all 
by  the  fact  that  anti-scorbutic  diet  produces  no  immediate  change  in 
the  symptoms.  The  diagnosis  of  rachitic  curvature  of  the  spine  from 
vertebral  caries  will  be  considered  in  connection  with  the  latter  disease. 

Prognosis. — Rickets  per  se  is  seldom,  if  ever,  a  cause  of  death.  It  is, 
however,  a  large  factor  in  the  mortality  of  the  first  two  years,  as  it 
predisposes  strongly  to  many  forms  of  acute  disease.  It  is  an  important 
etiological  factor  in  certain  serious  nervous  conditions,  especially  tetany. 
Eickets  adds  very  greatly  to  the  danger  from  all  acute  diseases  of 
infancy,  particularly  those  of  the  respiratory  tract.  The  encroach- 
ment upon  the  capacity  of  the  lungs  by  a  marked  thoracic  deformity. 


258  NUTRITION 

may  in  itself  be  enough  to  keep  a  child  in  a  delicate  condition  and 
retard  its  growth.  At  the  same  time  such  a  condition  is  a  constant 
invitation  to  acute  attacks  of  bronchitis  or  pneumonia.  The  effect  of 
rickets  upon  the  future  health  of  the  child  depends  chiefly  upon  the 
presence  and  extent  of  the  thoracic  deformity.  When  this  is  severe, 
the  child  usually  succumbs  to  some  acute  respiratory  disease  during 
the  first  few  years  of  life.  When  this  is  absent,  although  children 
may  remain  somewhat  dwarfed  on  account  of  their  short  legs,  in  other 
respects  they  may  be  as  well  as  if  they  had  never  been  the  subjects 
of  rickets. 

Treatment. — In  considering  the  treatment  of  rickets,  the  natural 
course  of  the  disease  is  to  be  kept  in  mind,  viz.,  that  active  symptoms 
frequently  continue  only  until  the  end  of  the  first  year,  rarely  longer 
than  the  eighteenth  or  twentieth  month.  The  most  important  period 
for  treatment,  therefore,  and  the  one  in  which  it  is  most  effective,  is 
from  the  sixth  to  the  eighteenth  month.  The  earlier  the  treatment 
is  begun  the  better  will  be  its  results.  General  treatment  after  the 
eighteenth  month,  has  very  little  effect  upon  the  disease,  for  by  this 
time  most  of  the  harm  has  been  done.  The  course  of  the  disease  when 
untreated  is  toward  spontaneous  recovery.  Most  of  the  cases  seen  in 
private  practice  are  of  a  mild  type  and  recover  without  special  treat- 
ment, often  no  diagnosis,  being  made  until  later  in  life,  when  the  bony 
deformities  or  stunted  growth  indicate  the  previous  existence  of  rickets. 

Diet. — The  most  frequent  dietetic  error  in  rachitic  patients  being  an 
excess  of  carbohydrates  and  an  insufficient  supply  of  fat,  it  follows 
that  condensed  milk,  proprietary  infant  foods,  and  large  amounts  of 
farinaceous  foods  of  every  description  should  be  stopped.  A  suitably 
modified  cow's  milk  should  be  substituted  or  for  young  infants  a 
wet-nurse  should  be  secured.  But  supplementary  feeding  of  cow's 
milk  should  be  given  so  as  to  insure  a  sufficient  supply  of  calcium.  As 
soon  as  possible  other  food,  such  as  thick  gruels,  scraped  meat,  fruit 
juices  or  stewed  fruit,  should  be  offered  and  vegetable  soups  from  which 
the  vegetables  have  been  strained  out  or  in  which  they  are  very  finely 
divided.  Most  infants  are  eight  to  ten  months  old  before  rachitic  symp- 
toms are  observed;  to  them  the  above  mentioned  articles  of  diet  may 
be  given  almost  immediately  unless  digestive  symptoms  are  marked. 
Breast  feeding  should  be  interrupted.  Cream  is  often  badly  borne  and 
some  other  form  of  fat  must  be  substituted.  The  fat  of  crisp  bacon 
upon  stale  bread  or  zwieback  serves  well.  The  change  to  solid  food 
should  be  made  earlier  than  with  normal  children,  and  not  more  than 
a  pint  of  milk  should  be  allowed  a  day. 

Hygiene. — In  large  cities  it  is  almost  impossible  to  secure  for  rachitic 
patients  the  surroundings  they  require.     Whenever  possible,  such  chil- 


KICKETS  259 

dren  shauld  be  sent  to  the  country ;  but  when  this  is  out  of  the  question, 
much  may  be  accomplished  by  frequent  excursions  upon  the  water  or 
into  the  country,  by  keeping  children  as  much  as  possible  in  the  parks 
and  open  squares  of  the  city,  and  securing  plenty  of  fresh  air  in  sleep- 
ing rooms.  Cold  sponge-baths  given  every  morning,  do  much  to  lessen 
their  susceptibility  to  rhinopharyngitis  and  bronchitis.  Sunshine, 
though  difficult  to  obtain  in  large  cities,  is  a  most  efficient  therapeutic 
agent.  The  establishment  of  suburban  hospitals  and  homes  for  these 
cases  would  do  much  to  lessen  the  mortality  from  rickets. 

Medicinal  treatment. — In  a  disease  which  tends  so  uniformly  to 
recovery  when  causal  conditions  are  removed,  it  is  difficult  to  estimate, 
by  clinical  observation,  the  real  value  of  medicinal  treatment.  Arsenic 
and  iron  are  valuable  in  the  treatment  of  rickets,  the  special  indication 
for  their  use  being  the  presence  of  marked  anemia.  Profuse  sweating 
may  be  relieved  by  small  doses  of  atropin,  i.  e.,  gr.  1/800,  three  or  four 
times  a  day,  to  a  child  of  six  months.  The  special  remedies  most  used 
are  cod-liver  oil,  phosphorus,  and  preparations  of  calcium. 

Various  preparations  of  calcium  have  long  been  employed  with  the 
belief  that  they  could  supply  lime  to  the  tissues.  It  is  now  practically 
certain  that  calcium  is  present  in  sufficient  quantity  in  the  blood.  It 
cannot  be  utilized.  Calcium,  therefore,  in  active  rickets  has  no  value.  In 
convalescence,  during  the  stage  of  extreme  calcium  retention,  it  may 
be  of  assistance.  It  may  be  offered  in  the  form  of  acetate  or  lactate. 
The  two  important  remedies  for  rickets  are  cod-liver  oil  and  phosphorus. 
No  remedy  for  rickets  has  held  its  place  so  long  as  has  cod-liver  oil. 
Phosphorus,  popularized  in  the  treatment  of  this  disease  by  Kassowitz, 
has  also  some  value;  its  most  striking  results  are  seen  in  the  early  cases 
and  when  nervous  symptoms  are  marked.  The  best  results  are  obtained 
by  a  combination  of  these  two  remedies.  The  officinal  oil  of  phosphorus 
is  used  in  combination  with  cod-liver  oil,  gr.  1/300  to  1/200  is  given 
three  times  a  day  with  one-half  dram  to  one  dram  of  the  oil.  Striking 
confirmation  of  the  clinical  observations  regarding  the  value  of  this 
combination  is  furnished  by  the  metabolism  experiments  of  Schabad  who 
found  the  percentage  of  calcium  retention  greatly  increased  by  the  use 
of  cod-liver  oil  and  phosphorus. 

Treatment  of  the  Rachitic  Deformities. — The  deformities  of  the 
chest  are  less  amenable  to  treatment  than  are  most  of  the  others.  After 
the  third  year  something  can  be  done  by  gymnastics  to  develop  the  chest 
muscles  and  to  increase  the  pulmonary  expansion. 

The  deformity  of  the  spine  (kyphosis)  may  usually  be  overcome  by 
postural  treatment.  The  patient  should  lie  upon  a  hard  bed ;  no  pillow 
should  be  allowed  under  the  head,  but  in  severe  cases  one  should  be 
placed  beneath  the  back,  so  that  the  head  and  buttocks  are  slightly  lower 


260  NUTRITION 

than  the  lumbar  spine.  While  sitting,  the  shoulders  should  .be  kept 
back  and  the  trunk  supported.  For  a  few  minutes  each  day  the  child 
should  be  placed  upon  the  face,  and  the  deformity  overcome  by  raising 
the  buttocks  while  pressure  is  made  upon  the  spine.  In  severe  cases, 
an  apparatus  for  giving  spinal  support,  either  by  a  steel  brace  or  a  plaster- 
of-Paris  jacket,  may  be  worn  a  few  hours  each  day  when  the  child  is 
sitting  up.  Other  means  should  be  employed,  especially  friction  and 
massage,  to  develop  the  spinal  muscles. 

In  very  many  cases  slight  deformities  of  the  extremities  are  outgrown 
when  the  general  treatment  can  be  properly  carried  out.  If  the  deform- 
ity is  not  great  and  not  increasing,  it  is  safe  to  continue  with  general 
treatment  only.  If  the  deformity  is  marked  or  if  it  increases  in  spite 
of  the  constitutional  treatment,  orthopedic  apparatus  should  be  applied. 
Something  may  be  done  toward  straightening  the  bones  by  intelligent 
manipulation.  Walking  should  be  discouraged  until  the  bones  are  quite 
firm.  Friction  of  the  extremities  and  massage  will  do  very  much  to  in- 
crease muscular  development.  The  halnt  of  sitting  cross-legged — a  very 
common  one  in  rachitic  children — should  be  prevented,  and  in  fact  any 
other  habitual  posture,  on  account  of  the  danger  of  increasing  certain 
deformities.  But  little  is  to  be  expected  from  the  use  of  apparatus  for 
the  correction  of  rachitic  deformities  after  the  child  is  two  and  a  half 
years  old;  since  at  this  time,  and  often  even  at  two  years,  the  bones  are 
so  firm  that  no  amount  of  pressure  from  a  steel  brace  will  have  any  effect. 

Without  going  fully  into  the  question  of  the  surgical  treatment  of 
rachitic  deformities,  for  which  the  reader  is  referred  to  text-books  of 
general  and  orthopedic  surgery,  we  will  only  state  that  osteotomy  seems 
to  us  to  offer  decided  advantages  over  the  other  means  of  treating  severe 
deformities.  The  best  results  from  osteotomy  are  obtained  when  the 
operation  is  delayed  until  the  fourth  or  fifth  year,  by  which  time  the 
bones  are  sufficiently  firm  and  solid.  Operations  in  the  second  year  are 
generally  unsatisfactory,  and  those  in  the  third  year  often  so,  because  of 
the  bending  of  the  bones  which  takes  place  subsequently.  The  deform- 
ities which  require  operation  are  bow-legs  and  knock-knees,  less  fre- 
quently the  curvatures  of  the  femur  or  the  bones  of  the  forearm. 


CHAPTER   VII 

DIATHESES 

The  conception  of  constitutional  differences  is  not  a  new  one.  It  has 
been  recognized  for  more  than  a  hundred  years  that,  under  the  same 
conditions,  one  person  reacts  physically  in  a  different  way  from  another. 


THE  EXUDATIVE  DIATHESIS  261 

and  that  this  is  especially  true  of  infants.  To  explain  this,  a  peculiarity 
of  constitution  has  been  assumed.  Before  the  development  of  bacteri- 
ology this  idea  was  generally  accepted  to  explain  such  a  condition  as 
scrofula.  When  it  became  apparent  that  many  of  the  symptoms  of 
scrofula  were,  in  reality,  symptoms  of  tuberculosis,  the  conception  was 
gradually  given  np.  But  in  the  last  few  years  emphasis  has  again 
been  laid  upon  variation  in  constitution  and  this  has  come  into  more 
and  more  prominence.  It  should  be  recognized,  however,  that  the  basis 
of  a  division  into  groups  rests  upon  clinical  symptoms  only,  and  for 
this  reason  there  have  beeii  great  differences  of  opinion  in  regard  to 
the  limits  of  the  various  diatheses  and  what  infants  should  be  included 
in  one  or  the  other  group.  While  many  diatheses  have  been  described, 
there  are  but  two  that  stand  out  with  sufficient  clearness  to  justify  their 
consideration  as  entities.  These  are  the  "exudative  diathesis''  of  Czerny 
and  the  "neuropathic"  or  "psychoneuropathic  diathesis." 


THE  EXUDATIVE  DIATHESIS 

This  diathesis  has  been  described  amder  different  names  by  many 
observers.  It  is  the  one  which  was  first  recognized.  Many  of  the  symp- 
toms were  formerly  classed  under  the  old  name  of  "scrofulous"  dia- 
thesis. But  the  symptoms  which  are  now  considered  by  Czerny  to 
belong  to  the  exudative  diathesis  depend  in  no  way  upon  tuberculosis. 
They  are  manifested  early  in  life  and  are  largely  confined  to  lesions  of 
the  skin  and  mucous  membranes.  Infants  with  this  diathesis  often 
show  early  seborrhea  of  the  scalp,  and  they  are  particularly  liable  to 
eczema,  which  may  develop  upon  the  face  alone  or  all  over  the  body. 
They  are  usually  well  nourished,  oftentimes  very  fat  infants,  but  their 
musculature  is  usually  flabby  and  there  is  almost  always  anemia  of 
greater  or  less  intensity.  Depending  upon  the  extent  of  the  eczema, 
eosinophilia  is  present.  Less  commonly,  in  this  country  at  least,  the 
papules  and  lesions  of  lichen  strophulus  are  formed.  There  is  a  marked 
tendency  to  rhinopharyngitis  and  as  a  result  there  is  frequently  otitis 
media.  The  superficial  glands,  especially  those  in  the  neighborhood 
of  the  lesions,  are  somewhat  enlarged. 

The  general  nutrition,  as  has  been  said,  is  usually  fairly  main- 
tained, but  when  the  eczema  is  severe  the  irritation  from  this  and  the 
consequent  loss  of  sleep  may  seriously  affect  the  infant's  general  con- 
dition. 

Though  chemical  changes  have  been  described  in  these  children, 
there  are  none  sufficiently  striking  to  justify  a  diagnosis  without  clinical 
symptoms.    There  is  a  tendency  to  retention  of  chlorids,  and  an  increased 


262  NUTRITION 

sugar   content  of  the  blood  has  been  claimed,   but  both  of  these  are 
inconstant. 

After  the  first  year  the  manifestations  of  the  exudative  diathesis 
usually  diminish  in  intensity;  they  are  frequently  absent  after  the  sec- 
ond or  third  year,  though  they  may  remain  in  evidence  for  a  longer 
period.  There  can  be  no  doubt  that  giving  a  large  amount  of  food 
increases  the  severity  of  the  symptoms  and  that  such  children  do  better 
upon  a  restricted  diet.  Fat  in  excess  in  the  diet  increases  the  severity 
of  the  cutaneous  symptoms  and  a  diet  of  milk  alone,  after  the  first  few 
months,  aggravates  the  condition.  It  is  wise  to  employ  carbohydrates 
as  early  as  possible.  For  this  reason  thick  gruels  should  be  used  as 
diluents,  even  in  the  first  few  weeks,  and  the  milk  replaced  by  them  as 
far  as  this  can  be  done.  By  the  eighth  or  ninth  month,  or  even  earlier, 
cereal  may  be  given  with  a  spoon  once  or  twice  a  day.  Thereafter,  milk 
should  form  only  a  small  part  of  the  diet  and  throughout  infancy  and 
childhood  the  quantity  of  food  should  be  regulated  and  restricted  more 
particularly  than  with  other  children. 


THE  NEUROPATHIC  DIATHESIS 

The  neuropathic  child  may  give  evidences  of  his  peculiar  constitution 
during  infancy,  or  sometimes  not  until  he  is  several  years  of  age.  'No 
matter  at  what  age  the  symptoms  are  manifest,  it  is  usually  inheritance 
that  is  responsible  for  the  highly  irritable  nervous  system  of  these  chil- 
dren. In  almost  all  instances  one  or  both  parents  are  neurotic.  Environ- 
ment plays  distinctly  a  secondary  part,  but  is  important  even  in  infancy. 

The  Neuropathic  Infant. — The  condition  may  reveal  itself  even  in 
the  first  weeks  of  life  in  an  unusually  early  reaction  to  sights  and  sounds. 
Infants  may  fix  their  attention  upon  people  and  objects  as  early  as  the 
third  or  fourth  week,  and  thus  are  readily  startled  and  terrified  by 
things  to  which  the  normal  infant  pays  no  attention.  Sleep  is  often- 
times disturbed.  Such  children  are  precocious  and  on  this  account 
often  receive  much  attention  from  parents  and  nurses,  which  practice 
has  a  tendency  greatly  to  increase  their  symptoms.  Ordinarily,  how- 
ever, not  much  notice  would  be  given  to  the  abnormal  constitution  except 
for  the  development  of  two  symptoms  which  are  particularly  striking. 
The  first  of  these  is  vomiting  and  the  second,  diarrhea. 

The  vomiting  is  usually  characterized  by  the  fact  that  it  takes  place 
very  readily  without  any  apparent  discomfort  and  that  the  simplest 
forms  of  food  and  even  water  may  be  vomited.  Vomiting  may  develop 
without  sufficient  cause  and  the  usual  symptoms  ordinarily  associated 
with  it  are  entirely  absent.     Frequently  the  food  is  simply  regurgi- 


THE  NEUROPATHIC  DIATHESIS  263 

tated  into  the  mouth  where  it  may  he  hehl  and  swallowed  again  or  it 
may  run  out  at  the  corners,  of  the  mouth. 

The  vomiting  may  he  only  occasional  with  no  interference  with  weight 
and  growth,  or  it  may  he  so  severe  as  to  cause  a  marked  loss  of  weio-lit 
and  even  threaten  life.  It  sometimes  ceases  spontaneously;  at  other 
times  it  may  be  most  obstinate.  The  diarrhea  also  varies  in  severity.  It 
may  occur  with  breast-fed  as  well  as  artificially-fed  infants.  The  stools 
may  be  only  slightly  more  frequent  than  normal,  three  to  five  a  day, 
and  well  digested;  or  they  may  be  much  more  numerous  and  passed 
through  the  intestinal  tract  so  rapidly  that  they  are  undigested  and 
frequently  contain  mucus. 

The  diarrhea  is  apparently  caused  by  an  excessive  irritability  of 
the  intestines,  an  increased  reaction  of  the  nerves  to  the  stimuli  which 
ordinarily  produce  moderate  peristalsis.  As  a  result,  the  food  is  hur- 
ried along  more  or  less  unchanged,  together  with  increased  intestinal 
secretions.  The  diarrhea  may  be  most  obstinate.  Marked  and  even 
serious  malnutrition  may  result. 

A  recognition  of  the  essential  condition  is  necessary  for  proper 
treatment.  Such  infants  should  be  kept  as  quiet  as  possible  with  no 
excitement  or  unnecessary  handling,  li  vomiting  is  present,  the  food 
should  be  given  at  four-hour  intervals.  When,  in  spite  of  reduction  of 
the  fat  and  elimination  of  sugar,  vomiting  continues,  solid  food  given 
with  a  spoon  is  usually  retained.  This  food  is  preferably  some  form 
of  cereal  such  as  farina  or  barley  thoroughly  cooked,  but  so  thick  that 
it  must  be  given  with  a  spoon.  Infants  as  young  as  four  or  five  months 
take  this  admirably, — two  or  more  ounces  every  four  hours.  The  propor- 
tion of  one  part  of  cereal  to  ten  parts  of  milk  is  usually  thick  enough ;  at 
limes,  however,  it  must  be  as  thick  as  one  part  of  the  cereal  to  five  of 
milk,  in  order  to  prevent  regurgitation.  If  a  flour  is  used,  this  should 
be  cooked  for  at  least  an  hour, — for  coarse  cereals  three  to  four  hours 
are  necessary.  This  diet  may  be  continued  until  other  food  is  added 
at  the  end  of  the  first  year.    Water  should  be  given  between  the  feedings. 

The  treatment  of  the  diarrhea  is  conducted  along  the  same  lines 
as  with  diarrhea  from  other  causes.  The  essential  condition,  an  in- 
creased peristalsis,  is  the  same  in  either  case.  The  irritation  of  the 
intestinal  contents  should  be  diminished.  The  irritating  products,  the 
lower  fatty  acids,  are  found  in  smaller  amount  when  there  is  an  excess 
of  protein  in  the  diet  and  when  the  fats  and  sugars  are  much  reduced. 
For  this  reason  with  nursing  infants  striking  benefit  is  often  seen  after 
substituting  buttermilk  for  one  or  more  feedings  of  breast  milk.  With 
artificially  fed  children  a  reduction  of  the  sugar  is  usually  necessary. 
Carbohydrates  in  the  form  of  gruels  are  much  better  borne  than  the 
sugars.     When  diarrhea  is  excessive,  protein  milk  may  be  necessary,  at 


264  XUTRITIOX 

first  without  and  later  with  the  addition  of  a  preparation  of  maltose. 
Success  is  only  obtained  with  continuous  and  intelligent  care. 

The  Neuropathic  Child. — He  is  the  product  of  both  hereditary  condi- 
tions and  the  environment  in  which  he  lives.  The  child  who  is  nervous 
by  inheritance  is  rendered  much  more  so  by  continual  association  with 
nervous  parents,  especially  if,  being  an  only  child,  he  is  the  subject 
of  their  undivided  solicitude.  Acquired  nervousness  is  by  no  means 
infrequent  as  the  result  of  disease  or  bad  environment,  but  is  lost  as 
soon  as  the  influence  that  is  responsible  for  it  is  removed.  Xervousness 
is  more  common  in  girls  than  in  boys  and  is  especially  seen  in  the  Hebrew 
and  Latin  races.  It  is  much  increased  by  a  faulty  method  of  living,  by 
late  hours  and  especially  by  tea  and  coffee  and,  in  boys,  by  cigarette 
smoking. 

The  symptoms  relate  not  only  to  the  nervous  system  but  to  the  physi- 
cal condition  of  the  child  as  well.  Xeurotic  children  are  almost  always 
poorly  nourished.  They  have  labile  vasomotor  systems  and  for  that 
reason  blush  readily  and  very  often  have  cold  hands  and  feet.  The  pulse 
is  apt  to  be  rapid  and  undergoes  a  marked  increase  in  rapidity  after 
slight  exertion,  or  as  the  result  of  the  slightest  nervous  impression. 
These  children  are  usually  anemic;  their  appetite  is  poor  and  they  often 
suffer  habitually  from  constipation.  It  is  not  infrequent  for  diarrhea 
to  occur,  particularly  as  the  result  of  excitement.  Cardiac  palpita- 
tion is  frequently  complained  of.  Nervous  vomiting  is  seen  with  chil- 
dren, girls  especially,  of  the  school  age.  It  occurs  in  the  morning 
immediately  after  breakfast,  is  accomplished  without  effort  and  there 
is  usually  no  nausea.  The  appetite  may  remain  fair  and  there  is  no 
vomiting  at  any  other  time.  Nocturnal  enuresis  is  found  with  many 
neurotic  patients,  and  masturbation  is  not  infrequent  even  in  those  of 
two  or  three  years. 

Mentally,  neuropathic  children  are  apt  to  be  bright,  often  preco- 
cious, but  they  usually  show  a  great  lack  of  concentration.  They  are 
frequently  animated,  talk  rapidly,  oftentimes  stammering.  They  are 
never  quiet,  are  full  of  restless  energ}',  changing  rapidly  from  one  occu- 
pation to  another  but  soon  tire  and  constantly  complain  of  fatigue. 
Headache  is  frequent  and  often  persistent.  Vague  pains  in  almost 
every  situation  are  complained  of.  Some  of  these  children  are  con- 
firmed hypochondriacs.  Many  are  affectionate  and  attractive,  but  they 
are  usually  self-willed  and  often  tyrannize  over  the  household.  They  are 
greatly  affected  by  nervous  impressions,  often  timid  and  readily  cry 
or  laugh.  Tremor  of  the  hands  or  eyelids  is  not  uncommon  and  the 
facial  phenomenon  (Chvostek's  symptom)  is  present  in  many.  All 
sorts  of  habit  spasm  are  of  frequent  occurrence  and  in  rheumatic  chil- 
dren chorea  is  a  common  manifestation. 


THE   NKUROPATHTC  DIATHESIS  265 

Sleep  is  usually  poor.  Such  children  have  gTeat  difficulty  in  going 
to  sleep  and  occasionally  have  night  terrors.  In  general,  nervous 
children  demonstrate  a  combination  of  irritability  to  all  impressions 
with  a  ready  exhaustion.  Untreated,  they  are  apt  to  grow  up  into 
nervous,  often  hypochondriacal  adults.  Even  with  the  greatest  care 
and  wisest  treatment  it  is  a  long  and  tedious  process  to  bring  about 
an  approach  to  the  normal. 

Treatment  consists  largely  in  the  wise  management  of  the  daily  life. 
It  is  frequently  necessary  to  remove  the  child  entirely  from  the  environ- 
ment in  which  he  has  been  living.  The  person  in  charge  should  be  one 
who  will  not  spoil  or  indulge  the  child  and  will  bring  about  a  proper 
regime  with  a  gentle  but  firm  control.  It  is  necessary  to  observe  with 
the  greatest  care  all  of  the  measures  which  promote  the  physical  wel- 
fare of  the  child  and  especially  to  prevent  any  unnecessary  stimuli  to 
the  nervous  system. 

I^ervous  children  are  much  benefited  by  association  with  others 
of  their  own  age.  jSTo  greater  mistake  can  be  made  than  to  keep  such 
a  child  by  himself  for  a  prolonged  period;  but  it  must  be  remembered 
that  he  is  usually  unable  to  bear  either  the  physical  or  the  mental  strain 
to  which  normal  children  are  constantly  subjected.  For  that  reason 
the  periods  both  of  study  and  play  should  be  short.  Education  at  home 
is  usually  undesirable;  but  school  hours  must  be  carefully  adjusted  to 
the  child's  endurance.  He  should  not  be  allowed  to  become  either  physi- 
cally or  mentally  exhausted.  Frequent  short  periods  6i  rest  are  neces- 
sary; it  is  often  desirable  to  keep  a  child  in  bed  for  two  or  three  days  once 
or  twice  a  month.  Particularly  to  be  avoided  are  such  things  as  motor- 
ing, children's  parties,  theaters,  moving  picture  shows,  etc.  Altogether 
the  most  satisfactory  way  of  bringing  up  such  a  child  is  in  the  country 
away  from  the  excitement  and  distractions  of  city  life. 

•  Drugs  play  a  very  insignificant  part  in  treatment  and  should  be 
given  only  for  particular  symptoms.  Tonics,  when  indicated,  may  be 
given,  but  sedatives  to  the  nervous  .system  should  be  avoided.  It  is 
quite  useless  to  expect  relief  from  such  operations  as  the  removal  of 
the  tonsils,  adenoids,  circumcision,  etc.  Unless  the  necessity  for  them 
is  plain,  they  often  do  more  harm  than  good. 


SECTION    III 
DISEASES    OF    THE    DIGESTIVE    SYSTEM 

CHAPTER    I 
DISEASES    OF    THE   LIPS,    TONGUE,    AND    MOUTH 

MALFORMATIONS 

Harelip. — This  is  one  of  the  most  frequent  congenital  deformities. 
It  is  caused  by  an  incomplete  fusion  of  the  central  process  with  one  or 
both  of  the  lateral  processes  from  which  the  upper  half  of  the  face  is  de- 
veloped. This  deformity  may  be  single  or  double ;  the  fissure  is  never  in 
the  median  line,  but  usually  just  beneath  the  center  of  the  nostril.  There 
may  be  simply  a  slight  indentation  in  the  lip,  or  the  fissure  may  extend 
to  the  nostril.  Both  single  and  double  harelip — niore  frequently  the  lat- 
ter— may  be  complicated  by  fissure  of  the  palate.  Double  harelip  is 
usually  accompanied  by  a  fissure  between  the  intermaxillary  and  the 
superior  maxillary  bone  of  each  side. 

Cleft  Palate. — This  is  second  in  frequency  to  harelip.  It  may  involve 
the  soft  palate  only,  or  the  fissure  may  extend  into  the  hard  palate,  pro- 
ducing a  wide  gap  in  the  roof  of  the  mouth.  The  most  frequent  form 
is  that  in  which  only  the  soft  palate  is  affected. 

For  the  surgical  treatment  of  both  these  deformities  the  reader  is 
referred  to  text-books  upon  surgery.  As  to  the  time  of  operation  with 
either  harelip  or  cleft  palate, — in  general,  operation  should  be  performed 
as  soon  as  the  condition  of  the  child  will  admit.  With  a  vigorous  child, 
it  should  be  done  in  the  first  two  weeks  of  life. 

If  the  child  is  premature  or  feeble,  it  is  not  wise  to  operate  at  once, 
'but  it  is  always  to  be  remembered  that  it  does  not  necessarily  follow  that 
the  child's  condition  will  be  better  at  another  time.  The  nutrition  is 
always  a  matter  of  much  difficulty  and  without  operation  a  very  large 
number  of  these  cases  die  of  inanition  and  marasmus,  even  with  the  best 
care.  The  medica!  treatment  consists  in  the  care  of  the  mouth  and  in  the 
nutrition  of  the  patient.  The  mouth,  in  all  cases,  must  be  kept  scrupu- 
lously clean,  but  the  greatest  care  is  necessary  not  to  injure  the  epi- 

267 


268  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

thelium.  A  camer''s-hair  brush  and  plain,  luke-warm  water,  or  a  weak 
alkaline  solution,  are  to  be  recommended.  Both  of  these  deformities 
are  exceedingly  likely  to  be  complicated  by  thrush.  This  is  a  serious 
menace  to  the  success  of  any  operation,  and  even  to  the  life  of  the  patient. 
In  cases  of  harelip,  if  the  fissure  is  so  great  as  to  interfere  with  nursing, 
the  mother's  milk  should  be  pumped  and  the  child  fed  with  a  spoon 
or  a  medicine  dropper  until  the  operation  can  be  performed.  In  cleft 
palate  there  may  be  attached  to  the  rubber  nipple  of  the  nursing  bottle 
a  flap  of  thin  sheet-rubber  in  such  a  way  that  it  closes  the  fissure  in 
the  mouth  when  once  the  nipple  is  in  place.  This  flap  should  be  shaped 
like  a  leaf,  one  extremit}^  being  sewed  to  the  neck  of  the  rubber  nipple 
and  the  other  end  left  free.  In  many  cases,  both  before  and  immediately 
after  operation,  feeding  by  gavage  may  be  resorted  to  with  the  greatest 
benefit  and  with  very  little  inconvenience. 

Congenital  Hypertrophy  of  the  Tong^ue. — This  is  usually  due  to  dis- 
ease of  the  lymphatics,  and  is  to  be  regarded  as  a  lymphangioma.  In  a 
few  cases  hypertrophy  of  the  muscular  fibers  has  been  present.  The 
tongue  may  reach  an  enormous  size,  so  that  it  is  impossible  for  it  to  be 
contained  within  the  cavity  of  the  mouth,  and  it  may  thus  interfere  with 
nursing,  deglutition,  and  even  with  respiration.  The  treatment  is  sur- 
gical; but  some  of  these  patients  have  been  strikingly  benefited  by 
radium. 

Cases  like  the  above  are  to  be  distinguished  from  those  of  enlarge- 
ment of  the  tongue  seen  in  sporadic  cretinism.  In  this  disease  the 
tongue  is  considerably  enlarged  and  may  protrude  slightly  from  the 
mouth,  but  it  is  rarely,  if  ever,  large  enough  to  cause  other  symptoms. 
It  diminishes  notably  under  treatment  with  thyroid  extract. 

Bifid  Tongue. — These  eases  are  extremely  rare.  Brothers  has  re- 
ported to  the  New  York  Pathological  Society  a  case  of  cleft  tongue  in  a 
child  of  one  month.    There  was,  in  addition,  a  fissure  of  the  soft  palate. 

Tong-ue-tie. — This  deformity  is  due  to  such  a  shortening  of  the  fre- 
num  that  it  is  impossible  to  protrude  the  tongue  to  a  normal  extent.  It 
differs  considerably  in  degree  in  different  cases.  In  some,  the  tongue 
can  not  be  protruded  beyond  the  gums.  Tongue-tie  may  interfere  with 
articulation,  and  even  with  sucking.  The  treatment  consists  in  liberat- 
ing the  tongue  by  dividing  the  frenuni  with  scissors  and  completing  the 
operation  with  the  finger  nail.  This  should  be  done  in  every  case  unless 
the  child  is  a  bleeder.  In  many  cases  the  mother  may  think  the  tongue 
tied  when  the  frenum  is  of  normal  length. 

Bifid  Uvula. — This  is  not  very  uncommon.  It  usually  occurs  in  con- 
nection with  cleft  palate,  but  is  occasionally  seen  when  there  is  no  other 
deformity  present.  It  may  be  complete  or  partial,  and  it  does  not  of  itself 
require  treatment. 


DISEASES  OF  THE  TONGUE  269 

DISEASES  OF  THE  LIPS 

Herpes.. — Herpes  labialis  is  an  exceedingly  common  affection  in  chil- 
dren, occurring  in  acute  febrile  diseases,  particularly  pneumonia,  and 
sometimes  alone.  It  is  the  familiar  "fever  sore"  or  "cold  sore"  of 
domestic  medicine.  The  appearance  is  similar  to  herpes  in  other  parts 
of  the  body.  There  is  first  a  group  of  vesicles,  then  rupture  and  the 
formation  of  crusts.  It  is  often  quite  difficult  to  cure  on  account  of  the 
disposition  of  children  to  pick  the  lip  with  the  fingers.  Although  it  heals 
without  treatment,  recovery  is  facilitated  by  the  use  of  some  antiseptic 
lotion,  such  as  dilute  boric  acid,  followed  by  a  dusting  powder  of  zinc 
oxid  and  boric  acid.  This  treatment  is  generally  inore  successful  than 
the  use  of  ointments.  Young  children  should  wear  mittens  or  elbow 
splints  at  night,  to  prevent  picking  at  the  crusts. 

Eczema  of  the  Lip. — This  is  an  exceedingly  common  condition,  and 
a  very  troublesome  one.  The  vermilion  border  is  dry  and  rough,  and 
prone  to  deep  cracks  or  fissures.  These  are  usually  seen  at  the  angles  of 
the  mouth  or  in  the  median  line.  When  severe  they  are  exceedingly 
painful,  bleed  freely,  and  are  the  cause  of  very  great  discomfort,  es- 
pecially in  the  cold  season.  The  lips  should  be  covered  at  night  by  boric 
acid  ointment,  and  this  should  be  used  as  much  as  possible  during  the 
day.  When  deep  fissures  form,  they  should  be  touched  with  burnt 
alum,  or  with  the  solid  stick  of  nitrate  of  silver.  Syphilitic  fissures 
are  considered  with  the  symptoms  of  that  disease. 

Perleche  (French,  perlecher  =^  to  lick). — This  name  was  first  given 
by  Lemaistre  to  a  form  of  ulceration  occurring  usually  at  the  angle 
of  the  mouth.  It  begins  in  most  cases  as  a  small  fissure,  which,  by 
constant  licking  and  irritation,  to  which  there  is  usually  added  infection, 
may  develop  into  an  intractable  ulcer  of  considerable  size.  It  often 
resembles  the  mucous  patch  of  hereditary  syphilis.  The  ulcer  is  of  a 
grayish  color,  is  quite  painful,  and  is  associated  with  considerable  swell- 
ing of  the  lip.  It  lasts  from  two  to  four  weeks.  The  treatment  is  the 
same  as  in  simple  fissure — viz.,  the  use  of  burnt  alum  or  nitrate  of  silver, 
and  covering  the  part  with  bismuth  or  oxid  of  zinc. 

DISEASES  OF  THE  TONGUE 

Epithelial  Desquamation. — This  is  a  disease  of  the  lingual  epithe- 
lium, which  is  characterized  by  the  appearance  upon  the  dorsum  or 
margin  of  the  tongue,  of  circular,  elliptical,  or  crescentic  red  patches, 
with  gray  margins  which  are  slightly  elevated.  The  gray  margins  are 
apparently  due  to  thickening  of  the  epithelial  layer  and  the  red  areas 


270 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


to  desquamation  of  the  epithelium.  It  is  sometimes  improperly  called 
psoriasis  of  the  tongue.  It  is  quite  a  common  condition,  and  is  probably 
congenital. 

As  usually  seen,  there  exist  upon  the  tongue  from  two  to  half  a  dozen 
of  these  red  patches  surrounded  by  a  gray  border,  which  is  about  one- 
twelfth  of  an  inch  wide,  and  slightly  elevated.  The  outline  of  the  patch 
is  nearly  always  crescentic  (Fig.  27).  From  day  to  day  the  con- 
figuration of  the  patches  changes;  the  gray  lines  advance  across  the 
tongue  from  side  to  side,  or  from  base  to  tip,  disappearing  as  they  reach 
the  border  or  the  extremity.     They  are  followed  by  the  red  patches, 

and  as  the  old  ones  fade  away  new  ones  form 
and  run  the  same  course.  The  red  patches 
are  of  a  bright  color  nearest  the  border, 
gradually  shading  oif  into  the  normal  color 
of  the  tongue.  Only  the  epithelium  is  in- 
volved, the  deeper  structures  being  unaf- 
fected. The  duration  of  the  disease  is  in- 
definite; it  usually  lasts  for  years.  Guinon 
reports  several  cases  which  recovered  during 
an  intercurrent  attack  of  measles  or  scarlet 
fever. 

The  cause  is  unknown.  The  condition 
occurs  rather  more  frequently  in  females 
than  in  males,  and  Gubler  has  reported  an 
instance  of  several  members  of  the  same 
family  being  affected.  The  condition  has 
been  thought  to  depend  upon  nearly  every  disease  of  childhood.  It  is 
not  accompanied  by  pain,  salivation,  or  by  other  symptoms  of  stomati- 
tis, and  is  of  little  practical  importance.  Its  symptoms  are  so  char- 
acteristic that  it  can  hardly  be  mistaken  for  any  other  condition.  Treat- 
ment is  unnecessary. 

Two  other  forms  of  epithelial  desquamation  have  been  observed, 
both  much  more  rare  than  that  described.  In  one  of  these  the  red  de- 
nuded portion  occupies  the  margin  of  the  tongue,  while  the  center  is 
gray  or  white;  the  irregular  wavy  outline  which  separates  the  two  sug-- 
gests  strongly  an  outline  map,  and  the  condition  is  sometimes  called  the 
"geographical  tongue."  This  term  is  frequently  employed  to  designate 
the  common  form.  In  another  variety  nearly  the  whole  organ  may  be 
uniformly  red,  from  loss  of  the  epithelium,  there  being  no  borders  or 
patches.  Both  these  varieties  are  of  much  shorter  duration  than  the 
more  common  form,  usually  lasting  only  a  few  weeks. 

Glossitis. — Inflammation  of  the  tongue  is  not  very  common  in  chil- 
dren.   It  is  usually  of  traumatic  origin.    The  injury  may  be  due  to  bit- 


FiG.  27. — Epithelial  DesquA' 

MATION    OF     THE    TONGUE 

(Guinon.) 


DISEASES  OF  THE  TONGUE  271 

ing  the  tongue  in  a  fall  or  in  an  epileptic  seizure.  Glossitis  is  sometimes 
excited  by  the  irritation  of  a  sharp  tooth,  causing  a  wound  which  may  be 
the  avenue  of  infection;  or  it  may  result  from  taking  into  the  mouth 
irritant  or  caustic  poisons.  In  a  small  number  of  cases  no  cause  can  be 
found.  The  symptoms  are  marked  swelling  of  the  tongue,  so  that  it  may 
protrude  from  the  mouth ;  and  it  may  even  be  so  great  as  to  cause  severe 
dyspnea.  There  are  also  seen  profuse  salivation,  difficulty  in  swallowing 
and  in  articulation,  and  often  considerable  local  pain.  There  may  be  a 
rise  of  temperature  to  102°  or  103°  F.  The  treatment  consists  in  the 
use  of  fluid  food,  which  in  severe  cases  may  be  introduced  through 
the  nose  by  means  of  a  catheter.  Ice  may  be  used  externally,  or,  bet- 
ter still,  pieces  of  ice  may  be  kept  in  the  mouth  continually.  If  there 
is  obstruction  to  respiration,  and  in  all  severe  cases,  scarification 
should  be  done  on  the  dorsum  of  the  tongue  along  the  side  of  the 
raphe. 

The  acute  swelling  of  the  tongue  and  lips  occurring  in  some  cases  of 
urticaria  may  be  mentioned  in  this  connection.  This  is  a  rare  condi- 
tion in  children,  but  it  may  develop  rapidly  and  to  such  a  degree  as  to 
cause  alarming  symptoms.  The  treatment  consists  in  the  use  of  ice 
locally,  free  purgation  by  salines,  and,  in  extreme  cases,  needle  punc- 
tures to  relieve  the  edema. 

Tongue-swallowing-. — This  term  is  used  to  describe  a  rare  condition 
seen  in  infants,  in  which  the  tongue  is  turned  backward  into  the 
pharynx,  so  as  to  obstruct  respiration.  It  may  be  drawn  quite  into 
the  esophagus.  Several  marked  cases  have  been  collected  by  Hennig. 
While  most  frequently  occurring  with  paroxysms  of  pertussis,  tongue- 
swallowing  has  been  seen  in  other  diseases.  This  should  not  be  forgot- 
ten as  one  of  the  explanations  of  sudden  asphyxia  in  a  young  infant. 
The  conditions  necessary  for  its  production  are  a  somewhat  relaxed  organ 
or  a  long  frenum.  In  none  of  the  fatal  cases  reported,  however,  had  the 
frenum  been  divided.  In  some  weak  infants,  falling  back  of  the  tongue, 
so  that  its  base  partly  covers  the  epiglottis,  produces  asphyxia,  precisely 
as  it  occurs  in  adult  life  under  full  anesthesia.  The  recognition  of  the 
condition  is  a  very  easy  one,  and  its  treatment  is  to  relieve  the  obstruc- 
tion by  drawing  the  tongue  forward  by  the  finger  or  forceps. 

Ulcer  of  the  Frenum. — The  friction  against  the  sharp  edges  of  the 
lower  central  incisors  frequently  causes  an  ulcer  of  the  frenum  in  in- 
fants. We  have  never  seen  it  in  older  children.  It  usually  occurs  in 
pertussis,  but  is  seen  in  other  conditions.  In  some  it  appears  to  be  pro- 
duced by  friction  of  the  teeth  during  nursing  from  the  breast  or  bottle. 
It  is  more  often  seen  in  children  who  are  delicate  or  cachectic  than  in 
those  who  are  healthy  and  well  nourished.  The  ulcer  may  be  confined 
to  the  frenum,  or  it  may  extend  quite  deeply  into  the  tongue.     It  is 


272  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

usually  about  one-fourth  of  an  inch  in  diameter,  and  of  a  yellowish-grajf 
color.  When  not  readily  cured  by  touching  with  alum  or  nitrate  of 
silver,  the  child  may  be  fed  by  gavage  for  several  days,  or  the  teeth  may 
be  covered  by  a  bit  of  absorbent  cotton. 


DENTAL  CARIES 

Although  the  teeth  do  not  strictly  belong  to  the  province  of  the  physi- 
cian, they  have  an  important  influence  upon  the  general  health.  The 
pernicious  effects  of  dental  caries  have  only  recently  been  appreciated. 
Eoutine  examinations  of  public-school  children,  made  in  various  cities, 
have  shown  that  fully  80  per  cent  have  extensive  dental  caries.  Among 
the  inmates  of  institutions  the  proportion  is  fully  as  great  as  this,  possi- 
bly greater,  unless,  as  in  a  few  modern  institutions,  special  attention  is 
given  to  this  subject. 

Among  the  causes  of  dental  caries  the  most  important  without  doubt 
is  want  of  cleanliness — the  almost  entire  neglect  of  the  toothbrush 
among  the  children  of  the  poor.  This  leads  to  decomposition  of  food 
and  secretions,  acid  fermentation,  erosions  of  the  enamel,  etc.  But  not 
all  caries  of  the  teeth  can  be  ascribed  to  this  cause.  Diet  has  certainly 
much  to  do  with  it.  It  is  our  belief  that  the  opinion  commonly  held, 
that  excessive  indulgence  in  sweets  is  responsible  for  dental  caries,  is 
well  founded.  Malnutrition  and  improper  food,  especially  in  early 
childhood,  certainly  affect  the  teeth.  In  some  children  a  congenitally 
defective  enamel  is  present.  Hereditary  syphilis  is  also  a  cause,  and  in 
children  with  congenital  mental  defects  the  teeth  are  prone  to  early 
decay. 

The  symptoms  are  both  local  and  general.  Locally,  as  a  result  of 
decomposition  and  infection,  there  are  present  foul  breath,  gingivitis, 
alveolar  abscess,  ulcerative  stomatitis,  toothache,  etc.  The  lymph  nodes 
in  the  neighborhood  frequently  become  enlarged  and  sometimes  tuber- 
culous. Tuberculosis  of  the  submaxillary  and  submental  lymph  nodes 
is  nearly  always  the  result  of  infection  through  the  teeth  or  the  gums. 
Whether  the  cervical  lymph  nodes  are  infected  in  the  same  way 
is  very  doubtful.  The  general  symptoms  result  in  part  from  improper 
mastication  of  food  and  in  part  from  sepsis  from  the  local  condition. 
There  may  be  seen  only  failing  nutrition,  loss  of  appetite  and  anemia; 
or  these  symptoms  may  be  accompanied  by  a  slight  but  continuous  fever 
which  may  persist  for  months.  In  more  marked  cases  there  may  be 
symptoms  of  a  pyemic  character;  higher  temperature,  joint  swellings, 
wasting,  etc.  Many  cases  of  illness  diagnosticated  acute  rheumatism 
and  accompanied  by  cardiac  complications  h&ve  their  origin   in  oral 


DIFFICULT  DENTITION  273 

sepsis  at  the  basis  of  which  are  carious  teeth,  and  no  treatment  has 
any  influence  upon  the  condition  until  these  are  removed. 

From  the  local  irritation  -various  nervous  symptoms  may  arise. 
The  most  common  are  habit  spasm,  facial  chorea,  headaches,  and,  ac- 
cording to  some  writers,  even  epileptiform  convulsions.  The  presence 
of  carious  teeth  is  a  menace  to  the  general  health.  They  certainly  pre- 
dispose to  local  tuberculosis.  Many  persons  assume  that  if  the  teeth 
affected  belong  to  the  first  set,  it  matters  little.  However,  the  perma- 
nent teeth  are  often  injured  by  extensive  decay  of  the  deciduous  set. 
The  treatment  of  this  condition  belongs  to  the  dentist ;  but  the  physician 
should  appreciate  the  importance  of  the  subject  and  urge  parents  and 
others  in  charge  of  children  to  give  proper  attention  to  cleanliness  and  to 
see  that  carious  teeth  of  the  first  set  are  either  filled  or  removed. 


ALVEOLAR  ABSCESS 

This  is  common  in  children,  especially  among  the  class  of  hospital 
and  dispensary  patients,  in  whom  little  or  no  attention  is  given  to  the 
care  of  the  teeth.  It  causes  severe  pain  and  acute  swelling,  which  may  be 
limited  to  the  gum,  or  it  may  involve  to  a  considerable  extent  the  perios- 
teum of  the  jaw  and  even  cause  swelling  of  the  whole  side  of  the  face. 
If  there  is  retention  of  pus,  there  may  be  quite  severe  constitutional 
symptoms,  such  as  chills  and  high  temperature;  but  in  most  of  the 
cases  these  are  wanting.  The  abscess  usually  opens  spontaneously  into 
the  mouth,  but  it  may  open  externally  if  the  molar  teeth  are  the  ones 
affected.  It  may  even  lead  to  necrosis  of  the  jaAV.  If  its  site  is  the  upper 
jaw,  the  pus  may  find  its  way  into  the  nasal  cavity  or  into  the  maxillary 
sinus. 

The  treatment  is,  in  the  first  place,  prophylactic.  This  requires  at- 
tention to  the  teeth  to  prevent  decay,  and  the  removal  of  old  carious 
fangs,  which  are  a  constant  menace  to  the-  health  of  the  child.  The  free 
use  of  the  toothbrush  and  some  antiseptic  mouth-wash  will,  in  the 
great  majority  of  cases,  prevent  the  occurrence  of  this  disease.  It  is 
important  that  the  abscess  be  opened  early  and  free  drainage  secured. 
If  there  is  a  carious  tooth  it  should  be  drawn. 


DIFFICULT  DENTITION 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  in- 
fancy is  one  which  has  given  rise  to  much  discussion.  From  a  very  early 
period  the  view  has  descended,  that  a  large  number  of  the  diseases  occur- 


274  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ring  between  the  ages  of  six  months  and  two  years  are  due  to  diiificult 
dentition.  The  list  of  such  diseases  is  a  long  one,  but  year  by  year  it  has 
been  shortened  as  one  after  another  has  Ijeen  shown  to  depend  upon 
other  causes,  dentition  being  only  a  coincidence. 

At  the  present  time  many  good  observers  deny  that  dentition  is  ever 
a  cause  of  symptoms  in  children ;  some  even  going  so  far  as  to  say  that 
the  growth  of  the  teeth  causes  no  more  symptoms  than  the  growth  of  the 
hair.  Without  doubt  the  usual  mistake  made  in  practice  is  to  overlook 
disease  of  the  brain,  ears,  lungs,  stomach,  and  intestines,  because  of  the 
tirm  belief  that  the  child  was  "only  teething."'  The  physician  who 
starts  out  Avith  the  idea  that  in  infancy  dentition  may  produce  all  symp- 
toms usually  gets  no  further  than  this  in  his  etiological  investigations. 
Although  no  doubt  the  importance  of  dentition  as  an  etiological  factor 
in  disease  has  been  in  the  past  greatly  exaggerated,  the  careful  and 
candid  observer  must  admit  that,  particularly  in  delicate,  highly  nervous 
children,  dentition  may  produce  many  reflex  symptoms,  some  even  of 
cpiite  an  alarming  character. 

Speaking  from  general  impressions  not  from  statistics,  we  should  say 
that  in  our  experience  fully  one-half  of  the  healthy  children  cut  their 
teeth  without  any  visible  symptoms,  local  or  general;  in  the  remainder 
some  disturbance  is  usually  seen,  and  though  in  most  cases  it  is  slight 
and  of  short  duration,  it  may  last  for  several  days  or  even  a  week.  The 
symptoms  most  commonly  seen  are  disturbed  sleep,  or  wakefulness  at 
night  and  fretfulness  by  day,  so  that  children  often  sleep  only  one-half 
the  usual  time.  There  is  loss  of  appetite,  and  much"  less  food  than  usual 
is  taken.  There  is  often,  but  not  always,  an  increase  in  the  salivary 
secretion,  a  slight  amount  of  catarrhal  stomatitis,  and  a  constant  dispo- 
sition on  the  part  of  the  child  to  put  the  fingers  into  the  mouth.  The 
bowels  are  often  constipated  or  there  may  be  slight  diarrhea.  The  ther- 
mometer may  show  a  slight  elevation  of  temj)erature  to  100°  or  101.5° 
F.  The  weight  often  remains  stationary  for  a  week  or  two,  and  there 
may  even  be  a  loss  of  a  few  ounces.  The  duration  of  these  symptoms  in 
most  cases  is  but  a  few  days,  and  they  require  no  special  treatment.  If 
the  food  is  forced  beyond  the  child's  inclination,  attacks  of  indigestion 
with  vomiting  and  diarrhea  are  easily  excited- 
Symptoms  more  severe  than  the  above,  are  rare  in  healthy  children, 
but  are  not  infrequent  in  those  who  are  delicate  or  rachitic.  In  such 
susceptible  children,  even  so  slight  a  thing  as  dentition  may  be  an  excit- 
ing cause  of  quite  serious  disturbances.  Often  there  is  some  other 
factor  in  the  case,  such  as  bad  feeding  or  feeble  digestion.  In  delicate 
or  rachitic  children  there  may  be  seen  the  symptoms  already  mentioned 
as  occurring  in  healthy  infants,  but  in  greater  severity;  and  in  addition 
there  may  be  severe  attacks  of  acute  indigestion.     Occasionally  there  is 


DIFFICULT  DEXTITIOX  275 

an  elevation  of  temperature  to  10-?'^  or  103°  F.,  lasting  usually  only  two 
or  three  days,  and  accompanied  Ijy  no  symptoms  except  almost  complete 
anorexia.  It  is  occasionally,  but  rarely,  seen  that  a  child  will  have  con- 
vulsions just  before  or  during  the  eruption  of  each  tootli.  Such  chil- 
dren are  almost  always  the  subjects  of  latent  tetany,  dentition  acting 
as  any  other  exciting  cause  to  determine  the  onset  of  the  convulsions. 
In  cases  of  eczema  the  symptoms  often  undergo  a  distinct  exacerba- 
tion with  the  eruption  of  each  group  of  teeth.  As  regards  almost 
all  the  other  diseased  conditions  which  are  commonly  attributed  to 
dentition,  we  believe  that  it  is  a  delusion  to  ascribe  them  to  this 
cause. 

The  physician  should  watch  a  child  carefully,  and  examine  him  fre- 
quently, to  be  sure  that  he  is  not  overlooking  some  serious  local  or  con- 
stitutional disease  before  he  allows  himself  to  make  the  diagnosis  of 
difficult  dentition.  Prol^ably  in  ninet3r-five  per  cent  of  the  cases  in  which 
symptoms  are  present,  they  are  due  to  some  cause  other  than  dentition. 
When,  however,  symptoms  such  as  any  of  those  mentioned  disappear 
immediately  Avhen  the  teeth  come  through,  and  when  we  see  them 
repeated  four  or  five  times  in  the  same  child  with  the  eruption  of  each 
group  of  teeth,  and  accompanied  by,  red  and  swollen  gums,  we  can 
not  escape  the  conclusion  that  dentition  is  a  factor  in  their  production, 
though  perhaps  not  the  only  one. 

In  the  treatment  of  this  condition  drugs  occupy  but  a  small  jDlace.  It 
should  be  remembered  that  infants  are  at  this  time  in  a  peculiarly  sus- 
ceptible condition  as  regards  the  digestive  tract,  and  attacks  of  indiges- 
tion, and  even  severe  diarrhea,  are  readily  excited  from  slight  causes, 
especially  from  overfeeding.  Special  care  should  be  exercised  in  this 
respect.  The  strength  of  the  food  should  be  reduced,  as  well  as  the 
amount  given.  A  poor  appetite  indicates  a  feeble  digestion,  which 
sliould  not  be  overtaxed.  As  attacks  of  bronchitis  and  acute  nasal  ca- 
tarrh are  readily  induced,  even  slight  exjDosure  should  be  guarded 
against.  The  nervous  symptoms,  when  severe,  may  be  relieved  by  the 
use  of  moderate  doses  of  the  bromids  or  by  phenacetin.  better  than  by 
opiates.  All  soothing  syrups  should  be  discountenanced.  All  the  vari- 
ous devices  for  making  dentition  easy  are  a  delusion.  In  a  small  num- 
ber of  cases  lancing  the  gums  is  of  value.  We  have  seen  in  a  few  rare 
instances  marked  and  undoubted  relief  given  by  it.  This  is  likely  to 
be  the  case  only  when  the  gums  are  tense,  swollen,  and  very  red,  with  the 
teeth  just  beneath  the  mucous  membrane.  To  press  a  tooth  through  the 
gum  by  simply  rubbing  gently  with  the  finger  covered  with  sterile  gauze 
is  frequently  more  effective  than  an  incision.  It  seldom  happens,  how- 
ever, that  the  relief  expected  is  seen  from  any  of  the  measures  men- 
tioned. 


276  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

CATARRHAL  STOMATITIS 

This  is  characterized  by  redness  and  swelling  of  the  mucous  mem- 
brane, and  by  increased  secretion  of  the  salivary  and  the  muciparous 
glands  of  the  mouth.  It  usually  involves  a  large  part  of  the  mucous 
membrane. 

Etiology. — Catarrhal  stomatitis  may  result  from  traumatism.  This 
injury  may  be  mechanical,  or  due  to  heat  or  any  irritant  accidentally 
taken  into  the  mouth.  It  frequently  occurs  at  the  time  of  the  eruption 
of  a  tooth.  It  complicates  measles,  scarlet  fever,  diphtheria,  influenza, 
and  many  other  infectious  diseases.  In  these  cases  and  in  many  others 
the  disease  is  probably  due  to  direct  infection. 

Lesions. — The  lesions  are  essentially  the  same  as  in  catarrhal  inflam- 
mation of  other  mucous  membranes.  There  is  congestion  with  des- 
quamation of  epithelial  cells  and  sometimes  the  formation  of  superficial 
ulcers.  The  process  may  be  a  very  superficial  one,  or  it  may  extend  to 
the  submucous  tissue. 

Symptoms. — The  mucous  membrane  is  intensely  injected,  all  the 
capillaries  are  dilated,  and  small  hemorrhages  easily  ezcited.  The  mu- 
cous membrane  is  swollen,  this  being  most  apparent  over  the  gums  or 
aborit  the  teeth.  There  may  be  some  swelling  of  the  lips.  The  mouth 
seems  hot,  and  the  local  temperature  is  certainly  increased.  There  is 
considerable  pain,  as  shown  by  fretfulness,  but  particularly  by  the  disin- 
clination to  take  food :  infants,  though  evidently  hungry,  either  refusing 
the  breast  or  bottle  altogether,  or  dropping  it  after  a  few  moments.  The 
increase  in  secretion  is  sometimes  marked,  so  that  the  saliva  pours  from 
the  mouth,  irritating  the  lips  and  face  and  drenching  the  clothing.  In 
other  cases  the  saliva  is  swallowed.  On  close  inspection  there  may  be 
seen  swelling  of  the  muciparous  follicles,  and  even  the  formation  of  tiny 
cysts  from  the  accumulation  of  secretion  within  them.  The  tongue  is 
usually  coated,  the  edges  reddened,  and  the  papillae  prominent.  In 
febrile  diseases,  such  as  typhoid,  etc.,  we  may  get  an  accumulation  of 
dead  epithelium  with  the  formation  of  cracks  and  fissures  of  the  tongue, 
and  the  lips  may  present  a  similar  condition.  The  neighboring  lym- 
phatic glands  are  slightly  enlarged  and  tender.  The  constitutional  symp- 
toms accompanying  simple  stomatitis  are  not  severe,  but  some  disturb- 
ance is  almost  always  present.  There  may  be  derangement  of  digestion 
with  vomiting,  and  even  a  mild  attack  of  diarrhea.  In  the  majority  of 
cases  the  disease  runs  a  short  course,  recovery  taking  place  in  a  few 
days  when  the  primary  cause  is  removed.  In  very  delicate  children  it 
may  be  prolonged,  and  from  the  interference  with  nutrition  may  even 
lead  to  serious  consequences. 


HERPETIC  STOMATITIS  277 

Treatment. — The  mouth  and  teeth  should  be  kept  clean.  Food  is 
more  acceptable  if  given  cold.  In  very  severe  cases,  when  food  is  refused, 
gavage  may  be  resorted  to  three  or  four  times  daily.  In  all  cases  chil- 
dren may  be  given  ice  to  suck.  This  is  refreshing,  both  on  account  of 
the  cold  and  from  the  relief  to  the  thirst.  The  mouth  should  be  kept 
clean  with  a  sokition  of  boric  acid,  ten  grains  to  the  ounce,  or  an  alkaline 
solution,  such  as  Dobell's,  diluted  with  an  equal  amount  of  cold  boiled 
water;  or  plain  water  may  be  used.  In  the  severe  forms,  where  there  is 
much  SM^elling  and  slight  catarrhal  ulceration,  astringents  are  required. 
In  our  experience  alum  is  the  best;  this  may  be  applied  in  the  form  of 
the  powdered  burnt  alum  mixed  with  an  equal  amount  of  bismuth,  or  in 
solution,  ten  grains  to  the  ounce,  with  a  swab  or  brush.  Where  ulcers 
are  slow  in  healing  and  very  painful,  the  powdered  burnt  alum  or  the 
solid  stick  of  nitrate  of  silver  may  be  applied  directly. 


HERPETIC    STOMATITIS 

{Aphthous,  Vesicular,  or  Follicular  Stomatitis) 

In  this  form  of  stomatitis  we  have  the  appearance  first  of  small 
yellowish-white  isolated  spots,  and  subsequently  the  formation  of  super- 
ficial ulcers.  These  ulcers  are  first  discrete,  but  may  coalesce  and  form 
others  of  considerable  size.  It  is  a  self-limited  disease,  usually  running 
its  course  in  from  five  days  to  two  weeks. 

Etiology. — Very  little  is  as  yet  positively  known  regarding  the  cause 
of  herpetic  stomatitis.  It  is  not  common  in  the  first  year,  but  after  that 
is  very  frequently  seen  throughout  childhood.  It  occurs  in  the  strong  as 
well  as  in  the  delicate.  It  is  often  associated  with  some  disturbance  of 
the  stomach,  and  occasionally  with  dentition.  We  have  adopted  the  term 
herpetic,  because  the  condition  is  analogous  to  herpes  of  the  lips  and 
face,  the  difference  in  appearance  being  due  chiefly  to  location.  It  is 
apparently  caused  by  something  which  acts  upon  terminal  nerve  fila- 
ments. 

Lesions. — The  generally  accepted  opinion  is  that  there  is  first  a  vesi- 
cle, followed  by  a  death  of  epithelial  cells  covering  it,  and  then  a  super- 
ficial ulcer.  The  white  appearance  is  due  to  the  fact  that  the  ulcers, 
being  on  a  mucous  membrane,  are  always  moist.  These  ulcers  may 
extend  superficially,  but  never  deeply;  they  heal  quickly  with  the  for- 
mation of  new  epithelial  cells,  leaving  no  cicatrices.  Herpetic  stoma- 
titis is  always  associated  with  more  or  less  catarrhal  inflammation. 

Symptoms. — The  disease  is  characterized  by  local  and  general  symp- 
toms.    The  latter  are  quite  indefinite — general  indisposition,   loss  of 


278  DISEASES  OP  THE  DIGESTIVE  SYSTEM 

appetite,  and  slight  fever.  The  local  symptoms  consist  in  the  develop- 
ment of  small,  shallow,  circular  ulcers,  usually  coming  in  successive 
crops.  While  most  frequent  at  the  border  of  the  tongue  and  the  inside 
of  the  lips,  they  may  be  found  upon  any  part  of  the  mucous  membrane 
of  the  mouth  or  the  pharynx.  There  may  be  only  half  a  dozen  present, 
or  the  mouth  may  be  filled  with  them.  They  are  first  of  a  yellowish 
color,  and  on  an  average  about  one-eighth  of  an  inch  in  diameter.  By 
the  coalescence  of  several  smaller  ulcers  there  may  form  patches  of  con- 
siderable size,  sometimes  nearly  covering  the  lips.  The  older  ulcers  are 
apt  to  have  a  dirty-gray  color,  and  in  places  may  look  not  unlike  a 
diphtheritic  membrane.  The  smaller  ones  are  surrounded  by  a  red 
areola,  and  when  healing  the  margin  is  of  a  bright  red  color.  Their 
appearance  is  often  more  like  that  of  an  exudation  upon  the  mucous 
membrane  than  an  ulceration.  The  other  symptoms  are  much  the 
same  as  those  of  catarrhal  stomatitis,  but  usually  of  greater  severity. 
The  pain  is  particularly  intense,  it  being  often  difficult  to  induce  chil- 
dren to  take  anything  in  the  form  of  food.  The  tongue  is  frequently 
coated,  but  there  is  never  the  foul  breath  of  ulcerative  stomatitis.  The 
duration  of  the  disease  is  from  one  to  two  weeks,  and,  if  the  child  is  in 
good  condition,  complete  recovery  takes  place  even  without  any  special 
treatment.  In  badly  nourished  children  the  disease  may  last  for  two  or 
three  weeks;  relapses  may  occur,  and  the  condition  may  interfere  very 
seriously  with  the  child's  nutrition. 

Treatment.- — This  is  the  same  as  in  catarrhal  stomatitis,  with  the 
addition  that  to  each  one  of  the  ulcers  finely  powdered  burnt  alum  should 
be  applied  with  a  camel's-hair  brush.  If  this  is  not  effective,  the  solid 
stick  of  nitrate  of  silver  may  be  used.  The  ulcers  will  usually  yield  rap- 
idly to  this  treatment.  In  our  experience,  drugs  given  with  the  purpose 
of  affecting  the  lesion  in  the  mouth  have  been  without  benefit. 


ULCERATIVE  STOMATITIS 

Ulcerative  stomatitis  is  believed  to  occur  only  when  teeth  are  pres- 
ent. It  is  characterized  by  an  ulcerative  process,  beginning  at  the  junc- 
tion of  the  teeth  and  the  gum,  and  extending  along  the  teetli ;  it  occa- 
sionally involves  other  parts  of  the  mouth,  but  never  spreads  beyond  the 
buccal  cavity. 

Etiolo^. — A  form  of  ulcerative  stomatitis  is  produced  by  certain 
metallic  poisons,  especially  mercury,  lead,  and  phosphorus ;  but  all  these 
are  now  rare.  Ulcerative  stomatitis  also  occurs  in  scurvy;  and  it  seems 
probable  that  an  allied  disturbance  of  nutrition,  with  spongy,  swollen 
gums,  precedes  some  other  forms   of  ulcerative  stomatitis.     Bad   sur- 


ULCERATIVE  STOMATITIS  279 

roundings  and  improper  food  act  as  predisposing  causes;  for  the  disease 
is  quite  common  in  institutions  for  children  and  in  hospital  and  dis- 
pensary patients,  although  rare  in  private  practice.  Local  causes  of  im- 
portance are  want  of  cleanliness  of  the  mouth  and  teeth  and  the  presence 
of  carious  teeth.  Conditions  which  produce  a  lowered  vitality  of  the 
gums  act  as  predisposing  causes,  and  infection  as  an  exciting  cause  of 
the  disease.  The  constant  clinical  features  of  ulcerative  stomatitis  and 
the  occasional  occurrence  of  epidemics  indicate  a  specific  cause  which  is 
probably  the  same  as  that  of  iilceromembranous  tonsillitis.  The  two 
conditions  often  exist  at  the  same  time.  From  the  investigations  of  Yin- 
cent,  Bernheim,  Plant  and  others  it  seems  probable .  that  noma  is  also 
produced  by  the  same  organism  but  represents  a  more  virulent  infection. 

Lesiona, — The  disease  may  begin  at  any  part  of  the  mouth,  but  most 
frequently  upon  the  outer  surface  of  the  gum  along  the  lower  incisor 
teeth.  From  this  point  it  extends  behind  the  teeth,  and  from  the  in- 
cisors to  the  canines  and  molars,  visually  of  one  side  only;  but  it  may 
involve  the  entire  gum  of  both  jaws.  From  the  gums  the  process  may 
spread  to  the  lips,  affecting  the  fold  of  mucous  membrane  between  the 
gum  and  the  lip,  and  also  to  the  inner  surface  of  the  cheek,  especially 
opposite  the  molar  teeth,  where  large^  ulcers  often  form.  In  neglected 
eases  the  disease  may  extend  into  the  alveolar  sockets,  the  teeth  loosen- 
ing and  falling  out.  The  periosteum  of  the  alveolar  process  may  be  in- 
volved, and  even  superficial  necrosis  of  the  jaw  may  occur,  as  has  hap- 
pened in  several  cases  that  came  under  our  observation.  These  severe 
forms  are  met  with  in  institutions  chiefly  and  then  generally  follow 
measles  or  scarlet  fever. 

Ulcers  similar  in  appearance  may  also  be  present  in  other  parts  of 
the  mouth — i.  e.,  on  the  soft  palate  or  the  tonsils,  sometimes  even  when 
the  gums  are  not  involved. 

Symptoms. — The  first  things  noticed  are  the  very  offensive  breath  and 
the  profuse  salivation.  It  is  usually  for  one  of  these  symptoms  that 
the  patient  is  brought  for  treatment.  On  inspection  of  the  mouth,  there 
are  seen  in  the  mild  cases,  swollen,  spongy  gums  of  a  deep-red  or  purplish 
color,  which  bleed  at  the  slightest  touch.  There  is  a  line  of  ulceration, 
usually  along  the  incisor  teeth,  most  marked  in  front,  which  may  ex- 
tend to  any  or  to  all  of  the  teeth;  sometimes  it  affects  only  the  gum 
along  the  molar  teeth,  the  incisors  escaping.  At  the  junction  of  the 
teeth  and  gum  is  seen  a  dirty,  yellowish  deposit,  on  the  removal  of  which 
free  bleeding  takes  place.  The  diseased  parts  are  very  painful,  and  the 
child  cries  and  resists  any  attempt  at  examination.  In  the  more  severe 
cases  and  in  those  of  longer  duration  the  teeth  are  loosened,  sometimes 
being  so  loose  that  they  can  be  picked  from  the  gum.  There  may  be 
necrosis  of  the  jaw,  and  even  a  loose  sequestrum  may  be  found.     In 


280  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

these  cases  the  ulceration  along  the  gums  is  deepei',  and  there  may  be 
ulcers  in  the  cheek  opposite  the  molar  teeth,  or  inside  the  lip.  The 
swelling  may  be  so  great  that  the  teeth  are  almost  covered;  this  is  seen 
particularly  in  the  scorbutic  form.  The  saliva  pours  from  the  mouth, 
adding  greatly  to  the  discomfort  of  the  patient.  Beneath  the  jaw  are 
felt  the  large,  swollen  lymphatic  glands,  which  are  painful  and  tender  to 
the  touch,  but  show  no  tendency  to  suppurate.  The  tongue  is  somewhat 
swollen,  and  shows  at  the  edges  the  imprint  of  the  teeth;  it  has  a  thick, 
dirty  coating. 

The  disease  is  attended  by  little  or  no  fever  or  other  constitutional 
symptoms.  The  general  condition  of  these  patients  is  often  poor,  and 
there  may  be  quite  a  marked  cachexia.  Other  forms  of  stomatitis  may  be 
associated,  and  it  should  not  be  forgotten  that  tlie  gangrenous  form  may 
follow. 

When  not  recognized  or  not  properly  treated,  ulcerative  stomatitis 
may  last  for  months.  When  properly  treated  it  tends  in  all  recent  cases 
to  recovery,  usually  in  from  five  to  ten  days.  No  deformity  of  the  mouth 
is  left,  the  only  untoward  results  being  shrinking  of  the  gum,  sometimes 
loss  of  some  of  the  incisor  teeth,  and  more  rarely  a  superficial  necrosis 
of  the  alveolar  process.  All  these  are  quite  uncommon.  Ulcerative 
stomatitis  can  hardly  be  confounded  with  any  other  form,  and  not  only 
should  a  diagnosis  of  the  lesion  be  made,  but  the  condition  upon  which 
it  depends  should,  if  possible,  be  discovered;  scorbutus,  particularly, 
should  not  be  overlooked. 

Treatment. — The  first  thing  to  be  done  is  to  remove  the  cause.  When 
dependent  upon  metallic  poisoning  the  source  should  be  discovered. 
Scorbutic  cases  should  have  the  usual  anti-scorbutic  diet.  Cleanliness  of 
the  mouth  is  of  great  importance,  and  this  may  best  be  accomplished  by 
the  use  of  peroxid  of  hydrogen  diluted  with  from  one  to  four  parts  of 
water.  It  should  be  followed  by  thorough  rinsing  with  plain  water,  and 
repeated  several  times  a  day.  In  other  cases  a  solution  of  alum,  five 
grains  to  the  ounce,  or  a  mouth-wash  of  chlorate  of  potash,  three  grains 
to  the  ounce,  may  be  employed.  The  only  objection  to  the  last  men- 
tioned is  the  pain  which  it  sometimes  produces.  A  strip  of  gauze  between 
the  cheek  and  the  gums  aids  greatly  in  cleanliness.  This  may  be 
left  in  place  and  affords  no  inconvenience,  but  on  the  contrary,  comfort 
to  the  patient. 

The  specific  remedy  for  ulcerative  stomatitis  is  chlorate  of  potash. 
The  best  method  of  administration  is  to  give  two  grains,  or  one-half  tea- 
spoonful  of  a  saturated  solution,  largely  diluted,  every  hour  during  the 
day  for  the  first  twenty-four  hours  and  subsequently  every  two  hours; 
when  improvement  occurs  the  dose  may  be  still  further  reduced.  Marked 
benefit  is  usually  seen  in  one  or  two  days  even  in  cases  that  have  lasted 


THRUSH  281 

for  several  weeks.  If  the  case  does  not  yield  readily  to  this  treatment 
there  is  probably  disease  at  the  roots  of  the  teeth,  and  when  loose  these 
should  be  removed,  and  the  jaw  examined  to  see  if  there  is  necrosis. 
Occasionally  when  there  is  no  disposition  to  heal,  the  shreds  of  necrotic 
tissue  should  be  carefully  removed,  and  burnt  alum  or  nitrate  of  silver 
applied. 

The  constitutional  and  dietetic  treatment  in  all  these  cases  should 
be  the  same  as  that  employed  in  scurvy — i.  e.,  plenty  of  fruit,  fresh  vege- 
tables, and  sometimes  the  internal  administration  of  mineral  acids,  espe- 
cially aromatic  sulphuric  acid.     Iron  is  indicated  in  most  of  the  cases. 

Ulceration  of  the  Hard  Palate. — This  is  usually  seen  in  the  first  few 
weeks  of  life,  but  may  occur  in  any  child  suffering  from  marasmus.  The 
primary  cause  is  often  the  injury  inflicted  in  cleansing  the  mouth.  In 
other  cases  it  is  due  to  the  friction  of  the  rubber  nipple,  or  some  other 
object  which  the  child  is  allowed  to  suck.  In  still  others  it  is  appar- 
ently produced  by  the  habit  of  tongue-sucking  frequently  observed  in 
these  young  infants.  The  appearances  are  quite  characteristic:  there  is 
found,  rather  far  back  upon  the  hard  palate,  usually  in  the  middle  line, 
a  superficial  ulcer,  from  a  fourth  to  a  half  inch  in  diameter.  There  are 
no  signs  of  acute  inflammation.  Thrush  may  coexist,  but  it  has  no  rela- 
tion to  the  production  of  the  disease.  Spontaneous  recovery  usually  oc- 
curs in  from  one  to  three  weeks,  providect  the  cause  can  be  removed.  In 
children  suffering  from  marasmus  these  ulcers  are  very  intractable,  and 
in  many  instances  their  cure  is  practically  impossible.  It  is  therefore 
especially  important  to  prevent,  if  possible,  their  formation  by  care  in 
cleansing  the  mouth,  and  in  avoiding  the  other  causes  referred  to.  When 
ulcers  have  appeared  they  should  be  treated  as  in  cases  of  herpetic 
stomatitis. 

THRUSH 

(Sprue;  German,  Soor;  French,  Muguet) 

Thrush  is  a  parasitic  form  of  stomatitis  characterized  by  the  appear- 
ance upon  the  mucous  membrane,  usually  of  the  tongue  or  the  cheeks, 
of  small  white  flakes  or  larger  patches.  It  is  common  in  infants  of  the 
first  two  or  three  months,  and  in  all  the  protracted  exhausting  diseases 
of  early  life. 

Etiolo^. — The  exact  class  to  which  the  vegetable  parasite  which,  pro- 
duces thrush  belongs  has  not  yet  been  definitely  settled.  Eobin's  opinion 
was  long  accepted  that  it  was  the  aidium  albicans;  the  view  of  Grawitz, 
that  it  is  the  saccharomyces  albicans,  is  now  more  generally  adopted.  If 
9,  little  of  the  exudate  from  the  mouth  is  placed  upon  a  slide  and  a 


282 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


drop  of  liquor  potassae  added,  the  structure  of  the  fungus  is  readily 
seen.  With  the  low  power  of  the  microscope  there  can  be  made  out 
fine  threads  (the  mycelium)  and  small  oval  bodies  (the  spores).  AVith 
a  high  power  the  threads  can  be  seen  to  be  made  up  of  a  number  of 
shorter  rods,  at  the  ends  of  which  the  spore  formation  takes  place  (Fig. 
28),  The  mycelium  is  produced  from  the  spores.  The  spores  of  this 
fungus  are  of  very  common  occurrence  in  the  atmosphere.  It  is  difficult 
or  impossible  for  thrush  to  develop  upon  a  healthy  mucous  membrane. 
Its  growth  is  favored  by  slight  abrasions,  such  as  are  often  produced  by 
rough  methods  of  cleansing  the  mouth;  also  by  catarrhal  stomatitis,  a 

scanty  salivary  secretion  and 
want  of  cleanliness.  The  na- 
ture of  the  process  which  it 
produces  is  in  all  probability 
a  sugar  fermentation,  the  acid 
reaction  of  the  mouth  being 
the  result  of  the  growth  rather 
than  its  cause.  Infection  may 
come  from  another  patient  by 
means  of  a  rubber  nipple  or  a 
cloth  which  has  been  used  for 
the  infected  mouth,  from  the 
nipple  of  the  nurse,  or  directly 
from  the  air.  Its  production 
is  favored  by  a  scanty  secre- 
tion of  saliva,  hence  it  is  fre- 
quent in  the  first  two  or  three 
months  of  life ;  also  by  an  altered  secretion  such  as  is  seen  in  protracted 
wasting  diseases,  enterocolitis,  marasmus,  typhoid,  tuberculosis,  etc.  It 
is  very  common  in  infants  suffering  from  harelip  or  any  other  deformity 
of  the  mouth.  The  disease  is  frequently  seen  in  foundling  asylums,  in 
all  places  where  many  young  infants  are  crowded  together,  and  where 
cleanliness  of  mouths,  bottles,  etc.,  is  neglected. 

Lesions. — The  spores  lodge  between  the  epithelial  cells  and  gradually 
separate  the  different  layers.  This  occurs  before  the  formation  of  the 
white  pellicle.  Later  the  disease  spreads  on  the  surface  of  the  mucous 
membrane,  and  also  penetrates  the  deeper  structures.  It  may  invade 
the  blood-vessels  and  cause  thrombosis  or  even  be  carried  to  distant  parts. 
Although  the  saccharomyces  albicans  is  commonly  found  upon  flat  epi- 
thelium, its  growth  is  not  confined  to  it.  It  usually  begins  at  many 
distinct  points  upon  the  mucous  membrane,  and  gradually  spreads  until 
coalescence  takes  place;  a  continuous  membrane  may  be  thus  formed. 
No  pus  is  produced  by  the  process. 


Fig.  28. — Thrush  Fttngus  (highly  magnified)- 
a,  mycelium;  h,  spores;  c,  epithelial  cells 
from  the  mouth;  d,  leucocytes;  e,  detritus, 
(v.  Jaksch.) 


THRUSH  283 

The  usual  seat  is  the  margin  of  the  tongue,  the  inside  of  the  lips  and 
cheeks,  and  the  hard  palate,  but  not  infrequently  it  involves  the  pillars 
of  the  fauces,  and  the  entire  pharynx.  Further  extension  in  the  digestive 
tract  than  this  is  rare,  although  the  esophagus,  the  stomach,  and  even  the 
intestines,  may  be  invaded.  We  have  seen  it  but  once  or  twice  in  the 
esophagus  and  never  in  the  stomach,  and  we  know  of  but  two  reported, 
cases  in  this  country  in  which  thrush  has  been  found  there.  Cases  in- 
volving the  esophagus  and  the  stomach  appear  from  reports  to  be  much 
more  common  in  Europe.  In  a  few  cases  in  the  Babies'  Hospital  the  sac- 
charomyces  albicans  has  been  found  in  the  lungs  of  infants  sufEering 
from  bronchopneumonia.  There  are  several  reported  cases  of  general 
blood  infection  from  this  organism. 

Symptoms. — The  essential  symptoms  of  thrush  are  the  appearance 
upon  the  mucous  membrane  of  the  mouth — usually  beginning  upon  the 
tongue  or  the  inner  surface  of  the  cheek — of  small  white  flakes  which 
resemble  deposits  of  coagulated  milk,  but  Mdiich  differ  from  them  in  the 
fact  that  they  can  not  be  wip'ed  off.  If  forcibly  removed,  they  usually 
leave  a  number  of  bleeding  points.  There  may  be  only  a  few  scattered 
patches,  or  the  mouth  and  pharynx  may  be  covered.  The  mouth  is  gen- 
erally dry  and  the  tongue  coated;  food  may  be  refused  on  account  of 
pain,  and  there  may  be  some  difficulty  in  swallowing.  The  other  symp- 
toms depend  upon  the  conditions  with  which  the  thrush  is  associated. 

Dia^osis. — This  is  rarely  difficult.  The  deposit  may  be  mistaken"  for 
coagulated  milk,  but  is  distinguished  by  the  features  just  mentioned. 
When  existing  upon  the  pharynx  and  fauces  it  has  been  confounded  with 
diphtheria,  although  this  mistake  can  hardly  be  made  if  all  the  facts 
of  the  case  are  taken  into  consideration — the  age  of  the  patient,  the 
involvement  of  the  lips  and  tongue,  the  dry  mouth,  the  absence  of  gland- 
ular enlargement,  etc.  In  any  case  of  doubt  the  examination  of  the 
deposit  under  the  microscope  at  once  reveals  its  true  nature. 

Prognosis. — Thrush  is  not  in  itself  a  dangerous  disease,  except  in  the 
very  rare  instances  where  it  may  obstruct  the  esophagus,  and  this  can 
hardly  occur  except  in  a  condition  of  exhaustion  which  is  necessarily 
fatal.  In  a  feeble  and  delicate  infant,  or  in  one  with  harelip  or  cleft 
palate,  thrush  may  be  a  serious  complication.  With  proper  treatment 
most  of  the  cases  involving  only  the  mouth  are  readily  cured. 

Treatment. — Thrush  may  usually  be  prevented  by  due  attention  to 
cleanliness  of  the  mouth,  rubber  nipples,  bottles,  cloths,  etc.  In  infants 
with  deformities  of  the  mouth  in  institutions,  it  frequently  develops 
despite  all  precautions.  All  rubber  nipples  should  be  kept  in  a  solution 
of  boric  acid  and  the  child's  mouth  should  be  cleansed  several  times  a 
day.  On  no  account  should  a  feeding-bottle  be  passed  from  one  child 
to  another. 


284  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

In  the  treatment  of  the  disease  the  essential  things  are  cleanliness, 
and  the  use  of  some  mild  antiseptic  mouth-wash.  The  best  routine  treat- 
ment is  to  cleanse  the  mouth  carefully  after  every  feeding  or-  nursing 
with  a  solution  of  bicarbonate  of  soda,  and  to  apply  twice  a  day  a  one- 
per-cent  solution  of  formalin.  All  applications  should  be  carefully  made, 
so  as  not  to  injure  the  epithelium.  The  best  method  of  cleansing  is  by 
a  small  swab  made  with  a  wooden  toothpick  and  absorbent  cotton.  Ap- 
plications to  be  especially  avoided  are  those  mixed  with  honey  or  any 
syrup.  In  hospital  cases  the  disease  seems  to  be  prolonged  by  the  irrita- 
tion of  the  rubber  nipple  of  the  feeding-bottle.  In  such  it  has  been 
our  practice  to  feed  by  gavage  for  two  or  three  days,  as  some  cases  im- 
proved much  more  rapidly  when  this  was  done. 


GONORRHEAL  STOMATITIS 

There  has  been  described  by  Dohrn  and  Eosinski  a  form  of  stomatitis 
in  the  newly  born,  due  to  a  gonorrheal  infection.  This  is  not  likely  to 
take  place  unless  the  epithelium  has  been  removed.  The  infection  in  all 
cases  occurred  from  the  mother.  The  lesion  consists  in  the  formation  of 
yellowish-white  patches  upon  the  tongue  or  hard  palate — regions  in 
which  the  epithelium  is  liable  to  be  injured  by  rough  attempts  at  cleans- 
ing the  mouth.  There  may  be  other  evidences  of  gonorrheal  infection 
especially  ophthalmia.  The  diagnosis  rests  upon  the  discovery  of  the 
gonococcus  in  the  exudate.  In  all  the  cases  cited  the  general  health  was 
not  affected,  and  recovery  followed  in  the  course  of  a  week  or  ten  days. 

The  treatment  consists  in  thorough  cleanliness  and  in  the  application 
of  a  saturated  solution  of  boric  acid  or  of  formalin,  as  in  thrush. 


SYPHILITIC  STOMATITIS 

The  buccal  symptoms  of  hereditary  syphilis  are  important  both  from 
a  diagnostic  and  a  therapeutic  standpoint.  The  most  frequent  lesions  are 
fissures,  ulcers,  and  mucous  patches.  Fissures  are  found  upon  the  lips, 
most  frequently  at  the  angle  of  the  mouth,  and  are  usually  multiple. 
They  may  be  quite  deep  and  cause  frequent  hemorrhages.  Mucous 
patches  are  superficial  ulcers  developing  from  papules  which  form  upon 
the  mucous  or  mucocutaneous  surfaces.  In  cases  of  acquired  syphilis 
in  children  the  primary  sore  may  be  seen  upon  the  tongue,  the  lip,  or  the 
tonsil.  All  these  symptoms  are  more  fully  considered  in  the  chapter  on 
Syphilis, 


GANGRENOUS  STOMATITIS— NOMA  285 


DIPHTHERITIC  STOMATITIS 


In  severe  cases  of  diphtheria  the  niemhrane  is  found  not  only  upon  the 
pharynx  and  tonsils,  but  it  may  appear  anywhere  upon  the  buccal 
mucous  membrane  or  the  lips.  It  is  questionable  whether  the  diphther-  - 
itic  process  ever  begins  on  the  mucous  membrane  of  the  mouth,  or  is 
ever  limited  to  this  part.  In  our  own  experience  diphtheritic  stomatitis 
has  always  been  associated  with  deposits  upon  the  tonsils  and  pharynx. 
It  is  seen  only  in  the  severest  cases,  and  in  those  which,  from  other  con- 
ditions present,  are  almost  necessarily  fatal.  Bearing  in  mind  the  above 
points,  it  can  hardly  be  mistaken  for  any  other  variety  of  stomatitis, 
although  not  infrequently  the  mistake  is  made  of  regarding  as  diph- 
theritic, cases  of  herpetic  stomatitis  in  which  the  ulcers  have  coalesced. 
The  treatment,  so  far  as  the  mouth  is  concerned,  consists  in  cleanliness 
by  frequent  gargling  or  irrigation  with  a  hot  saline  solution.  Forcible 
removal  of  the  membrane  is  not  to  be  advised. 


GANGRENOUS  STOMATITIS— NOMA 
(Oancrum  oris) 

The  term  noma  is  used  to  designate  all  forms  of  spontaneous  gan- 
grene occurring  in  children,  which  involve  mucous  membranes  or  muco- 
cutaneous orifices.  The  most  frequent  situation  being  the  mouth,  noma 
and  gangrenous  stomatitis  are  often  used  synonymously.  Noma  may, 
however,  affect  the  nose,  external  auditory  canal,  vulva,  prepuce,  or  anus. 
It  is  a  rare- disease,  and  usually  terminates  fatally. 

Etiology. — i^oma  is  seldom  seen  outside  of  institutions  for  children, 
where  small  epidemics  are  not  uncommon.  It  is  usually  secondary  to 
some  of  the  infectious  diseases,  most  frequently  following  measles,  and 
next  to  this  scarlet  fever,  typhoid,  or  whooping-cough.  While  it  may 
occur  at  any  age,  most  of  the  cases  are  in  children  under  five  years,  and 
in  those  of  poor  general  condition.  Koma  seldom  attacks  parts  previ- 
ously healthy.  In  the  mouth  it  may  be  preceded  by  catarrhal,  or  more 
often  by  ulcerative  stomatitis ;  in  the  auditory  canal,  by  a  chronic  otitis 
media.  There  seems  little  doubt  that  the  disease  is  contagious.  We 
once  saw  five  cases  in  a  single  ward,  all  beginning  in  the  auditory 
canal,  which  were  apparently  produced  by  the  use  of  the  same  syringe 
to  clean  the  ears  without  proper  disinfection.  All  these  children  were 
suffering  from  whooping-cough  at  the  time. 

It  is  now  quite  well  established  that  the  exciting  cause  of  noma  is  the 
11 


286  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

same  as  that  of  ulcerative  stomatitis  (q.  v.).  The  pathological  process 
in  one  case  is  of  a  mild  type  occurring  in  patients  of  considerable 
resistance.  In  the  other  it  is  of  a  severe  or  malignant  type  occurring  in 
patients  of  feeble  resistance  as  a  result  of  previous  acute  disease.  In 
the  gangrenous  tissue  pyogenic  cocci  and  putrefactive  bacteria  are 
abundant.  In  the  border  zone,  and  extending  into  the  adjacent  healthy 
tissue  the  specific  organisms  of  the  disease  are  usually  found. 

Lesions. — The  process  is  one  of  slowly  spreading  gangrene.  In  most 
of  the  cases  there  are  thrown  out  inflammatory  products  in  quite  large 
amount,  but  there  is  little  or  no  tendency  to  limitation  of  the  disease. 
This  usually  advances  steadily  until  death  occurs.  In  a  small  number  of 
cases  a  line  of  demarcation  finally  forms  and  the  slough  separates,  leav- 
ing a  large  area  to  be  partially  filled  in  by  granulation  and-  cicatrization. 
Other  infectious  processes  are  likely  to  accompany  the  disease,  partic- 
ularly bronchopneumonia. 

Symptoms. — The  constitutional  symptoms  are  not  usually  severe  until 
the  local  disease  has  existed  for  several  days.  Then  those  of  marked 
prostration  and  sepsis  develop,  sometimes  quite  rapidly.  The  tempera- 
ture is  usually  elevated  to  102°  or  103°  F.,  ancT sometimes  to  104°  or 
105°  F.  There  is  dulness,  apathy,  feeble  pulse,  muscular  relaxation, 
and  very  often  diarrhea.  Before  death  the  temperature  may  be  sub- 
normal. 

Of  the  local  symptoms,  often  the  first  to  attract  attention  is  the  odor 
of  the  breath;  sometimes  it  is  the  dusky  spot  on  the  cheek  or  lip.  On 
examination  of  the  mouth,  there  usually  is  found  upon  the  gum  or  inside 
of  the  cheek  a  dark,  greenish-black  necrotic  mass,  surrounded  by  tissues 
which  are  swollen  and  edematous,  so  that  the  cheek  or  lips  may  be 
two  or  three  times  their  normal  thickness.  Externally  the  parts  are 
tense  and  brawny  from  the  swelling,  this  infiltration  always  extending 
for  some  distance  beyond  the  gangrenous  part.  As  the  process  extends, 
the  teeth  loosen  and  fall  out ;  there  may  be  necrosis  of  the  alveolar  process 
of  the  jaw  and  perforation  of  one  or  both  cheeks  or  lower  lip;  ex- 
tensive sloughing  of  the  face  may  take  place,  usually  upon  one  side, 
sometimes  upon  both,  giving  the  patient  a  horrible  appearance.  In  one 
patient  the  process  began  in  the  right  cheek,  subsequently  involving 
the  left;  perforation  occurred  in  both  cheeks,  and  before  death  a  large 
part  of  the  face  was  gangrenous.  The  odor  from  a  severe  case  is  very 
offensive,  and,  in  spite  of  all  efforts  at  disinfection,  it  may  fill  the  ward 
or  even  the  house.  Pain  is  rarely  severe,  and  in  many  cases  it  is  ab- 
sent.   Extensive  hemorrhages  are  rare. 

We  have  notes  of  seven  cases  in  which  noma  affected  the  ear,  being 
preceded  by  chronic  otitis  media  in  every  instance.  The  disease  began 
in  the  deeper  structures  of  the  canal,  the  first  symptom  noticed  usually 


GANGRENOUS  STOMATITIS— NOMA  287 

being  a  nodular  swelling  just  beneath  the  ear,  crowding  the  lobe  upward. 
Shortly  afterward  there  appeared  the  dirty  brown  discharge  with  a  gan- 
grenous odor.  Later,  the  gangrenous  circle  surrounded  the  meatus, 
which  gradually  extended,  until  in  some  cases  the  whole  side  of  the  face 
and  head  were  involved.  A  probe  could  readily  be  passed  into  the  cra- 
nial cavity.     All  these  cases  ended  fatally. 

The  usual  duration  of  the  disease  is  from  five  to  ten  days.  If 
recovery  takes  place,  there  is  first  seen  a  line  of  demarcation ;  then  the 
slough  is  thrown  off,  and  granulation  and  cicatrization  begin,  but  require 
a  long  time,  usually  leaving  an  unsightly  deformity. 

The  prognosis  is  grave,  fully  three-fourths  of  the  cases  proving  fatal. 
The  results  depend  not  only  upon  the  disease  itself,  but  upon  the  con- 
dition of  the  patient  with  which  it  is  associated. 

Gangrenous  stomatitis  can  hardly  be  mistaken  for  any  other  form  of 
disease  occurring  in  the  mouth,  and  early  recognition  is  of  great  impor- 
tance, since  only  early  treatment  is  likely  to  be  successful. 

Treatment. — Much  can  be  done  to  prevent  the  disease  by  careful 
attention  to  all  the  milder  forms  of  stomatitis,  particularly  to  the  ulcera- 
tive variety.  Frequent  and  thorough  cleansing  of  the  mouth  in  all  acute 
infectious  diseases  is  a  part  of  the  treatmeiit  which  is  too  often  neglected. 
This  should  be  a  matter  of  routine  in  every  severe  illness  in  a  young 
child.  Recognizing  the  malignant  nature  of  gangrenous  stomatitis,  its 
treatment  should  be  radical  from  the  very  outset.  Of  the  measures 
which  have  been  proposed,  that  which  seems  to  offer  the  best  chance  of 
arresting  the  process  is  excision  with  cauterization.  This  should  be 
done  under  anesthesia.  In  excising,  one  should  go  some  distance  into 
tissues  apparently  healthy,  for  the  reason  that  the  process  has  always 
advanced  farther  in  the  subcutaneous  tissues  than  in  the  skin.  The 
edges  of  the  wound  should  then  be  thoroughly  cauterized,  best  by  the 
Paquelin  cautery.  Of  the  other  means  employed,  the  use  of  strong  car- 
bolic acid  immediately  followed  by  alcohol  is  probably  the  best.  This  is 
to  be  used  after  excising  or  curetting  the  necrotic  tissue.  The  mouth 
should  be  kept  as  clean  as  possible  by  the  use  of  peroxid  of  hydrogen. 
The  general  treatment  should  be  supporting  and  stimulating.  As  the 
possibility  of  contagion  exists,  every  case  should  be  isolated. 


288  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

CHAPTEK  II 

DISEASES  OF  THE  PHARYNX 

ACUTE  PHARYNGITIS 

Acute  pharyngitis  may  exist  as  a  primary  disease,  or  with  any  of  the 
infectious  diseases,  particularly  scarlet  fever,  measles,  diphtheria,  or 
influenza.  Secondary  pharyngitis  will  he  considered  in  connection  with 
these  different  diseases. 

Certain  children  have  a  constitutional  predisposition  to  attacks  of 
acute  pharyngitis,  and  contract  it  upon  the  slightest  provocation.  In 
some  of  them  there  is  a  strongly  marked  rheumatic  diathesis.  Attacks 
of  acute  pharyngitis  often  follow  exposure.  In  many  cases  they  are 
associated  Avitli  acute  disturbances  of  digestion.  All  of  the  above  causes 
probably  act  by  jjroducing  local  and  general  conditions  favorable  to 
the  de\elopment  of  microorganisms  already  present  in  the  mouth.  The 
bacteria  most  frequently  associated  with  severe  attacks  are  the  staphylo- 
coccus, the  pneumococcus,  the  streptococcus,  and  less  frequently,  the 
influenza  bacillus. 

In  acute  catarrhal  pharyngitis  the  inflammation  may  involve  the  en- 
tire mucous  membrane  of  the  tonsils,  fauces,  uvula,  posterior  and  lateral 
pharyngeal  Avails,  or  any  part  of  it.  It  may  exist  alone,  or  in  connection 
with  a  similar  inflammation  in  the  rhinopharynx  or  in  the  larynx.  In 
the  beginning  there  is  seen  an  acute  redness,  usually  involving  the  entire 
pharynx.  This  may  entirely  subside  after  twenty-four  hours,  or  it  may 
be  followed  by  the  usual  changes  of  acute  catarrhal  inflammation — 
dryness,  swelling,  and  edema.  Later  there  is  increased  secretion  of 
mucus,  and  finally  there  may  be  muco-pus.  Occasionally  slight  hemor- 
rhages are  present. 

There  is  pain  at  the  angle  of  the  jaws,  which  is  increased  by  swallow- 
ing, also  a  sensation  of  dryness  and  roughness  in  the  pharpix,  and  often 
an  irritating  cough.  There  may  be  slight  swelling  of  the  neighboring 
lymphatic  glands.  The  constitutional  symptoms  in  young  children  are 
often  severe.  Xot  infrequently  there  is  a  sudden  onset  with  vomiting, 
and  a  rise  of  temperature  to  102°  or  even  10^°  F.  These  symptoms  are 
usually  of  short  duration,  frequently  less  than  twenty-four  hours,  and  in 
two  or  three  days  the  patient  may  be  entirely  well.  In  other  cases  the 
pharyngitis  may  be  accompanied  or  followed  by  laryngitis. 

Acute  primary  pharyngitis  is  to  be  distinguished  from  scarlet  fever, 
diphtheria,  measles,  and  influenza.  A  positive  diagnosis  from  scarlet 
fever  is  impossible  until  a  sufficient  time  has  elaj^Dsed  for  the  eruption  to 


ELONGATED  UVULA  289 

appear,  and  the  patient  should  be  closely  watched  for  the  first  sign  of 
this.  If  scarlet  fever  is  prevalent,  a  child  with  the  symptoms  of  severe 
pharyngitis  should  at  once  be  isolated  while  waiting  for  the  diagnosis 
to  be  settled.  There  is  commonly  less  difficulty  in  excluding  measles 
because  of  the  absence  of  Koplik's  sign  on  the  buccal  mucous  membrane, 
and  of  the  accompanying  catarrh  of  the  eyes  and  nose.  Catarrhal  diph- 
theria can  be  excluded  only  by  culture. 

The  first  step  in  the  treatment  of  acute  pharyngitis  is  to  open  the 
bowels  freely  by  means  of  calomel,  castor  oil,  or  magnesia.  The  child 
should  be  kept  in  bed,  and  the  diet  should  be  fluid,  or,  in  the  case  of 
infants,  the  amount  of  food  should  be  much  reduced.  Pieces  of  ice  may 
be  swallowed  frequently  for  the  relief  of  pain  and  thirst.  Internally 
there  may  be  given  two  grains  of  phenacetin  every  four  hours  to  a  child 
of  three  years.  It  is  important  at  the  outset  to  induce  free  perspiration. 
The  disease  is  not  serious,  and  the  indications  are  to  make  the  child  as 
comfortable  as  possilde  during  the  short  attack. 


UVULITIS 

Acute  inflammation  of  the  uvula,  with  swelling  and  edema,  occurs 
as  a  part  of  the  lesion  in  acute  pharyngitis.  In  rare  instances  the  uvula 
may  be  the  principal  or  the  only  seat  of  inflammation.  Huber  (Xew 
York)  has  reported  two  cases,  one  of  which  is  unique.  An  infant  ten 
months  old  was  apparently  well  until  two  hours  before  he  was  seen,  when 
there  was  noticed  a  constant  irritating  cough,  accompanied  by  consider- 
able gagging.  Later  there  could  be  seen  in  the  mouth  a  prominent  red 
mass,  the  enlarged  and  elongated  uvula.  There  were  also  paroxysms 
of  coughing,  which  interfered  both  with  nursing  and  deglutition.  The 
general  symptoms  were  quite  alarming.  The  uvula  was  found  to  be 
fully  one  inch  long  and  half  an  inch  wide,  red  and  edematous;  in  other 
respects  the  throat  was  normal.  The  symptoms  were  relieved  by  multiple 
needle  punctures  and  the  use  of  ice.  In  such  conditions  the  greatest 
relief  is  often  afforded  by  the  application  of  epinephrin  or  its  use  as  a 
spray  or  gargle. 

ELONGATED  VYVLA 

Probably  this  is  primarily  a  congenital  condition.  It  is  increased  by 
repeated  attacks  of  acute  or  subacute  inflammation.  The  degree  of 
elongation  varies  in  different  cases;  in  some  it  may  be  an  inch  in 
length.  Only  the  mucous  membrane  is  involved  in  the  elongation.  The 
symptoms  are  those  of  local  irritation,  especially  a  cough  upon  lying 


290  DISEASES  OP  THE  DIGESTIVE  SYSTEM 

down,  and  the  sensation  of  a  foreign  body  in  the  pharynx.  In  some 
cases  it  may  be  a  reflex  cause  of  asthma,  or,  more  frequently,  of  catarrhal 
spasm  of  the  larynx.  The  diagnosis  is  very  easily  made  by  inspecting 
the  throat.  The  treatment  consists  in  grasping  the  tip  of  the  uvula  with 
forceps  and  cutting  off  the  excess  with  the  scissors,  or  a  uvulotome. 
Care  should  be  taken  not  to  cut  off  too  much  of  the  uvula,  or  severe 
hemorrhage  may  occur. 


RETROPHARYNGEAL  ABSCESS 

•  Two  distinct  varieties  are  seen :  ( 1 )  The  so-called  idiopathic  abscesses 
which  belong  to  infancy,  and  (2)  abscesses  secondary  to  caries  of  the 
cervical  vertebrae. 

Retropharyngeal  Abscess  of  Infancy.^All  of  the  later  investigations 
regarding  this  disease  indicate  that  primarily  it  is  not  a  cellulitis,  but 
a  suppurative  inflammation  of  the  lymph  nodes  (lymphatic  glands) 
with  a  surrounding  cellulitis.  The  retropharyngeal  lymph  nodes  form  a 
chain  on  either  side  of  the  median  line  between  the  pharyngeal  and  the 
prevertebral  muscles.  These  nodes  are  said  to  undergo  atrophy  after 
the  third  year,  and  in  some  cases  to  disappear  entirely.  Eetropharyngeal 
abscess — or,  more  properly,  retropharyngeal  lymphadenitis,  since  the 
process  does  not  invariably  go  on  to  suppuration — is  probably  never 
primary,  but  secondary  to  infectious  catarrhs  of  the  pharynx,  and  is  set 
up  by  the  entrance  of  pyogenic  bacteria,  usually  the  staphylococcus  or 
streptococcus.  Its  pathology  is  the  same  as  the  more  frequent  suppura- 
tive inflammation  of  the  external  cervical  lymph  nodes,  with  which 
it  is  sometimes  associated.  Usually  only  a  single  node  is  involved,  but 
sometimes  two  or  three  are  affected,  and  these  may  be  situated  upon 
opposite  sides.  We  have  frequently  seen  retropharyngeal  lymphadenitis 
so  severe  as  to  give  rise  to  marked  local  symptoms,  although  it  did  not 
go  on  to  suppuration.  Kormann's  observations,  however,  show  that 
swelling  of  these  glands  in  diseases  of  the  mouth  and  throat  is  very 
much  more  common  than  is  generally  supposed.  Similar  abscesses  from 
suppurative  inflammation  of  other  lymph  nodes  in  the  neighborhood 
of  the  pharynx  may  occur.  We  have  seen  one  situated  between  the 
epiglottis  and  the  base  of  the  tongue. 

Etiology. — These  cases  almost  invariably  occur  in  infancy.  Fully 
three-fourths  of  those  that  have  come  under  our  observation  have  been  in 
patients  under  one  year.  Bokai  (Buda-Pesth)  reports  that  of  sixty  cases 
observed,  forty-two  occurred  during  the  first  year,  eleven  during  the 
second  year,  and  only  seven  at  a  later  period.  The  primary  disease  is 
usually  a   severe  rhinopharyngitis,   or  an   attack   of  epidemic   catarrh. 


RETROPHARYNGEAL  ABSCESS  X291 

but  rarely  it  occurs  as  a  sequel  of  scarlet  fever  or  measles.  In  six  hun- 
dred and  sixty-four  cases  of  scarlet  fever,  Bokai  noted  retropharyngeal 
abscess  in  seven  cases.  After  measles  it  is  even  more  rare.  Eetro- 
pharyngeal  abscess  usually  occurs  in  winter  or  spring,  on  account  of  the 
prevalence  of  the  diseases  upon  which  it  depends.  It  is  seen  quite  as 
frequently  in  children  who  were  previously  robust  as  in  those  who  are 
delicate,  but  is  more  common  in  those  who  are  prone  to  severe  catarrhal 
affections. 

Symptoms. — The  early  symptoms  in  most  cases  are  merely  those  of 
an  ordinary  rhinopharyngeal  catarrh.  After  this  has  subsided  the  tem- 
perature may  remain  slightly  elevated,  often  for  a  week  or  more,  before 
local  symptoms  are  noticeable.  Sometimes,  without  any  distinct  history 
of  previous  catarrh,  there  are  seen  quite  high  temperature,  from  102°  to 
104°  F.,  loss  of  flesh,  and  prostration.  A  careful  examination  may  be 
required,  and  sometimes  observations  for  a  day  or  two,  before  the  ex- 
planation of  these  constitutional  symptoms  is  discovered.  In  other  cases 
the  early  constitutional  symptoms  are  so  slight  as  to  escape  notice,  and 
the  local  symptoms  are  the  only  ones  present.  Although  usually  these 
are  not  severe,  retropharyngeal  abscess  may  cause  dyspnea,  which  in  a 
short  time  assumes  an  alarming  character.  The  duration  of  the  inflam- 
matory process  before  abscess  forms  is  generally  five  or  six  days,  but  it 
may  be  several  weeks.  The  temperature  is  invariably  elevated,  usually 
from  100°  to  103°  F.;  occasionally  it  may  be  104°  or  105°  F.,  with 
symptoms  of  prostration  seemingly  out  of  all  proportion  to  the  local 
disease,  but  which  are  to  be  explained  by  the  tender  age  and  feeble 
resistance  of  the  patient. 

The  most  characteristic  local  symptoms  are  the  posture,  the  head 
being  drawn  far  backward  to  relieve  pressure  on  the  larynx,  the  noisy 
respiration  with  the  mouth  open,  difficulty  in  deglutition  and  some 
external  swelling.  Sometimes  the  first  thing  to  attract  notice  is  a  sudden 
attack  of  dyspnea  severe  enough  to  cause  asphyxia.  This  is  due  to  the 
pressure  forward  of  the  abscess  encroaching  upon  the  larynx.  The  mouth 
may  be  dry,  or  there  may  be  a  copious  secretion  of  pharyngeal  mucus. 
The  dyspnea  is  in  most  cases  greater  on  inspiration,  and  in  some  it  is 
noticed  only  then,  expiration  being  normal.  The  difficulty  in  swallowing 
is  greater  when  the  tumor  is  low.  The  child  may  find  it  impossible  to 
swallow,  and  in  consequence  may  refuse  to  nurse;  or  the  difficulty  in 
nursing  may  depend  upon  the  nasal  obstruction.  Sometimes  there  is 
regurgitation  of  food  through  the  nose  or  mouth.  The  voice  is  usually 
nasal.  Generally  there  is  no  hoarseness,  but  a  peculiar  short  cry  which 
is  quite  characteristic.  There  may  be,  although  rarely,  aphonia.  Usually 
there  is  some  swelling  to  be  seen  externally,  just  below  the  angle  of  the 
jaw  in  front  of  the  sternomastoid  muscle;  exceptionally  this  may  be 


292  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

more  prominent  than  the  internal  swelling.  Occasionally  torticollis  is 
an  early  symptom. 

On  inspection  of  the  throat  there  is  seen  a  distinct  bulging  of  the 
lateral  wall  of  the  pharynx^,  usually  a  little  above  the  base  of  the  tongue. 
The  swelling  may  be  so  great  as  to  crowd  the  uvula  to  one  side  and 
nearly  fill  the  pharynx.  It  is  rarely,  if  ever,  in  the  median  line.  There 
is  usually  redness  of  the  mucous  membrane  and  edema  of  the  uvula  and 
of  the  adjacent  parts.  On  digital  examination  the  swelling  is  made  out 
even  better  than  by  inspection.  It  may  be  situated  so  low  down  as  not 
to  be  visible  at  all.  In  the  early  stage  there  may  be  felt  only  a  localized 
induration  or  a  somewhat  diffuse  swelling,  but  by  the  time  the  swelling 
is  large  enough  to  produce  marked  symptoms^,  fluctuation  can  generally 
be  discovered. 

Prognosis. — When  left  to  itself  the  abscess  may  open  into  the  pharynx^ 
the  pus  being  swallowed  or  expectorated.  The  cavity  may  close  rapidly 
by  granulation,  and  in  a  few  days  the  patient  be  entirely  well;  or  the 
abscess  may  refill.  External  opening  almost  never  takes  place.  It  is 
rare  for  much  burrowing  to  occur.  In  young  or  very  delicate  infants 
the  constitutional  symptoms  may  be  so  severe  that  the  child  continues 
to  fail  even  after  the  evacuation  of  the  abscess,  and  dies  usually  from 
-jDronchopneumonia. 

Death  may  occur  from  asphyxia  due  to  pressure  upon  the  larynx, 
to  edema  of  the  glottis,  or  from  rupture  of  the  abscess  into  the  air 
passages,  especially  if  this  occurs  during  sleep.  Carmichael,  Bokai,  and 
others  have  reported  deaths  from  ulceration  into  the  carotid  artery,  or 
one  of  its  large  branches.  Carmichael's  patient  was  only  five  weeks  old. 
The  general  mortality  is  from  five  to  ten  per  cent;  many  deaths  are 
due  to  a  failure  to  make  the  diagnosis.  Gautier  has  collected  ninety- 
five  cases,  with  forty-one  deaths.  In  our  experience  death  has  most  fre- 
quently resulted  from  late  bronchopneumonia;  in  one  case  it  was  due 
to  a  secondary  retro-esophageal  abscess. 

Diagnosis. — Eetropharyngeal  abscess  is  to  be  suspected  if  in  an  infant 
there  is  difficulty  in  swallowing,  noisy  dyspnea,  mouth-breathing,  and 
the  head  drawn  backward.  A  positive  diagnosis  is  possible  only  by  a 
digital  examination  of  the  pharynx.  The  mistake  most  often  made  is, 
that  the  physician,  called  to  a  young  child  suffering  from  great  dyspnea, 
has  jumped  at  a  diagnosis  of  laryngeal  stenosis,  and  forthwith  jDerformed 
tracheotomy  or  intubation,  without  taking  the  trouble  to  get  the  history 
or  to  make  a  careful  examination  of  the  pharynx.  Many  such  cases 
are  reported  in  which  the  child  has  died  during  the  operation  or  imme- 
diately afterward,  the  autopsy  first  revealing  the  nature  of  the  disease. 
A  sudden  attack  of  dyspnea  like  that  caused  by  the  rupture  of  an  abscess 
might  be  produced  by  the  lodgment  of  a  foreign  body  in  the  pharynx 


RETROPHARYNGEAL  ABSCESS  293 

or  larynx.  A  digital  examination  would  aid  in  the  diagnosis.  We  once 
saw  in  an  infant  a  sarcoma  of  the  pharyngeal  lymph  nodes  which  gave 
an  external  and  internal  tumor  exactly  like  that  of  a  retropharyngeal 


Treatment. — Before  the  abscess  has  pointed,  hot  applications  may  be 
made  to  the  throat  to  relieve  the  symptoms  and  to  hasten  the  formation 
of  pus,  since  resolution  is  not  to  be  expected.  Spontaneous  opening 
should  never  be  waited  for,  on  account  of  the  danger  of  the  rapid  develop- 
ment of  serious  symptoms  from  pressure  or  edema,  or  of  suffocation 
from  an  opening  into  the  air  passages,  especially  during  sleep. 

As  soon  as  the  diagnosis  is  made  the  case  should  be  carefully  watched, 
and  as  soon  as  a  point  of  superficial  fluctuation  is  detected,  but  not  be- 
fore, the  pus  should  be  evacuated.  External  incision  has  been  advocated, 
but  the  internal  opening  is  much  to  be  preferred.  In  opening  through 
the  mouth  the  patient  should  be  seated  in  an  upright  position  and  the 
head  firmly  held.  The  use  of  a  mouth-gag  may  cause  asphyxia.  The 
abscess  may  be  opened  with  a  bistoury  which  has  been  guarded  to  its 
point  by  winding  with  rubber  plaster,  or  better  with  a  pair  of  blunt 
pointed  scissors  or  with  an  artery  clamp.  Often  a  finger-nail  sharpened 
to  a  point  is  all  that  is  necessary.  After  opening  it  is  well  to  insert  the 
finger  into  the  cavity  to  enlarge  the  opening  and  break  down  any  septa; 
for  after  a  simple  puncture  the  abscess  may  refill.  The  head  should  then 
be  bent  forward,  to  allow  the  pus  to  escape  through  the  mouth.  The 
amount  of  pus  evacuated  varies  from  one  dram  to  half  an  ounce.  In 
the  majority  of  cases  no  after-treatment  is  required.  The  relief  of  the 
dyspnea  and  dysphagia  is  immediate,  and,  except  in  young  infants, 
recovery  usually  rapid.  Occasionally  there  is  so  much  edema  that  even 
after  evacuation  tracheotomy  may  be  necessary. 

Retropharyngeal  Abscess  from  Pott's  Disease. — This  form  is  rare  in 
comparison  with  that  just  described,  and  under  three  years  of  age  it  is 
extremely  so.  These  abscesses  are  usually  larger,  and  the  amount  of 
pus  contained  may  be  from  four  to  eight  ounces.  They  form  very  much 
more  slowly,  often  lasting  for  months,  and  as  with  other  secondary 
abscesses,  the  constitutional  symptoms  are  seldom  severe.  The  swelling 
is  frequently  in  the  median  line,  and  is  not  so  circumscribed  as  in  the 
idiopathic  cases.  The  pus  often  burrows  along  the  spine  for  several 
inches. 

The  symptoms  of  Pott's  disease  of  the  cervical  region  are  usually 
present  for  several  months  before  the  appearance  of  the  abscess.  Some- 
times the  abscess  precedes  the  deformity,  and  it  may  be  the  first  intima- 
tion of  the  existence  of  bone  disease.  The  local  symptoms  resemble 
those  of  the  idiopathic  cases,  but  they  develop  more  slowly,  and  sudden 
attacks  of  fatal  asphyxia  are  very  rare.     External  swelling  is  usually 


294  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

seen,  and  it  may  be  quite  large,  extending  almost  from  one  ear  to  the 
other,  forming  a  distinct  collar.  On  digital  exploration  there  may  be 
found  an  irregularity  of  the  anterior  surface  of  the  cervical  vertebrae, 
and  occasionally  a  marked  angular  prominence. 

When  left  to  themselves  these  abscesses  may  open  externally  in  front 
of  the  sternomastoid  muscle  just  below  the  jaw,  sometimes  nearly  as  low 
as  the  clavicle;  they  may  rupture  internally  into  the  pharynx,  the 
esophagus,  or  the  air  passages;  or  they  may  burrow  a  long  distance  in 
front  of  the  spine.  Death  may  result  from  pressure  upon  the  larynx, 
or  from  rupture  into  the  larynx,  trachea,  or  pleura;  all  these,  however, 
are  rare.  The  abscesses  not  infrequently  refill  after  they  are  evacuated, 
and  occasionally  a  discharging  sinus  is  left  for  many  months. 

Treatment. — These  abscesses  should  be  opened  or  aspirated  as  soon  as 
they  are  large  enough  to  give  rise  to  local  symptoms.  The  external 
incision  just  in  front  of  the  sternomastoid  muscle  is  generally  to  be  pre- 
ferred to  opening  through  the  mouth,  since  it  gives  better  drainage,  and 
the  after-treatment  is  more  easily  carried  on ;  and  a  sinus  opening  exter- 
nally is  less  objectionable  than  one  opening  into  the  pharynx. 


ADENOID  GROWTHS  OF  THE  VAULT  OF  THE  PHARYNX 

This  is  a  very  common  condition  and  one  formerly  much  neglected  by 
the  general  practitioner.  It  is  the  source  of  more  discomfort  and  the 
origin  of  more  minor  ailments  than  almost  any  other  pathological  condi- 
tion of  childhood. 

There  is  a  mass  of  lymphoid  tissue  situated  at  the  vault  of  the  phar- 
ynx which  in  structure  closely  resembles  the  tonsils.  It  is  often  spoken 
of  as  the  "pharyngeal  tonsil."  Like  the  faucial  tonsils,  this  may  become 
greatly  hypertrophied,  so  as  to  form  a  tumor  large  enough  to  fill  the 
rhinopharynx  completely.  Those  tumors  have  a  broad  attachment 
which  is  sometimes  more  to  the  roof,  and  sometimes  more  to  the  pos- 
terior wall  of  the  pharynx.  The  term  adenoid  vegetations  was  given 
to  them  by  Meyer,  who  first  described  them  in  1868.  In  infancy  these 
growths  are  soft,  vascular,  and  spongy;  in  older  children  they  become 
firm,  dense,  and  more  fibrous.  Their  appearance  is  well  shown  in  Fig. 
29.  Adenoid'  vegetations  are  associated  with  hypertrophy  of  the  faucial 
tonsils  in  about  one-third  of  the  cases.  Growths  large  enough  to  cause 
decided  nasal  obstruction  may  in  time  produce  changes  in  the  facial 
bones  amounting  to  positive  deformity.  The  bony  palate  may  be  dome- 
shaped  or  even  acutely  arched;  the  dental  arch  of  the  upper  jaw  be- 
comes almost  V-shaped.  Deformities  of  the  thorax  also  occur,  which  will 
be  described  with  the  symptoms. 


ADENOID  GROWTHS  295 

Etiology. — Hereditary  influences  certainly  play  some  part  in  the 
production  of  this  condition.  Frequently  every  one  of  a  large  family 
of  children  may  be  affected,  and  often  the  parents  have  suffered  from 
the  same  condition.  While  infants  are  born  with  adenoid  tissue  in  the 
nasopharynx,  it  is  in  almost  all  instances  small  in  amount  and  seldom 
increases  markedly  in  size  until  after  several  months.    What  causes  the 


Fig.  29. — ^Adenoid  Vegetations,  Natural  Size.  (1)  From  child  eight  months  old; 
(2)  from  child  twenty-two  months  old;  (3)  from  child  two  and  one-half  years  old; 
(4)  from  child  two  and  one-half  years  old;  (5)  from  child  three  years  old.  With  the 
■exception  of  (5)  all  were  removed  with  a  single  sweep  of  the  curette.  Although  the 
growths  represented  are  somewhat  larger  than  the  average  for  the  ages  mentioned, 
just  such  ones  are  constantly  met  with  in  practice. 


abnormal  development  of  this  tissue  it  is  hard  to  say.  Adenoid  growths 
are  most  common  in  damp,  changeable  climates.  Their  first  symptoms 
often  follow  an  attack  of  measles,  scarlet  fever  or  diphtheria.  The 
repeated  attacks  of  rhinopharyngitis  associated  with  adenoid  growths  are 
more  often  a  result  than  a  cause  of  the  condition. 

Czerny  believes  that  the  excessive  growth  of  tissue  in  the  rhino- 
pharynx  is  in  many  instances  the  result  of  overfeeding.  It  is  certainly 
true  that  adenoid  growths  are  much  more  common  in  well  nourished 
than  in  poorly  nourished  children.  Much  interest  has  lately  been  awak- 
ened regarding  the  relation  of  adenoid  gtowths  to  tuberculosis.  Of 
945  cases  collected  by  Lewin  in  which  specimens  of  adenoids  were  ex- 


296  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

amined,  tuberculosis  was  present  in  five  per  cent.  Though  this  propor- 
tion is  no  doubt  much  higher  than  will  be  found  in  private  practice, 
the  fact  is  an  important  one;  for  it  is  highly  probable  that  this  is  the 
channel  of  infection  in  not  a  few  cases  of  tuberculosis. 

Symptoms. — The  s}anptoms  of.  adenoid  growths  are  usually  first  no- 
ticed when  children  are  from  eighteen  months  to  three  years  old;  but 
they  may  be  present  almost  from  birth.  We  have  in  several  instances  seen 
them  to  a  marked  degree  in  infants  only  a  few  months  old.  The  symp- 
toms generally  increase  in  severity  as  age  advances,  being  always  better 
in  summer  and  worse  in  winter,  until  the  age  of  six  or  seven  is  reached. 
The  chief  symptoms  are  those  which  relate  to  (1)  chronic  rhinopharyn- 
geal  catarrh,  (2)  mechanical  obstruction,  (3)  otitis  and  other  aural 
conditions,  (4)  general  malnutrition  and  anemia,  (5)  reflex  nervous 
phenomena. 

The  rhinopharyngeal  catarrh  shows  itself  by  a  persistent  nasal  dis- 
charge, or  frequently  recurring  acute  attacks  of  head-colds  during  the 
Avinter  season.  In  susceptible  children  these  attacks  are  often  the  begin- 
ning of  a  bronchitis,  which  may  keep  a  young  child  indoors  almost  the 
entire  winter. 

The  obstructive  symptoms  are  inability  to  blow  the  nose,  mouth- 
breathing  constantly  or  only  during  sleep,  and  a  nasal  voice.  The 
difficulty  in  breathing  is  increased  when  the  child  lies  upon  the  back. 
In  consequence  of  this,  children  sleep  in  all  sorts  of  positions — lying 
upon  the  face,  sometimes  upon  the  hands  and  knees,  and  often  toss  rest- 
lessly about  the  crib  in  the  vain  endeavor  to  find  some  position  in  which 
respiration  is  easy.  The  attacks  of  dyspnea  at  night  may  amount  almost 
to  asphyxia,  and  are  the  explanation  of  many  of  the  so-called  night- 
terrors  from  which  children  suffer.  When  the  obstruction  has  existed 
from  infancy  there  are  often  deformities  of  the  chest;  these  are  most 
marked  in  rachitic  subjects.  The  most  frequent  one  consists  in  deep 
lateral  depressions  of  the  lower  part  of  the  chest,  with  a  prominence 
of  the  sternum.  The  deformity  is  due  to  interference  with  pulmonary 
expansion.  There  is  often  seen  a  flattening  at  the  root  of  the  nose,  and 
sometimes  a  prominence  of  the  transverse  vein  in  this  region. 

Some  impairment  of  hearing  exists  in  a  large  proportion  of  the  cases. 
Blake  (Boston)  found  this  to  be  true  in  39  out  of  47  cases  examined; 
in  35  of  these  marked  improvement  in  the  hearing  followed  removal 
of  the  adenoid  growths.  Deafness  may  be  due  to  tubal  catarrh  or  to 
otitis.     Often  a  history  is  given  of  several  attacks  of  suppurative  otitis. 

Many  young  children  who  are  subject  to  attacks  of  spasmodic  croup 
have  adenoid  growths,  the  removal  of  which  is  frequently  followed  by 
the  complete  cessation  of  such  attacks.  Other  respiratory  symptoms 
associated  with  adenoid  growths  are  intractable  cough  without  bronchial 


ADENOID  GROWTHS  297 

symptoms  or  signs,  and  persistent  hoarseness  lasting  for  months,  or  even 
for  years  and  recurring  every  cold  season.  These  symptoms  are  the  result 
of  the  chronic  inflammation  in  the  rhinopharynx,  sometimes  extending 
to  the  larynx,  with  an  increased  secretion  of  thick  mucus.  Both  these 
conditions  are  often  cured  by  the  removal  of  the  adenoid  growths  after 
all  other  treatment  has  been  without  effect.  Bronchial  asthma  seems 
at  times  to  be  dependent  upon  these  growths. 

The  reflex  symptoms  ascribed  to  adenoid  growths  have  been  greatly 
exaggerated.  Children  become  nervous  if  they  have  obstructive  symp- 
toms with  disturbed  sleep,  or  if  they  spend  much  of  the  time  in  bed  or  in 
the  house.  Such  children  present  a  number  of  nervous  manifestations 
that  may  be  due  to  other  factors  producing  nervousness,  quite  as  much 
as  to  adenoid  growths.  Incontinence  of  urine  is  very  rarely  cured  by  the 
removal  of  such  growths.  Headaches  with  them  are,  however,  common. 
Stammering,  chorea  and  even  epileptiform  seizures  have  been  attributed 
to  adenoid  growths,  but  without  sufficient  justification. 

The  general  health  of  patients  suffering  from  adenoid  growths  may 
be  impaired  from  loss  of  sleep  and  from  confinement  to  the  house  neces- 
sitated by  attacks  of  bronchitis  or  rhinopharyngitis.  Anemia  is  often 
present.  In  old  cases  of  a  severe  character,  children  may  have  a  dull 
and  stupid  facial  expression.  They  are  languid,  listless,  often  depressed 
and  this  associated  with  deafness  frequently  causes  them  to  be  regarded 
in  school  as  children  who  are  somewhat  deficient  mentally. 

These  patients  are  always  better  in  summer  and  worse  in  winter. 
The  natural  course  of  the  growths  if  left  to  themselves  is  to  increase  up 
to  a  certain  point,  and  then  to  remain  stationary  until  puberty,  when 
they  usually  undergo  some  degree  of  atrophy.  This,  with  the  marked 
increase  in  the  capacity  of  the  rhinopharynx  which  occurs  at  this  time, 
results  in  a  disappearance  of  the  most  aggravated  symptoms.  The  re- 
moval of  the  patient  to  an  elevated  region  with  a  dry  atmosphere  will 
often  result  in  a  relief  from  all  the  symptoms,  and  a  diminution  in  the 
size  of  the  growth,  but  unless  such  a  change  in  residence  is  permanent 
the  symptoms  are  liable  to  return..  Under  ordinary  conditions  there 
is  little  or  no  tendency  to  spontaneous  recovery.  In  children  with 
adenoid  growths  attacks  of  diphtheria,  scarlet  fever,  measles,  and  whoop- 
ing-cough are  all  likely  to  be  more  severe. 

Diagnosis. — In  a  well-marked  case  the  condition  is  usually  evident 
from  the  history,  and  can  scarcely  be  overlooked.  The  intractable  nasal 
catarrh,  upon  which  no  treatment,  local  or  general,  has  more  than  a  tem- 
porary influence,  the  mouth-breathing,  the  disturbed  sleep,  and  the  slight 
deafness — all  are  characteristic.  At  other  times  the  patients  come  for 
treatment  on  account  of  the  general  symptoms — the  nervous  depression, 
the  headaches,  or  the  anemia.    In  rare  cases  the  leading  symptom  may 


2S8  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

be  epistaxis.  The  symptoms  do  not  always  depend  upon  the  size  of  the 
growth,  for  in  a  small  throat  quite  a  small  growth  may  cause  very  marked 
symptoms. 

Although  the  history  is  in  most  cases  clear,  only  an  examination  can 
make  us  certain  that  an  adenoid  growth  exists.  The  growth  is  ordinarily 
felt  as  an  irregular,  granular,  soft,  velvety  mass,  or  sometimes  as  a  firm 
tumor  completely  blocking  the  passage ;  and  the  finger,  when  withdrawn, 
is  frequently  covered  with  blood.  By  posterior  rhinoscopy,  the  growth 
in  older  children  can  be  seen. 

Treatment. — The  disappearance  of  adenoid  growths  is  possible  only 
when  they  are  small.  This  is  aided  by  removal  to  a  warm,  dry  climate 
for  the  winter  season.  All  possible  means  should  be  employed  to  prevent 
these  patients  from  taking  cold.  With  the  larger  growths  these  methods 
may  improve  the  catarrhal  symptoms,  but  can  hardly  affect  the  obstruc- 
tive ones.  The  reduction  of  tumors  of  any  considerable  size  by  local 
applications  is  a  delusion ;  every  marked  case  that  has  come  to  our  notice 
has  been  relieved  only  by  operation. 

Eemoval  of  adenoid  growths  is  indicated:  (1)  When  the  obstructive 
symptoms — habitual  mouth-breathing,  disturbed  sleep,  nasal  voice,  chest 
deformities,  etc. — are  marked;  (2)  for  a  chronic  nasal  discharge,  con- 
stantly recurring  attacks  of  rhinopharyngitis,  particularly  when  these 
tend  to  develop  into  bronchitis  or  laryngitis;  (3)  when  there  is  asthma 
or  repeated  attacks  of  catarrhal  spasm  of  the  larynx;  (4)  with  deafness, 
chronic  otitis,  or  repeated  attacks  of  acute  otitis.  Although  striking 
improvement  is  not  infrequent,  one  should  be  cautious  about  promising 
too  much  from  operation,  especially  as  regards  the  nervous  conditions ; 
also  in  older  children  when  there  is  deafness  or  asthma. 

The  preferable  time  for  operation  is  the  late  spring  or  early  summer, 
in  order  that  during  the  warm  months  the  mucous  membranes  may  have 
an  opportunity  to  regain  their  normal  condition;  however,  operation 
may  be  done  at  any  time  except  during  attacks  of  acute  catarrh.  Unless 
the  symptoms  are  very  marked,  it  is  desirable  to  defer  operation  until 
a  child  is  at  least  two  years  old. 

Eemoval  of  adenoids  by  scraping  with  the  finger  uail  is  at  best  a  very 
uncertain  method,  and  is  not  to  be  advised.  Operation  for  the  removal 
of  adenoids  is  preferably  done  with  general  anesthesia.  So  many 
deaths  from  operations  done  under  chloroform  have  now  been  reported, 
and  so  many  narrow  escapes  have  occurred  that  have  not  been  reported, 
that  chloroform  anesthesia  should  be  given  up  altogether.  Deep  anes- 
thesia is  not  usually  necessary,  and  if  the  semi-erect  position  is  assumed 
it  increases  the  danger  of  the  entrance  of  blood  or  portions  of  the  growth 
into  the  larynx,  which  might  cause  asphyxia.  The  operation  should  only 
be  done  by  one  skilled  in  its  performance. 


ADENOID  GROWTHS  299 

Hemorrhage  is  always  abundant,  and  seems  alarming  to  one  who 
sees  it  for  the  first  time,  but  it  generally  ceases  in  a  few  minutes. 
There  is  evidence  that  the  administration  of  fifteen  or  twenty  grains 
of  calcium  lactate  during  the  twenty-four  hours  preceding  the  opera- 
tion materially  lessens  the  bleeding.  A  child  should  not  pass  from 
the  physician's  observation  until  all  hemorrhage  has  stopped.  He 
should  be  kept  quiet,  preferably  in  bed,  for  twenty-four  hours;  and  in 
the  house  for  five  or  six  days,  unless  the  weather  is  warm.  No  after- 
treatment  is  necessary.  Kecurrences  are  occasionally  seen  even  after  a 
thorough  operation  by  an  experienced  surgeon;  but  many  of  them  are 
due  to  the  fact  that  the  primary  operation  was  incomplete.  The  im- 
provement generally  begins  in  a  few  days,  sometimes  at  once,  though 
the  full  benefit  may  not  be  seen  for  a  month.  The  breathing  becomes 
freer,  the  sleep  more  quiet;  the  mouth  may  soon  be  habitually  closed; 
voice  and  hearing  improve,  and  the  benefit  to  the  general  health  is  soon 
apparent.  The  pallor,  listlessness,  and  inattention  disappear,  and  a 
rapid  increase  in  weight  often  follows.  The  entire  appearance  of  the 
child  may  in  a  few  months  be  transformed. 

Dangers  and  Accidents  from  Operation.- — While  it  is  rare  that  any 
accidents  of  a  serious  nature  are  met  with,  it  should  not  be  forgotten 
that  they  may  occur.  Undue  laceration  of  the  parts  may  result  from  a 
bungling  operation,  particularly  with  too  large  curettes  or  with  the  for- 
ceps. Hemorrhage  may  be  excessive  or  even  fatal.  We  have  seen  but 
one  case  of  fatal  hemorrhage,  this  in  a  bleeder,  and  but  two  other  in- 
stances of  serious  hemorrhage.  A  fatal  result  is  exceedingly  rare. 
Hemorrhage  may  be  continuous  after  operation,  or  secondary,  in  which 
case  it  almost  invariably  occurs  within  twenty-four  hours.  It  is  impor- 
tant, therefore,  that  the  patient  be  kept  under  observation  for  that  time. 
Bleeding  is  best  controlled  by  injecting  into  the  rhinopharynx  through 
the  nostrils  one  or  two  drams  of  hydrogen  peroxid,  full  strength,  or, 
this  failing,  a  solution  of  epinephrin  (1-1000)  may  be  used  in  the  same^ 
manner.  If  this  is  not  effective,  plugging  of  the  rhinopharynx  and 
posterior  nares  may  be  resorted  to.  In  all  cases  the  patient  should  be 
kept  absolutely  quiet. 

Occasionally  an  acute  attack  of  bronchitis  or  otitis  occurs  after  opera- 
tion; and  in  a  few  recorded  instances  acute  meningitis  has  followed. 
The  danger  of  asphyxia  from  the  entrance  of  blood  or  the  tumor  into 
the  larynx  has  already  been  mentioned. 

The  danger  from  chloroform  anesthesia  is  due  not  so  much  to  the 
nature  of  the  operation  as  to  the  condition  of  the  patient.  It  is  now 
well  established  that  all  children  in  whom  the  condition  known  as  status 
lymphaticus  is  present,  bear  chloroform  very  badly. 


300  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

CHAPTER    III 
DISEASES    OF    THE    TONSILS 

The  tonsils  are  lymphoid  structures  closely  resembling  Peyer's 
patches^,  but,  instead  of  having  a  flattened  surface,  the  lymphoid  tissue  in 
the  tonsils  is  folded  upon  itself,  forming  quite  deep  depressions — the  ton- 
sillar crypts.  These  crypts,  like  the  surface  of  the  tonsils,  are  lined  by 
epithelial  cells.  They  contain  lymphoid  cells,  desquamated  epithelium, 
particles  of  food,  and  bacteria.  Under  normal  conditions  the  tonsils 
take  no  part  in  absorption  from  the  mouth.  When,  however,  their  epi- 
thelium is  diseased  or  removed,  the  tonsils  absorb  with  very  great  facil- 
ity every  sort  of  poison  which  the  mouth  may  contain. 

The  most  im|)ortant  chronic  infection  which  takes  place  through 
the  tonsils  is  that  of  tuberculosis;  the  most  important  acute  or  sub- 
acute infection  is  probably  that  of  pyogenic  organisms.  Poisons  absorbed 
by  the  tonsils  are  taken  up  by  the  lymphatic  vessels  and  through  them 
reach  the  cervical  lymph  nodes  and  finally  may  be  carried  into  the  gen- 
eral circulation. 

Acute  inflammation  of  the  tonsils,  like  that  of  the  pharynx,  occurs 
regularly  in  diphtheria,  scarlet  fever,  and  measles,  less  frequently  in  the 
other  infectious  diseases.  The  secondary  forms  will  be  considered  with 
the  diseases  with  which  they  are  associated. 

Acute  catarrhal  tonsillitis,  or  inflammation  of  the  mucous  membrane 
covering  the  tonsils,  occurs  as  part  of  the  lesion  in  acute  pharyngitis, 
but  very  rarely  is  seen  alone. 


MEMBRANOUS  TONSILLITIS 

{Pseudodiphtheria ;  Streptococcus  Angina;  Croupous  Tonsillitis;  Septic  Sore 

Throat) 

This  occurs  both  as  a  primary  inflammation  and  secondary  to  the 
acute  infectious  diseases,  especially  scarlet  fever  and  measles.  The  an- 
gina of  scarlet  fever  is  essentially  a  part  of  that  disease  and  is  more 
fully  considered  in  connection  with  it. 

Etiology. — As  was  first  shown  by  Prudden  in  1888,  and  abundantly 
confirmed  by  others  since  that  time,  this  inflammation  is  usually  due  to 
the  streptococcus ;  it  may  be  found  alone,  or  associated  with  the  staphy- 
lococcus aureus,  and  occasionally  the  staphylococcus  may  be  found  alone. 

The  streptococcus  is  very  frequently  found  in  the  throats  of  healthy 


MEMBRANOUS  TONSILLITIS  301 

children,  particailarly  in  winter  and  in  cities,  and  more  often  in  those 
who  live  in  tenements  or  who  are  inmates  of  hospitals  or  other  institu- 
tions. The  local  conditions  in  the  mucous  membranes  during  an  attack 
of  measles,  scarlet  fever,  and  other  infectious  diseases,  are  especially 
favorable  for  the  development  of  these  germs,  which  at  such  times  are 
very  often  present  in  great  numbers  even  when  no  membrane  is  seen. 
There  are  seen  occasionally,  especially  in  cities,  epidemics  of  great 
severity  in  which  many  persons,  adults  as  well  as  children,  but  the  latter 
chiefly,  are  attacked.  Such  epidemics  have  in  recent  years  broken  out  in 
Boston,  Chicago  and  Baltimore.  Several  of  these  have  been  carefully 
studied  epidemiologically  and  have  been  traced  to  the  milk  supply.  The 
milk  has  been  infected  from  one  or  more  cows  suffering  from  septic 
infection  of  the  udder.  The  organism  has  been  found  to  be  a  hemolytic 
streptococcus  with  rather  distinct  cultural  characteristics. 

In  the  presence  of  an  epidemic  of  severe  tonsillitis,  the  milk  supply 
should  always  be   suspected. 

Lesions. — In  the  primary  cases  the  membrane  is  generally  confined 
to  the  tonsils  or  is  chiefly  there,  only  small  deposits  appearing  elsewhere. 
In  the  secondary  cases,  the  entire  pharynx  may  be  covered  and  the  disease 
may  extend  to  the  nose,  the  mouth,  the  middle  ear,  and  rarely  to  the 
larynx,  trachea,  and  bronchi. 

The  structure  of  the  membrane  resembles  that  of  true  diphtheria, 
and  it  may  be  impossible  by  a  microscopical  examination  to  separate  the 
two  diseases. 

In  the  mild  cases  the  inflammation  of  the  mucous  membrane  is  a 
superficial  one  and  the  pseudomembrane  is  not  very  adherent.  In  the 
severe  cases,  chiefly  the  secondary  ones,  the  process  extends  much  deeper. 
Besides  the  pseudomembrane  upon  the  surface,  there  is  intense  con- 
gestion, edema,  and  cell-infiltration  of  all  the  lymphoid  and  cellular 
tissue  of  the  pharynx.  It  may  involve  the  tonsils,  soft  palate,  uvula,  epi- 
glottis, adenoid  tissue  of  the  vault  and  the  entire  pharyngeal  ring,  and 
also  extend  to  the  external  lymph  nodes  and  surrounding  cellular  tissue. 
The  process  both  in  the  throat  and  externally  in  the  neck  may  terminate 
in  resolution,  suppuration,  or  in  necrosis.  In  severe  cases,  especially  in 
the  epidemic  form,  there  are  found  the  lesions  of  general  septicemia 
or  pyemia.  There  may  be  peritonitis,  endocarditis,  pericarditis,  menin- 
'gitis,  arthritis  and  erysipelas. 

The  streptococci  are  found  in  the  false  membrane,  in  the  underlying 
mucous  membrane,  in  the  lymph  spaces,  in  the  lymph  nodes,  and  in  the 
visceral  lesions. 

Symptoms. — 1.  The  Primary  Cases. — The  onset  is  usually  abrupt, 
with  well-marked  symptoms:  there  are  frequently  chilly  sensations,  head- 
ache, vomiting,  general  pains,  and  in  most  cases  the  child  conaplains  of 


302  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

soreness  of  the  throat  and  pain  on  swallowing.  There  are  first  seen  a 
general  redness  and  swelling  of  the  tonsils,  sometimes  of  the  entire 
pharynx;  shortly  afterward  membranous  patches  appear  upon  the  ton- 
sils. These  vary  greatly  in  appearance.  In  color  they  are  yellow  or 
gray,  often  changing  later  to  a  dirty  olive  tint.  The  membrane  seems 
loosely  attached  and  can  frequently  be  wiped  off  with  a  swab.  It  is 
often  irregular  in  its  outline,  which  is  not  sharply  defined.  The  mem- 
brane usually  remains  but  three  or  four  days  and  disappears  rapidly. 
As  a  rule,  it  is  limited  to  the  tonsils,  and  does  not  spread  after  it  first 
forms.  Occasionally,  however,  small  patches  are  also  seen  upon  the 
fauces  or  the  pharynx.  The  constitutional  symptoms  are  generally 
severe  during  the  first  two  days,  and  the  temperature  may  be  103°  or 
104°  F.,  but  by  the  third  day  it  falls,  and  most  of  the  symptoms  subside. 
It  is  rare  for  the  disease  to  extend  either  to  the  nose  or  the  larynx. 

The  epidemic  cases  are  usually  more  severe  and  the  course  prolonged, 
i^-fter  the  first  few  days,  the  throat  symptoms  may  nearly  disappear,  but 
the  fever  continues  at  times  for  many  weeks.  The  enlargement  of  the 
cervical  glands  is  a  striking  feature,  especially  of  those  eases  that  recover, 
and  this  enlargement  may  persist  for  a  consideralile  time  after  the 
establishment  of  convalescence.  Suppuration  of  the  glands  is  infre- 
quent. Eruptions  are  quite  common.  They  may  be  small,  punctate 
and  hemorrhagic  or  erythematous.  If  of  the  latter  type,  they  may  be 
mild  or  intense,  at  times  closely  simulating  scarlet  fever. 

The  tendency  to  complications  is  great.  One  of  the  most  common 
is  peritonitis,  which  is  jlmflsf^_imif o r mly_jatal^  Endocarditis  and  peri- 
carditis_axe,.Jrec[Ti£iitly  seen.  There  may  be  septic  arthritis,  erysipelas" 
or  localized  abscesses^  Otitis  media  is  often  associated.  Death  may  be 
due  to  the  complications  or  to  the  septicemia.  It  is  a  very  severe  form 
of  disease.  Except  in  the  epidemic  cases,  the  complications  and  sequelae 
are  infrequent. 

2.  The  Secondary  Cases. — Some  of  these  are  mild,  but  the  majority 
are  severe.  The  clinical  picture  of  the  latter  is  that  of  scarlatina  angi- 
nosa,  as  given  by  the  older  writers. 

In  measles  the  throat  symptoms  are  somewhat  later  than  in  scarlet 
fever;  they  may  begin  at  the  height  of  the  primary  fever,  and  increase 
while  the  eruption  fades.  The  process  is  almost  invariably  compli- 
cated by  Taronchopneumonia. 

Secondary  cases  as  a  class  are  characterized  l)y  high  temperature 
(Fig.  30),  rajaid,  feeble  j3iilse,_great  prostration,  delirium,  apathy  or 
stupor,  and  often  albuminuria.  In  fatal  cases  death  usually  occurs 
at  the  height  of  the  diseaseTTfoln^sthenia,  bronchopneumonia,  or  nephri- 
tis. If  none  of  these  coniplications  develop,  patients  may  withstand  the 
toxic  symptoms^vinwHeDr^iiey^'e-  Very~&&vere. 


MEMBRANOUS  TONSILLITIS 


303 


There  may  be  in  connection  with  the  local  process  in  the  throat,  deep 
sloughing  of  the  tonsils  or  adjacent  structures,  suppuration  of  the  lym- 
phatic glands  or  in  the  cellular  tissue  of  the  neck,  occasionally  followed 
by  serious  hemorrhage.  However,  these  complications  are  rare,  and  if 
the  patient  survives  the  danger  of  the  acute  stage  of  the  disease,  he 
usually  recovers. 

Dia^osis. — The  clinical  features  which  distinguish  membranous  ton- 
sillitis from  diphtheria  are  considered  under  the  latter  disease.     It  is 


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Fig.  30. — Streptococcus  Angina,  following  Measles.  The  chart  begins  at  the  time 
of  the  full  eruption  in  a  severe  case  of  measles.  On  the  third  day  the  temperature 
fell,  with  fading  eruption,  and  child  seemed  convalescent.  With  secondary  rise  in 
temperature,  the  tonsils,  which  before  had  been  only  red,  showed  membranous 
patches,  the  exudation  rapidly  spreading  until  the  entire  pharynx  was  covered; 
throat  symptoms  very  severe,  with  great  swelling  of  cervical  glands,  but  the  mem- 
brane did  not  extend  beyond  the  pharynx.  From,  sixth  to  twelfth  day  a  most  pro- 
found septicemia,  so  that  life  was  despaired  of.  The  patient  was  a  vigorous  child, 
and,  escaping  both  nephritis  and  pneumonia,  made  a  good  recovery.  Convalescence 
quite  rapid;  no  sequelae.  Repeated  cultures  were  made  from  the  throat,  but  all 
showed  only  streptococci.  Patient  a  girl  four  years  old.  Case  observed  in  private 
practice. 

inipossible_in  any  case  to  be  certain  of  the  diagnosis  except  by  cultures; 
for,  although  by  clinical  symptoms  alone  one  may  in  the  greafnmjofTtjr 
of  cases  be  certain  that  a  given  case  is  one  of  true  diphtheria,  to  say 
that  any  membranous  inflammation  of  the  throat  is  not  diphtheria  is 
impossible. 

A  membranewhich  appears  in  the  throat  earjy  in  the  course  of 
nieasles  or  scarlet_fgi:er^_or  atthe  heightjjf^  the  prima  ry_djsease,  is  usu- 
ally due  to  the  streptococcus  ;whiIe^oiiewhich  develops  late  or  after  the 
primary  fever  has  subsided,  is  frequently  due  to  the  diphtheria  bacillus. 
When  an  eruption  is  present  the  diagnosis  from  scarlet  fever  may  be 
very  difficult,  at  times  well  nigh  impossible. 

Prognosis. — In  a  child  previously  healthy,  primary  membranous  ton- 
sillitis, except  the  epidemic  form,  is  not  a  serious  disease.     In  the  sec- 


304  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ondary  cases,  we  find  very  different  conditions.  From  tlie  best  available 
statistics  it  would  appear  that  the  usual  mortality,  when  it  is  secondary 
to  scarlet  fever  and  measles,  is  from  fifteen  to  twenty  per  cent.  How- 
ever, when  these  diseases  prevail  epidemically  in  institutions,  the  mor- 
tality is  often  higher  than  this. 

Treatment. — Every  child  with  a  membranous  patch  on  the  tonsils 
requires  close  watching;  strict  quarantine  should  be  enforced  until  the 
diagnosis  is  positively  settled,  and  even  if  it  is  not  diphtheria,  close 
contact  with  other  people  should  be  prevented.  If  under  three  years 
old,  unless  the  case  can  be  seen  frequently,  diphtheria  antitoxin  should 
be  administered,  pending  the  result  of  a  bacteriological  examination. 
The  primary  cases  require  only  the  treatment  of  an  attack  of  tonsillitis. 

In  the  severe  secondary  and  septic  cases  the  nose  and  pharynx  should 
be  syringed  with  a  warm  saline  solution  every  two  hours  by  day  and 
every  four  hours  by  night.  Where  the  swelling  and  edema  are  great, 
benefit  may  result  from  frequent  spraying  with  solutions  containing 
epinephrm,  also  from  inhaling  hot  vapor  impregnated  with  eucalyptol, 
benzoin,  etc.  As  an  external  application,  whenever  there  is  great  adenitis 
and  cellulitis,  nothing  is  so  beneficial  as  the  ice-bag. 

The  general  management  of  these  cases  as  to  feeding,  stimulants, 
etc.,  is  the  same  as  in  diphtheria.  Aside  from  stimulants  no  internal 
medication  should  be  attempted  with  young  children.  Those  who  are 
older  may  take  with  advantage  tr.  ferri  chlor.,  gtt.  v  to  x,  with  glycerin, 
every  three  or  four  hours.  All  milk  should  be  boiled  when  there  is  an 
outbreak  of  several  cases  of  severe  tonsillitis  in  a  community  or  family. 


ULCEROMEMBRANOUS   TONSILLITIS 

{Vincent's  Angina) 

This  is  an  inflammation  somewhat  resembling  croupous  tonsillitis, 
but  it  is  often  unilateral  and  associated  with  superficial  ulceration.  The 
tonsil  is  covered  with  a  dirty  yellowish  exudation,  which  may  be  mistaken 
for  diphtheria.  There  is  superficial  necrosis,  and  when  this  tissue  is 
wiped  away  with  a  swab,  bleeding  occurs.  The  disease  is  further  dis- 
tinguished by  the  swollen  lymph  nodes  at  the  angle  of  the  jaw,  and  by 
the  fact  that  the  constitutional  symptoms  which  accompany  other  forms 
of  tonsillitis  are  either  very  slight  or  absent  altogether.  The  etiology 
is  similar  to,  if  not  identical  with  that  of  ulcerative  stomatitis,  with 
which  it  is  sometimes  associated.  At  such  times  the  breath  is  foul  and 
there  is  often  profuse  salivation. 

Ulceromembranous   tonsillitis  was   first   described   1)V  Yincent,   and 


FOLLICULAR  TONSILLITIS  305 

by  him  attributed  to  a  fusiform  bacillus  which  he  described,  although  a 
spirillum  was  found  associated  with  it.  Vincent's  observations  have  been 
confirmed,  and  it  has  been  shown  that  the  spirillum  is  a  degenerative 
form  of  the  bacillus. ^ 

The  chief  interest  in  ulceromembranous  tonsillitis  lies  in  the  diag- 
nosis, although  it  is  not  an  infrequent  disease.  It  is  to  be  treated,  like 
ulcerative  stomatitis,  by  the  internal  administration  of  chlorate  of  pot- 
ash, combined  with  the  local  application  of  some  antiseptic,  such  as 
peroxid  of  hydrogen  or  a  ten-per-cent  solution  of  nitrate  of  silver. 


FOLLICULAR  TONSILLITIS 

Tliis  is  the  most  frequent  and  most  characteristic  form  of  inflamma- 
tion of  the  tonsil.  It  is  essentially  an  inflammation  of  the  tonsillar 
crypts,  and  secondarily  of  the  whole  glandular  structure. 

Etiology. — There  is  seen  in  certain  children  a  predisposition  to  at- 
tacks of  tonsillitis,  so  that  from  very  slight  exciting  causes  these  occur — 
sometimes  from  exposure,  sometimes  possibly  from  derangement  of  the 
stomach,  and  sometimes  without  any  evident  reason.  Children  with  a 
rheumatic  inheritance  appear  to  be  more  susceptible  than  others.  One 
attack  predisposes  to  a  second.  Patients  suffering  from  chronic  hyper- 
trophy of  the  tonsils  are  exceedingly  prone  to  acute  tonsillitis.  It  is  not 
very  common  in  infancy,  but  after  this  period  it  is  very  frequent  through- 
out childhood.  The  disease,  in  all  probability,  begins  as  an  infectious 
inflammation  at  the  bottom  of  the  crypts,  due  to  the  presence  of  strep- 
tococci or  staphylococci,  which  readily  enter  from  the  mouth,  and  excite 
an  attack  whenever  favorable  conditions  are  present. 

Lesions. — As  a  result  of  the  inflammation,  the  tonsillar  crypts  are 
filled  with  epithelial  cells,  pus  cells,  mucus,  and  bacteria.  These  form 
masses  which  appear  at  the  mouth  of  the  crypts  as  small  yellow  dots, 
often  miscalled  ulcers.  Sometimes,  in  addition,  fibrin  is  poured  out, 
and  forms,  with  the  other  inflammatory  products,  little  plugs  which 
project  somewhat  from  the  surface  of  the  mucous  membrane,  and  which 
can  easily  be  pressed  out.  Accompanying  the  changes  in  the  mucous 
membrane  above  mentioned,  there  are  acute  congestion  and  swelling  of 
the  whole  tonsils,  with  more  or  less  proliferation  of  the  lym23hoid  tissue. 

^  Vincent's  bacillus  is  about  twice  as  long  as  the  Klebs-Loeffler  bacillus.  It  is 
thin,  with  pointed  ends,  and  sometimes  bent;  it  is  negativa  to  Gram's  stain.  -The 
fusiform  bacillus  is  occasionally  found  alone;  the  spirillum,  never  alone.  The 
bacillus  is  found  in  smears  from  the  affected  tonsil,  in  making  which  it  is  recom- 
mended to  go  deeply  into  the  necrotic  tissue,  since  the  superficial  parts  are 
crowded  with  other  bacteria.  It  is  grown  with  difficulty  and  only  upon  special 
culture  media. 


306  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Follicular  tonsillitis  is  almost  always  bilateral.  Although  the  patholog- 
ical process  is  generally  limited  to  the  tonsilS;,  there  may  be  more  or 
less  pharyngitis  associated. 

Symptoms. — The  general  symptoms  visually  appear  before  the  local 
ones,  and  are  often  quite  severe.  The  onset  is  abrupt  with  chilly  sensa- 
tions, occasionally  a  distinct  rigor.  In  infants  there  is  often  vomiting, 
and  sometimes  diarrhea.  There  is  pain  in  the  back,  in  the  muscles  of 
the  extremities,  and  in  the  head.  Sometimes  there  is  pain  in  the  lateral 
cervical  muscles.  The  temperature  rises  rapidly  to  102°  or  103°  F., 
often  it  touches  104°  or  105°  F. 

The  first  local  symptoms  are  some  swelling  of  the  tonsils  and  the  ap- 
pearance upon  them  of  isolated  yellow  spots  a  little  larger  than  a  pin's 
head.  Often  these  can  be  wiped  off  with  a  swab,  or  the  little  plugs  can  be 
squeezed  out,  leaving  slight  depressions.  Later  there  is  acute  congestion 
of  the  tonsil,  with  more  swelling.  Even  when  the  disease  is  at  its  height 
the  local  pain  and  discomfort  may  be  only  moderate,  and  in  many  cases 
scarcely  noticeable.  The  swelling  and  tenderness  of  the  lymph  glands 
behind  the  angle  of  the  jaw  are  not  great,  and  may  be  absent. 

The  constitutional  symptoms,  as  a  rule,  last  three  days,  and  are  most 
severe  upon  the  first  day.  The  local  symptoms  last  somewhat  longer,  but 
usually  by  the  end  of  the  fourth  day  the  exudate  has  disappeared, 
although  enlargement  of  the  tonsil  may  persist  for  a  week  or  even  longer. 
On  account  of  the  connection  of  tonsillitis  with  rheumatism,  the  heart 
should  be  watched  during  attacks,  especially  in  those  who  are  subject 
to  them. 

Diagnosis. — Tonsillitis  may  be  confounded  at  its  onset  with  scarlet 
fever.  The  great  frequency  of  tonsillitis  makes  inspection  of  the  throat 
imperative  in  every  case  of  acute  illness  in  children.  The  diagnosis  from 
diphtheria  is  considered  in  connection  with  that  disease. 

Treatment.^Follicular  tonsillitis  is  a  mild  disease  without  danger  to 
life,  and  one  which  runs  a  short,  self-limited  course.  The  indications 
are,  therefore,  to  make  the  patient  as  comfortal)le  as  possible  by  the 
relief  of  individual  symptoms.  Older  children,  particularly  those  who 
are  rheumatic,  should  be  treated  with  sodium  salicylate,  or  aspirin,  four 
or  five  grains  every  three  hours  being  given  for  the  first  twenty-four 
hours,  and  later  less  frequently.  To  infants  these  drugs  must  be  given 
in  smaller  doses  and  with  care,  lest  they  upset  the  stomach.  The  general 
muscular  pains  of  the  first  day  are  best  relieved  by  phenacetin,  two 
grains  every  four  hours  to  a  child  three  years  old.  Later  it  may  be 
used  in  smaller  doses,  but  enough  should  be  given  to  make  the  patient 
comfortable. 

Local  treatment  is  better  omitted  with  infants.  Older  children  may 
gargle  with  a  solution  of  boric  acid  or  may  use  a  spray  of  Dobell's  solu- 


PHLEGMONOUS  TONSILLITIS  307 

tion.  Benefit  often  follows  painting  the  tonsils  with  tincture  of  iodin 
or  a  ten-per-cent  solution  of  silver  nitrate.  In  all  doubtful  cases  the 
patient  should  be  isolated  and  the  same  general  treatment  adopted  as  in 
diphtheria. 


PHLEGMONOUS     TONSILLITIS— PERITONSILLAR     ABSCESS— QUINSY 

This  is  an  inflammation  of  the  cellular  tissue  surrounding  the  tonsil, 
sometimes  invading  the  tonsil  itself.  It  may  terminate  in  resolution,  but 
usually  goes  on  to  the  formation  of  an  abscess.  Phlegmonous  tonsillitis 
is  much  less  common  in  children  than  in  adults,  and,  compared  with  the 
other  forms,  it  is  a  rare  disease  in  early  life.  It  is  the  only  variety  which 
is  regularly  unilateral.  In  most  cases  the  inflammatory  process  is  cir- 
cumscribed, but  in  rare  instances  there  is  seen  a  diffuse  phlegmonous 
inflammation  of  the  pharynx. 

In  certain  patients  there  exists  a  constitutional  predisposition  to  the 
disease,  which  may  be  associated  with  rheumatism.  The  exciting  cause 
may  be  exposure,  or  anything  which  may  reduce  the  patient's  general 
health,  to  which  there  is  added  local  infection.  Catarrhal  pharyngitis 
predisposes  to  this  disease. 

Symptoms. — The  onset  resembles  that  of  follicular  tonsillitis,  the 
temperature  is  often  high,  and  the  muscular  pains  and  prostration  severe. 
There  is  acute  pain  in  the  throat,  which  is  increased  by  deglutition, 
and  finally  may  be  so  great  that  swallowing  is  almost  impossible.  It  is 
difficult  to  open  the  mouth.  There  is  pain  in  the  lateral  muscles  of  the 
neck,  and  often  tenderness.  In  the  beginning  but  little  can  be  seen  on 
inspection,  even  though  the  patient  complains  of  a  very  sore  throat.  This 
is  always  a  suspicious  circumstance,  and  should  lead  one  to  look  out  for 
quinsy.  It  is  due  to  the  fact  that  the  inflammation  begins  in  the  deeper 
tissues,  and  that  the  mucous  membrane  is  affected  later.  After  twenty- 
four  or  forty-eight  hours  there  is  usually  quite  marked  swelling,  which 
is  rather  more  behind  the  tonsil  than  elsewhere,  pushing  it  upward  and 
forward ;  sometimes  it  is  more  in  front  of  the  tonsil.  A  little  later  there 
is  intense  inflammation  of  the  mucous  membrane  covering  the  tonsil, 
fauces,  and  uvula,  and  not  infrequently  a  fibrinous  exudate;  the  uvula 
may  be  pushed  to  one  side,  and  the  isthmus  of  the  fauces  diminished  to 
barely  one-half  its  natural  size.  In  one  of  our  own  cases  marked  tor- 
ticollis was  present,  and  existed  for  two  or  three  days  before  the  diagnosis 
of  quinsy  could  be  made  by  the  other  symptoms. 

In  most  cases  the  recognition  of  quinsy  is  quite  easy  by  attention  to 
the  symptoms  above  mentioned.  By  inspection  of  the  throat  less  in- 
formation is  sometimes  obtained  than  by  palpation;  by  this  means  a 


308  DISEASES  OE  THE  DIGESTIVE  SYSTEM 

fulness,  and  later  a  point  of  fluctuation,  can  readily  be  made  out.  Acute 
phlegmonous  tonsillitis  generally  involves  no  danger  to  life.  In  very 
young  infants  serious  results  may  follow  spontaneous  rupture  during 
sleep';  and  in  older  children  occasionally  there  may  be  edema  of  tlie 
glottis.  If  not  treated,  abscess  usually  forms  in  from  five  to  seven  days, 
and  opens  spontaneously. 

Treatment, — Many  drugs  have  been  advocated,  but  to  our  minds  the 
best  is  salol,  which  should  be  given  in  doses  of  two  grains  every  two 
hours  to  a  child  of  five  years.  In  some  patients  larger  doses  may  be 
used.  This  may  be  combined  with  small  doses  (gr.  14)  of  Dover's 
powder.  Eelief  may  be  afforded  by  very  hot  or  cold  applications,  ac- 
cording to  the  sensations  of  the  patient.  The  holding  of  ice  in  the 
mouth  and  the  application  of  an  ice-bag  externally,  often  give  great 
comfort.  In  other  cases,  gargling  with  very  hot  water  and  the  applica- 
tion of  hot  flaxseed  poultices  externally,  will  be  preferred.  As  soon  as 
fluctuation  is  detected  an  incision  should  be  made  with  a  guarded  bis- 
toury. If  made  too  early,  only  a  small  amount  of  pus  is  evacuated  and 
the  abscess  may  refill.  After  spontaneous  rupture  the  relief  to  symp- 
toms is  usually  immediate. 


CHRONIC  HYPERTROPHY  OF  THE  TONSILS— CHRONIC  TONSILLITIS 

The  condition  known  as  chronic  hypertrophy  is  a  permanent  enlarge- 
ment due  to  a  proliferation  of  the  lymphoid  tissue  of  the  tonsils,  and  an 
increase  in  the  connective-tissue  stroma.  If  the  increase  in  the  con- 
nective tissue  is  slight,  the  tonsil  is  soft;  if  it  is  gTeat,  the  tonsil  is  firm 
and  hard,  almost  like  a  fibrous  tumor.  All  degrees  are  found.  Asso- 
ciated with  hypertrophy  of  the  tonsils  there  are  usually  found  adenoid 
growths  of  the  pharynx,  both  of  these  depending  upon  similar  local  and 
constitutional  conditions.  There  is  in  nearly  all  marked  cases  a  chronic 
pharyngeal,  catarrh  which  may  involve  the  Eustachian  tubes. 

Etiology. — Hypertrophy  of  the  tonsils  is  an  exceedingly  common  con- 
dition in  the  cities  of  the  seacoast  and  lake  districts  of  the  temperate 
zone.  In  a  routine  examination  of  3,000  New  York  school  children. 
Chappell  found  enlargement  of  the  tonsils  sufficiently  marked  in  270 
cases  to  be  considered  pathological.  The  causes  are  constitutional  and 
local.  The  condition  frequently  exists  in  certain  families  for  several 
generations.  It  occurs  in  children  who  are  in  other  respects  healthy. 
According  to  Czerny,  overfeeding  may  produce  tonsillar  enlargement 
just  as  it  does  enlargement  of  the  adenoid  tissue  of  the  rhinopharynx. 
The  most  important  of  the  local  causes  are  attacks  of  acute  or  subacute 
pharyngitis.     While  it  is  true  that  attacks  of  acute  inflammation  are 


HYPEETROPflY  OF  THE  TONSILS  309 

often  the  cause  of  hypertrophy,  it  is  also  true  that  hypertrophy  is  one 
of  the  most  frequent  predisposing  causes  of  acute  attacks^  and  that  it  may 
he  seen  in  children  who  have  never  had  acute  tonsillitis. 

Symptoms. — Hypertrophy  of  the  tonsils  is  rarely  marked  enough  to 
cause  any  decided  symptoms  before  the  end  of  the  second  year,  although 
occasionally  in  younger  children  enlargement  sufficient  to  bring  the  two 
tonsils  into  contact  may  be  seen.  The  most  important  local  symptoms, 
formerly  ascribed  to  hypertrophied  tonsils,  are  now  known  to  depend 
upon  adenoid  growths  of  the  pharynx.  As  these  conditions  are  so  fre- 
quently associated,  it  is  somewhat  difficult  to  determine  which  symptoms 
are  due  to  the  tonsils  ■  alone.  In  a  marked  case,  the  most  prominent 
symptoms  are  mouth-breathing,  disturbed  sleep  accompanied  by  snoring, 
and  nasal  voice — the  patient  in  some  cases  talking  as  though  he  had 
food  in  his  mouth.  There  may  be  some  difficulty  in  swallowing  solid 
food.  Enlarged  tonsils  may  often  be  felt  externally.  As  a  consequence 
of  the  obstruction  of  the  Eustachian  tubes  there  may  be  deafness.  De- 
formities of  the  chest,  such  as  pigeon-breast,  are  occasionally  seen,  but 
probably  depend  more  upon  obstructed  respiration  by  adenoids  than  by 
the  tonsils. 

There  are  seen  in  certain  children  tonsils  which  show  only  a  very 
moderate  amount  of  enlargement,  but  are  of  unhealthy  appearance 
and  are  accompanied  by  low  fever  and  other  indefinite  symptoms  of 
illness  which  may  persist  for  months.  The  tonsils  appear  to  act 
in  such  cases  as  the  avenue  of  absorption  which  results  in  a  general 
infection. 

The  soft  tonsils  may  diminish  somewhat  in  size  spontaneously.  They 
sometimes  shrink  very  decidedly  after  an  attack  of  acute  tonsillitis, 
scarlet  fever,  or  diphtheria.  As  a  rule  the  tonsils  become  firmer  and 
harder  as  time  jjasses.  They  usually  increase  in  size  up  to  a  certain 
point,  and  then  remain  nearly  stationary  until  about  puberty,  when 
they  may  diminish  considerably.  During  intercurrent  attacks  of  inflam- 
mation, the  swelling  is  much  increased,  and  the  symptoms  are  propor- 
tionately aggravated.  In  cases  of  marked  enlargement  very  little  spon- 
taneous improvement  is  to  be  looked,  for  during  childhood. 

Treatment. — Aery  lai'ge  tonsils  are  a  source  of  continued  danger  to 
the  patient,  and  in  every  case  of  marked  hypertrophy  treatment  should 
be  advised.  The  danger  may  be  from  Eustachian  catarrh  and  deafness, 
or  from  repeated  attacks  of  acute  tonsillitis.  But  quite  as  important  as 
these  is  the  fact  that  they  increase  the  liability  to  contract  diphtheria, 
and  add  to  the  dangers  both  from  diphtheria  and  scarlet  fever.  If  the 
patient  is  removed  from  the  locality  in  which  acute  tonsillitis  is  liable  to 
occur,  to  a  dry  climate,  considerable  improvement  is  likely  to  result  in 
a  young  child  in  whom  the  tonsils  are  soft,   but  not  much  is  to  be 


310  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

expected  in  older  children  with  hard,  tibrous  tonsils,  except,  perhaps,  a 
cure  of  the  accompanying  pharyngeal  catarrh. 

No  internal  remedy  offers  much  chance  of  benefit.  Astringent  ap- 
plications may  accomplish  something  in  recent,  but  practically  nothing 
in  old  cases.  In  every  marked  case,  operation  is  the  only  thing  which 
can  be  relied  upon  to  effect  a  cure.  For  convenience  of  consideration, 
the  cases  may  be  divided  into  four  groups:  (1)  Those  in  which  the 
tonsils  are  nearly  or  quite  in  contact;  (3)  those  in  which  they  project 
only  slightly  beyond  the  faucial  pillars;  (3)  those  in  which  the  tonsils, 
although  large,  are  deeply  imbedded;  (4)  diseased  tonsils,  though  show- 
ing only  moderate  enlargement,  especially  when  associated  with  tubercu- 
lous glands  of  the  neck.  All  of  the  first  group  should  unquestionably 
be  operated  upon,  unless  the  patient's  general  condition  is  such  as  to 
forbid  operation  of  any  kind.  In  the  second  group  operation  is  not  indi- 
cated unless  there  are  repeated  acute  attacks  of  inflammation.  Whether 
an  operation  is  done  in  the  third  group  will  depend  upon  the  individual 
case.  If  there  are  frequent  attacks  of  acute  tonsillitis  or  evidence  of 
involvement  of  the  ears  operation  should  be  performed.  In  the  fourth 
group  operation  is  indicated  if  general  symptoms  are  present. 

Of  the  various  operations  proposed  for  the  removal  of  hypertrophied 
tonsils  complete  enucleation  is  clearly  to  be  preferred.  It  is  a  painful 
operation,  some  preliminary  dissection  is  usually  required,  and  hence  gen- 
eral anesthesia  is  necessary.  The  risk  of  serious  liemorrhage  in  children 
is  slight,  but  preparations  should  always  be  made  to  control  it  as  even 
with  non-bleeders  one  can  never  tell  how  severe  it  may  be.  Enlarge- 
ment of  the  tonsil  subsequent  to  simple  amputation  is  quite  frequently 
seen,  especially  if  the  patient  operated  on  is  under  two  years  old. 

We  have  more  than  once  seen  physicians  greatly  alarmed  at  the  gray 
wound  on  the  day  following  tonsillotomy,  the  appearance  being  such  as  to 
lead  in  several  cases  to  the  diagnosis  of  diphtheria.  It  is  seldom  that  any 
but  good  results  follow  the  operation  of  tonsillotomy  if  properly  per- 
formed. When  adenoids  of  the  pharynx  are  also  present,  the  symptoms 
may  depend  more  upon  them  than  upon  the  enlarged  tonsils,  and  little 
benefit  is  seen  unless  the  adenoids  also  are  removed. 


ACUTE  ESOPHAGTTIS  311 

CHAPTER    IV 
,     DISEASES  OF  THE  ESOPHAGUS 

MALFORMATIONS 

Congenital  anomalies  of  the  esophagus  are  often  associated  with 
those  of  the  lower  part  of  the  respiratory  tract. 

There  may  be,  (1)  Congenital  fistula  of  the  neck,  due  to  a  want  of 
closure  between  the  second  and  third  branchial  arches.  This  gives  an 
external  opening  just  above  and  to  the  outside  of  the  sternoclavicular 
articulation,  which  communicates  with  the  upper  part  of  the  esophagus 
or  the  lower  part  of  the  pharynx.  (2)  The  esophagus  may  be  absent, 
the  pharynx  ending  in  a  blind  pouch.  (3)  The  esophagus  may  be  oblit- 
erated in  certain  portions,  being  represented  only  by  a  fibrous  cord.  (4) 
There  may  be  stenosis  and  dilatation  or  diverticula.  (5)  There  may 
be  fistulous  communication  with  the  trachea,  existing  either  alone  or  asso- 
ciated with  some  of  the  other  deformities  mentioned.  This  is  the  variety 
which  we  have  most  frequently  met  with.  From  above,  the  esophagus 
usually  terminates  in  a  blind  pouch.  From  below,  it  communicates  with 
the  trachea  a  short  distance  below  tlie  larynx.  The  two  parts  of  the 
esophagus  are  usually  coimected  by  a  fibrous  cord. 

Congenital  narrowing  of  tlie  esophagus  and  fistula  of  the  neck  are 
amenable  to  surgical  treatment.  The  cases  of  complete  obstruction  in 
the  esophagus  are  almost  of  necessity  fatal,  the  patients  dying  from  in- 
anition four  or  five  days  after  birth. 

The  symptoms  of  esophageal  obstruction  are  regurgitation  on  at- 
tempts at  swallowing  and  the  impossibility  of  passing  the  stomach  tube. 
An  X-ray  picture  after  the  administration  of  bismuth  often  gives  valu- 
able information. 

ACUTE  ESOPHAGITIS 

It  is  quite  remarkable,  considering  the  frequency  of  pathological 
processes  in  the  pharynx,  that  these  so  rarely  extend  to  the  esophagiis. 
Thrush,  when  very  extensive  in  the  pharynx,  may  involve  the  upper  part 
of  the  esophagus;  but  there  it  gives  rise  to  no  new  symptoms.  Diph- 
theria of  the  pharynx  may  invade  the  esophagus,  but  this  is  seen  only 
in  rare  instances.  Diphtheria  of  the  esophagus  produces  no  symptoms 
by  which  it  can  be  diagnosticated  during  life. 

Catarrhal   Esophagitis. — Catarrhal   esophagitis    is   very   rarely   met 


312  DISEASES  OF  THE  DIGESTIVE  SYSTE:\[ 

with.  It  may  be  caused  by  lacerations  due  to  swallowing  a  foreign  body, 
Avhicli  may  excite  a  simple  catarrhal  infiammatiou,  or,  if  the  foreign 
body  is  sharp  and  angular,  lacerations  may  be  produced  which  result  in 
ulcerations  of  variable  depth.  The  chief  symptoms  of  catarrhal  esoph- 
agitis  are  soreness  and  j^ain  on  swallowing.  These  lacerations,  when  slight, 
are  healed  in  a  few  days,  and  are  rarely  followed  by  any  after-effects. 

Corrosive  Esophagitis. — This  is  altogether  the  most  frequent  form, 
and  the  only  one  which  is  of  clinical  importance.  The  usual  causes  are 
the  same  as  of  corrosive  gastritis,  viz.,  the  swallowing  of  caustic  alkalis 
or  strong  acids.  It  is  often  in  the  esophagus  that  the  most  extensive 
injury  is  done.  The  effects  are  superficial  or  deep,  according  to  the 
amount  of  the  irritant  swallowed  and  its  degree  of  concentration.  There 
may  be  simply  a  destruction  of  the  epithelial  layer,  which  is  followed  by 
no  serious  consequences,  or  the  mucous  membrane  may  be  destro3'ed  and 
the  submucous  coat  invaded;  rarely,  however,  does  the  injury  extend  to 
the  muscular  layer.  If  the  patient  survives  the  dangers  incident  to  the 
irritant  poisoning  and  the  acute  inflammation  which  follows,  healing  by 
granulation  and  cicatrization  takes  place,  the  contraction  of  the  cicatrix 
gradually  narrowing  the  lumen  of  the  esophagus  until  stricture  is  pro- 
duced. 

The  early  symptoms  of  corrosive  esophagitis  are  mingled  with  those 
of  inflammation  of  the  mouth,  pharynx,  and  stomach.  There  is  a  burn- 
ing pain  in  the  parts,  great  thirst,  and  spasm  of  the  esophagus  on  at- 
tempts at  swallowing.  There  follows  a  period  of  acute  inflammation  of 
several  days'  duration,  with  great  dysphagia  and  pain,  in  which  the 
principal  danger  is  edema  of  the  glottis.  After  this  the  patient  may 
be  comparatively  well  until  the  symptoms  of  stricture  begin,  usually  in 
from  three  to  six  months  after  the  injury. 

The  indications  for  treatment  in  the  early  stages  are,  to  neutralize  the 
caustic  in  order  to  prevent  if  possible  its'  deep  action,  to  give  oils,  demul- 
cent drinks  and  ice  for  the  local  effect,  and  morphin  for  the  pain. 

The  treatment  of  esophageal  stricture  is  purely  surgical. 


RETRO-ESOPHAGEAL  ABSCESS 

Acute  retro-esophageal  abscess  occurs  in  infancy,  though  very  rarely, 
the  patholog}^  being  the  same  as  in  acute  retro-pharyngeal  abscess,  the 
difference  being  merely  one  of  location.  A  striking  case  of  this  kind 
occurred  in  the  Xew  York  Foundling  Hospital.  An  infant  six  months 
old  was  admitted  with  no  loss  of  voice  but  with  high  fever  (10i°  F.) 
and  severe  dyspnea  which  were  the  prominent  symptoms  until  death 
occurred  four  days  later.     There  was  a  leucocytosis   of   100,000.     At 


RETRO-ESOPHAGEAL  ABSCESS  313 

autopsy  ail  abscess  was  found  containing  about  three  ounces  of  pus  be- 
tween the  esophagus  and  the  spine,  extending  from  the  larynx  to  below 
the  bifurcation  of  the  trachea.  Shortly  afterward  a  very  similar  case 
occurred  at  the  Babies'  Hospital,  following  a  retro-pharyngeal  abscess 
which  had  been  opened  two  weeks  before.  iSimilar  abscesses  have  also 
been  observed  after  acute  pharyngitis  with  the  acute  infectious  diseases. 

Eetro-esophageal  adenitis,  or  enlargement  of  the  lymph  nodes  in 
this  situation  without  suppuration,  is  also  rare.  We  once  met  with  a  case 
of  this  sort  in  which  the  gland  formed  a  tumor  nearly  an  inch  in  diam- 
eter at  the  upper  part  of  the  esophagus,  causing  pressure  symptoms 
necessitating  tracheotomy.  The  growth  was  at  first  thought  to  be  malig- 
nant, but  completely  disappeared  after  a  summer  in  the  country. 

Eetro-esophageal  abscess  may  result  from  tlie  l)reaking  down  of 
tuberculous  lymph  nodes  in  the  posterior  mediastinum,  and  may  give  rise 
to  symptoms  like  those  Avhich  result  from  an  abscess  due  to  Potfs  disease. 

Perforation  of  the  esophagus  and  a  food-fistula  connecting  the  esoph- 
agus and  the  trachea  may  result  from  ulceration  caused  by  a  tracheal 
canula  or  by  a  foreign  body.     This  may  be  accompanied  by  abscess. 

The  most  common  variety  of  retro-e^ophageal  abscess  is  that  due  to 
Potfs  disease  of  the  lower  cervical  or  upper  dorsal  region.  The  symp- 
toms are  obscure,  and  an  exact  diagnosis  is  not  often  made  during  life. 
Death  may  occur  quite  suddenly  when  the  previous  symptoms  have  been 
so  slight  as  to  be  easily  overlooked.     The  following  is  a  fair  example: 

A  girl  two  years  old  was  admitted  to  the  Babies'  Hospital  with  caries 
of  the  upper  dorsal  region  of  two  months'  duration.  The  patient  was 
kept  in  bed  and  a  plaster-of -Paris  jacket  applied.  About  a  month  later 
dyspnea  was  first  observed;  this  was  at  times  quite  intense,  and  again 
almost  absent.  It  was  always  on  inspiration,  expiration  being  easy.  No 
explanation  for  this  was  found  in  the  lungs.  There  was  no  difficulty  in 
swallowing,  and  very  little  cough.  After  these  symptoms  had  lasted  for 
about  a  week,  the  child  while  eating  was  suddenly  seized  with  violent 
dyspnea,  and  in  a  few  moments  became  completely  asphyxiated.  Trache- 
otomy was  immediately  done,  and  by  means  of  artificial  respiration  the 
patient  was  restored  to  comparative  comfort,  x'^.bout  two  hours  later  a 
second  attack  occurred,  and  the  patient  died  in  an  hour.  At  the  autopsy 
there  was  found  an  abscess  a  little  larger  than  a  hen's  egg,  containing 
about  two  ounces  of  curdy  pus,  overlying  the  bodies  of  the  first  three 
dorsal  vertebrae  and  communicating  Avith  them.  These  vertebrae  were 
carious.  The  right  pneumogastric  nerve,  an  inch  and  a  half  above  the 
bifurcation  of  the  trachea,  was  compressed  between  the  abscess  and  a 
large  tuberculous  lymph  node,  with  the  capsule  of  which  it  Avas  blended. 
In  the  lungs  were  a  few  small  tuberculous  deposits  and  the  usual  condi- 
tions found  in  death  by  asphyxia.     The  dyspnea  seems  to  have  been  of 


314  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

nervous  and  not  of  mechanical  origin,  and  caused  by  irritation  of  the 
pneumogastric.  The  fatal  issue  was  apparently  from  an  increase  of  the 
pressure  upon  the  nerve. 

We  have  seen  but  one  other  case,  and  this  closely  resembled  the  one 
reported.  In  the  thirteen  cases  collected  by  Griffith  the  symptoms  in  all 
were  much  alike.  Dyspnea,  usually  of  Si  spasmodic  character,  was 
prominent  in  nearly  all,  and  generally  it  was  the  most  prominent  symp- 
tom. It  was  more  marked  on  inspiration,  and  often  accompanied  by  a 
spasmodic  cough,  suggesting  laryngeal  stenosis.  The  voice  was  affected 
in  but  two  cases,  in  one  complete  aphonia  being  present.  It  is  striking 
that  in  no  case  was  there  any  difficulty  in  swallowing,  in  marked  con- 
trast to  retropharyngeal  abscess.  Swelling  in  the  neck  was  noted  in  but 
three  cases.  Spinal  caries  was  stated  to  be  present  in  seven  cases  and 
absent  in  two.  The  final  attack  of  asphyxia  sometimes  came  without 
Avarning,  sometimes  was  preceded  for  several  days  or  longer  by  milder 
attacks. 

The  diagnosis  of  this  condition  is  very  difficult,  and  a  positive  diag- 
nosis almost  impossible.  It  may  be  suspected  in  cases  of  Pott's  disease 
of  the  lower  cervical  or  upper  dorsal  regions,  when  there  is  spasmodic 
inspiratory  dyspnea,  especially  if  accompanied  by  irritative  cough.  It 
should,  however,  be  remembered  that  precisely  similar  symptoms  may 
depend  upon  the  irritation  of  a  tuberculous  node,  and  that  the  sudden 
asphyxia  is  exactly  like  that  caused  by  the  vilceration  of  such  a  node 
into  the  trachea  or  a  large  bronchus.  The  latter,  however,  may  occur 
without  the  presence  of  Pott's  disease.  If  the  abscess  is  higher  up,  there 
may  be  a  swelling  on  either  side  of  the  neck,  just  above  the  clavicle. 
In  most  of  the  cases  there  are  no  external  signs  of  disease.  Such 
abscesses  are  too  low  to  be  reached  by  digital  examination  of  the  pharynx. 
The  attack  of  asphyxia  may  also  be  confounded  Avith  that  due  to  the 
presence  of  a  foreign  body  in  the  larynx. 

The  prognosis  in  cases  of  retro-esophageal  abscess  is  exceedingly  bad. 
Death  usually  results  from  pressure  upon  the  pneumogastric,  as  in  the 
cases  reported.  The  abscess  may  rupture  into  the  esophagus  and  recov- 
ery follow.  This  termination  is  very  rare,  but  such  a  case  has  been  re- 
ported by  Knight.  A  fatal  one  is  reported  by  Loschner  and  Lambl.  The 
abscess  may  burrow  along  the  esophagus  into  the  abdominal  cavity  and 
excite  peritonitis;  finally,  it  may  open  externally. 

But  little  is  to  be  said  under  the  head  of  treatment.  The  symptoms 
are  rarely  definite  enough  to  justify  a  radical  surgical  operation.  Trache- 
otomy gives  but  temporary  relief  to  the  asphyxia.  This  operation  should 
be  performed,  however,  in  every  case,  because  of  the  impossibility  of 
making  a  diagnosis  of  retro-esophageal  abscess  from  other  conditions 
in  which  the  operation  might  be  curative. 


DIGESTION  IN  INFANCY  31-5 

CHAPTER   V 

DISEASES  OF  THE  STOMACH 

It  is  difficult  wholly  to  separate  diseases  of  the  stomach  from  those 
of  the  intestine.  Although  in  older  children  they  are  often  quite  dis- 
tinct, in  infancy  they  are  more  frequently  associated;  but  at  one  time 
the  gastric  symptoms  may  be  prominent,  and  at  another  the  intestinal 
symptoms.  Functional  disorders  particularly  are  likely  to  involve  the 
whole  tract.  Serious  organic  lesions  are  more  frequently  limited  in 
their  extent  either  to  the  stomach  or  to  the  intestine.  The  former  are 
rare,  while  the  latter  are  very  common.  The  diseases  in  which  the  stom- 
ach is  alone  or  chiefly  involved  will  be  considered  by  themselves.  Those 
in  which  both  the  stomach  and  intestine  are  involved  are  classed  with 
the  intestinal  diseases,  as  the  intestinal  symptoms  usually  predominate. 

DIGESTION  IN  INFANCY 

The  first  step  in  the  process  of  digestion  in  the  newly-born  infant  is 
sucking.  During  this  act  the  nipple  is  grasped  between  the  lower  lip  and 
tongue  below,  and  the  upper  lip  and  jaw  above.  The  back  of  the  mouth 
is  closed  by  the  palate.  A  strong  downward  movement  of  the  lower  jaw 
causes  a  partial  vacuum  in  the  mouth,  and  produces  the  suction  force 
which  causes  the  milk  to  flow.  Sucking  can  be  carried  on  only  when  the 
nose  is  free  for  respiration  and  the  palate  and  upper  jaw  intact.  Chil- 
dren with  deformities  of  the  mouth,  like  cleft  palate  and  harelip,  suck 
only  with  the  greatest  difficulty,  and  complete  nasal  obstruction  prevents 
nursing. 

The  Saliva. — This  is  present  at  birth  only  in  very  small  amount,  and 
the  part  which  it  plays  in  digestion  in  early  infancy  is  an  insignifi- 
cant one.  During  the  third  and  fourth  months  it  increases  markedly  in 
quantity,  and  at  this  time  it  possesses  quite  actively  the  power  of  trans- 
forming starch  into  sugar.  This  property  is  present  only  to  a  very  slight 
degree  during  the  early  weeks. 

The  Stomach. — Our  knowledge  of  the  anatomy  and  physiology  of  the 
infant's  stomach  has  been  greatly  increased  through  the  use  of  the  X-ray. 
The  position  varies  considerably  in  normal  conditions  and  very  greatly 
in  pathological  conditions.  The  stomach  is  usually  somewhat  obliquely 
situated  in  the  abdomen,  not  only  from  side  to  side,  but  from  before 
backward,  as  the  cardiac  orifice  is  quite  near  the  spine  while  the  pylorus 
is  much  anterior.     The  pylorus  is  usually  considerably  to  the  right  of 


316  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  median  line  and  generally  situated  somewhat  hehind  the  pyloric  third 
of  the  stomach. 

When  inflated  after  death  the  normal  infant's  stomach  resembles 
a  curved  cylinder  with  a  greatly  shortened  superior  border.  After 
the  first  year  the  great  development  of  the  fundus  occurs  and  the  shape 
is  much  like  that  of  the  adult  stomach.  During  life  the  shape  of  the 
stomach  varies  greatly  Avith  the  amount 'of  food  and  gas  it  contains  and 
with  the  condition  of  its  muscular  walls,  whether  relaxed  or  contracted. 
It  enlarges  wdth  great  facility  with  the  introduction  of  food.  In  con- 
ditions when  there  is  a  lowered  muscular  tone,  as  in  rickets  or  mal- 
nutrition, great  changes  in  size,  shaj)e  and  position  are  met  with.  In 
some  cases  the  stomach  is  almost  entirely  to  the  left  of  the  median  line. 
The  abnormal  shapes  are  temporary  or  permanent,  according  to  cir- 
cumstances, and  no  doubt  have  much  to  do  with  the  facility  with  which 
the  stomach  empties  itself  during  digestion. 

In  the  nursing  infant,  food  begins  to  leave  the  stomach  almost  at 
once,  and  within  five  minutes  a  very  considerable  proportion  of  the 
amount  taken  has  often  reached  the  intestine.  At  the  end  of  half  an 
hour  the  greater  part  of  the  food  has  usually  left  the  stomach.  In 
infants  taking  cow's  milk,  the  food  passes  out  more  slowly  but  after  the 
first  few  minutes  food  is  seen  in  the  intestines.  The  opening  of  the 
pylorus  is  much  influenced  by  the  reaction  of  the  gastric  contents.  It 
normally  opens  when  a  certain  degree  of  acidity  is  reached.  The  addi- 
tion of  alkalis  to  cow's  milk  markedly  delays  the  emptying  of  the  stom- 
ach. This  is  also  influenced  by  the  composition  of  the  food;  when  the 
food  contains  a  high  fat  percentage,  emptying  of  the  stomach  is  much 
delayed.  The  whey  first  reaches  the  intestine,  afterwards  the  casein, 
and  lastly  the  fat.  Solid  food  is  retained  in  the  stomach  a  longer  time 
than  milk. 

The  stomach  always  contains  gas,  and,  by  the  X-ray,  after  every 
feeding  a  large  bubble  of  gas  is  seen  above  the  food,  often  half  filling 
the  stomach.  Most  of  this  gas  is  air  that  has  been  swallowed.  In 
conditions  of  disordered  digestion  the  amount  may  be  very  great.  There 
is  a  natural  tendency  for  the  stomach  to  contract  and  expel  this  gas 
after  taking  food;  but  if  the  infant  is  placed  upon  his  back  and  kept 
there,  this  is  mechanically  impossible,  as  has  been  well  shown  by  the 
investigations  of  C.  H.  Smith. 

Gastric  Digestion. — The  role  of  the  stomach  in  digestion  is  not  so 
important  in  infants  as  in  adults.  The  gastric  part  of  digestion  is  only 
preliminary  and  partial;  the  major  part  of  digestion  takes  place  in 
the  intestines.  While  the  function  of  the  stomach  is  largely  that  of  a 
reservoir  into  which  the  milk  is  received  and  from  which  it  is  allowed 
to  pass  gradually  into  the  intestines,  certain  definite  changes  take  place 


DTGESTTON  JN  INFAXCY  317 

there  chiefly  owing  to  the  activity  of  the  rennet  ferment  and  the  gastric 
lipase.  It  was  until  recently  believed  that  the  action  of  the  gastric 
juice  was  chiefly  upon  the  protein  of  the  food  by  virtue  of  the  pepsin 
and  hydrochloric  acid  contained  in  it.  It  has  been  shown,  however, 
that  for  each  gastric  ferment  a  certain  concentration  of  acid  is  neces- 
sary for  its  activity.  In  a  large  series  of  cases,  different  observers  have 
determined  that  the  concentration  of  acid  in  the  gastric  juice  of  normal 
infants  fed  upon  cow's  milk  is  low,  much  less  than  that  of  adults.  Pepsin 
is  inert  in  a  solution  of  such  weak  concentration.  It  is  therefore  alto- 
gether probable  that  gastric  digestion  by  pepsin  is  practically  negligible. 
Nevertheless,  pepsin  is  found  in  the  stomach  at  birth  and  may  even 
be  demonstrated  in  the  fetus  as  early  as  the  fourth  month. 

The  concentration  of  acid  in  the  stomach,  although  insufficient  for 
the  action  of  pepsin,  is  sufficient  for  the  activity  of  the  rennet  ferment 
and  the  lipase.  Coagulation  is  the  first  change  which  milk  undergoes 
in  the  stomach.  Woman's  milk  coagulates  in  loose  flocculi  and  quite 
imperfectly,  while  cow's  milk  coagulates  in  much  firmer,  more  compact 
masses,  owing  to  the  larger  amount  of  casein.  The  motility  of  the 
stomach  plays  an  important  part  in  digestion.  The  churning  movements 
soon  break  up  these  casein  masses  into  much  smaller  particles.  Eennet 
has  a  feeble  digestive  action  upon  protein.  Many  good  authorities  con- 
sider that  rennet  is  not  a  separate  substance  but  that  coagulation  is  one 
of  the  properties  of  pepsin.  The  question  is  as  yet  undecided  but  pepsin 
and  rennet  are  always  present  in  coresponding  amounts.  It  has  been 
shown  that  a  lipase  or  fat-splitting  ferment  is  present  in  the  stomach 
even  of  infants  and  that  it  increases  the  activity  of  the  pancreatic  lipase. 
Its  importance  in  the  stomach  is  not  clearly  known. 

Pepsin  is  found  in  the  stomach  at  birth,  and  even  in  the  fetus  as 
early  as  the  fourth  month.  In  fifteen  minutes  after  feeding  the  reaction 
of  the  stomach  contents  is  always  acid.  Free  hydrochloric  acid  can  not 
usually  be  demonstrated  until  about  an  hour  after  feeding,  then  only  in 
small  quantities,  and  in  very  many  cases  not  at  all.  The  reason  for  this 
is,  that  the  acid  combines  with  the  casein  and  the  salts  of  milk,  those  of 
cow's  milk  in  particular  having  a  great  power  of  combining  with  hydro- 
chloric acid. 

The  duration  of  gastric  digestion  varies  with  the  age  of  the  infant 
and  with  the  food.  During  the  first  month  the  stomach  of  healthy 
nursing  infants  is  usually  found  empty  in  an  hour  and  a  half  after 
feeding,  often  in  one  hour.  In  those  taking  cow's  milk  the  average  is 
at  least  one  hour  longer.  In  infants  from  two  to  eight  months  old 
the  average  is  two  hours  for  those  receiving  breast  milk,  and  two  and  a 
half  to  three  and  a  half  hours  for  those  fed  upon  cow's  milk.  The  time 
is  influenced  by  the  size  of  tlie  meal  taken  and  Ijy  the  composition  of 
12 


318  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  food.  The  higher  the  proportion  of  fat  in  the  meal,  the  hunger  the 
food  is  retained  in  the  stomach,  and  also  the  smaller  the  amount  of 
gastric  juice  secreted.  Very  little  absorption  takes  place  from  the  stom- 
ach. There  is  here  absorbed  a  certain  proportion  of  sugar  and  peptones, 
but  practically  no  water,  fat,  or  salts.  The  amount  of  gastric  juice 
secreted  is  very  large.  In  experiments  upon  animals  it  has  been  shown 
to  be  nearly  as  great  as  the  volume  of  milk  taken. 

The  bacteria  of  the  stomach  are  very  few  as  compared  with  those  of 
the  intestine,  and  no  varieties  are  constantly  present. 

The  Intestines. — The  length  of  the  small  intestine  at  birth  is  about 
nine  feet;  that  of  the  large  intestine  about  eighteen  inches.  The  great 
length  of  the  sigmoid  flexure  is  the  most  striking  peculiarity,  this  being 
nearly  one-half  the  length  of  the  large  intestine. 

Intestinal  Digestion.— KW  the  important  elements  of  food — protein, 
carbohydrates,  and  fat — are  acted  upon  by  the  pancreatic  juice.  The 
protein  is  converted  into  peptones  by  trypsin.  The  digestion  of  protein 
is  completed  by  the  erepsin  of  the  intestinal  juice,  which  converts  pep- 
tones and  albumoses  into  amino  acids.  In  this  form  the  nitrogenous 
portion  of  the  food  is  finally  absorbed. 

The  amylolytic  ferment  of  the  pancreas  has  the  power  of  converting 
starch  into  maltose.  This  action  is  feeble  during  the  first  four  or  five 
months,  but  is  present  even  in  early  infancy.  Milk  sugar  is  changed  into 
galactose  and  glucose,  and  cane  sugar  and  maltose  into  glucose  through 
the  agency  of  the  intestinal  and  pancreatic  juices.  Fats  are  partly  emul- 
sified and  partly  saponified  by  the  pancreatic  juice  in  connection  with 
the  bile. 

Absorption. — From  the  small  intestine  absorption  takes  place  very 
rapidly.  The  protein  is  absorbed  in  the  form  of  peptids  and  amino  acids. 
Sugars  of  all  varieties  are.  changed  to  gliicose  during  absorption.  Fat  is 
absorbed  in  the  form  of  fatty  acids  and  soaps;  but  in  their  passage 
through  the  wall  of  the  intestine  the  fatty  acids  are  converted  into 
neutral  fats.  Absorption  from  the  large  intestine,  except  of  water,  is 
quite  imperfect.  Fat  absorption  is  very  slight.  Sugar,  salts,  and  pep- 
tones, however,  may  be  absorbed  with  moderate  facility. 

Intestinal  Bacteria. — For  the  fundamental  work  upon  this  subject  we 
are  indebted  to  the  researches  of  Escherich.  Bacteria  are  absent  from 
the  entire  gastro-enteric  tract  at  birth.  They  quickly  enter  by  the  mouth 
and  rectum,  and  by  the  end  of  twenty-four  hours  they  are  usually  found 
in  all  parts  of  the  intestinal  tract.  The  meconium  bacteria  are  derived 
from  the  inspired  air,  and  hence  vary  somewhat  with  surroundings.  As 
soon  as  the  ingestion  of  milk  begins  these  varieties  are  displaced,  and 
throughout  the  period  in  which  the  infant  has  this  food  exclusively,  there 
liave  been  found  in  healthy  conditions  but  few  varieties  which  are  con- 


FECES  319 

staJitJy  j/reseiit.  Those  are  tlie  h.  hiclis  aerogeurs  llie  b.  coU  cuimnuiiis, 
and  the  b.  bifidus.  The  number  of  bacteria  varies  in  different  parts  of  the 
intestine.  They  are  found  in  greatest  numbers  in  the  cecum  and  colon, 
and  are  relatively  few  in  the  small  intestine.  The  b,  lactis  aerogenes 
is  found  most  abundantly  in  the  upper  part  of  the  small  intestine,  in 
small  numbers  only  in  the  colon,  and  usually  there  are  none  in  the 
feces. 

The  b.  coil  communis  is  found  in  but  small  numbers  in  the  upper 
small  intestine,  becoming  more  abundant  lower  down.  In  the  colon  and 
in  the  feces  it  is  present  in  considerable  numbers.  The  most  abundant 
organism  in  the  large  intestine,  however,  is  the  b.  bipdus.  A  change 
from  a  milk  diet  to  a  mixed  diet  of  meat  and  farinaceinis  fotjd  produces 
a  marked  change  in  the  character  of  the  intestinal  bacteria. 

Feces, — The  first  discharges  after  birth  consist  of  meconium;  this  is 
of  a  dark  brownish-green  color,  semi-solid,  and  usually  ])assed  from 
four  to  six  times  daily  during  the  first  two  or  three  days.  On  the  third 
day  the  stools  begin  to  change  in  character,  and  by  the  fourth  or  fifth 
day  they  have  usually  assumed  the  appearance  of  normal  milk-feces. 
Under  many  abnormal  conditions  the  stools  may  continue  to  have  the 
character  of  meconium  for  a  week  or  ^more.  Meconium  is  composed 
of  intestinal  mucus,  bile,  the  vernix  caseosa,  epithelial  cells  from  the 
epidermis,  hairs,  fat-globules,  and  cholesterin  crystals.  For  its  forma- 
tion there  are  necessary  the  secretions  of  the  intestine  and  the  liver  and 
the  swallowing  of  a  considerable  amount  of  amniotic  fluid. 

Milk-feces. — The  amount  of  feces  discharged  daily  by  a  healthy 
nursing  infant  is  from  two  to  three  ounces  (60-90  gms.).  Sucli  stools 
have  the  color  of  the  yolk  of  egg  but  may  be  paler,  and  from  time  to  time 
even  slightly  greenish.  They  are  seldom  entirely  smooth  and  homogene- 
ous but  usually  contain  a  large  number  of  small  light-yellow  particles. 
The  consistency  is  butter-like  but  often  rather  looser  than  this.  Under 
normal  conditions  the  stools  are  never  watery.  The  reaction  is  acid,  and 
there  is  a  slightly  sour  but  not  unpleasant  odor.  The  reaction  is  due 
to  the  presence  of  fatty  acids  or  lactic  acid.  The  color  depends  upon 
bilirubin.  The  stools  of  an  infant  fed  upon  cow's  milk  may,  in  con- 
ditions of  perfect  digestion,  differ  in  no  respect  from  those  just  de- 
scribed; usually,  however,  they  are  firmer,  rather  more  homogeneous, 
of  a  paler  yellow  color,  and  may  be  neutral  or  even  alkaline  in  reaction. 
The  normal  stool  of  a  nursing  infant  contains  about  85  per  cent  of  Avater 
and  15  per  cent  of  solids;  that  of  one  taking  cow's  milk  has  about  80 
per  cent  water  and  20  per  cent  solids. 

The  only  gases  present  are  hydrogen  and  carbon  dioxid.  Sulphur- 
etted hydrogen  and  marsh  gas,  to  which  the  odor  of  adult  stools  is  largely 
due,  are  not  present. 


320  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  solids  of  the  stools  are  chiefly  fat^  salts  and  nitrogenous  matters. 
Sugar  is  not  found,  but  its  derivative,  lactic  acid,  may  be  present  in  small 
amount.  The  fat  makes  up  from  20  to  40  per  cent  of  the  dried  matter, 
and  is  in  the  form  principally  of  soaps  and  fatty  acids,  with  a  smaller 
proportion  of  neutral  fats.  The  inorganic  salts  form  about  10  per  cent 
of  the  solids  of  the  breast-milk  stool,  and  from  20  to  35  per  cent  of  the 
solids  of  the  cow's-milk  stool,  about  three-fourths  of  this  being  calcium 
phosphate.  The  nitrogenous  elements  of  the  cow's-milk  stool  make  up 
about  25  per  cent  of  the  dried  residue,  but  only  a  small  proportion  of 
this  represents  unabsorbed  protein.  They  are  chiefly  derived  from  the 
intestinal  secretions  and  the  bodies  of  bacteria.  Amino  acids,  represent- 
ing unabsorbed  food  protein,  make  up  from  2.1  to  2-1  per  cent  of  the 
nitrogen  of  the  stool.  The  protein  of  woman's  milk  is  almost  entirely 
absorbed,  and  that  of  cow's  milk  largely  so,  under  almost  ail  condi- 
tions. 

A  healthy  nursing  infant  absorbs  about  85  to  90  per  cent  of  his  in- 
gested fat,  about  95  per  cent  of  his  protein^,  and  about  80  to  85  per 
cent  of  his  salts.  A  healthy  infant  taking  cow's  milk  absorbs  about  85 
to  90  per  cent  of  his  ingested  fat,  about  90  to  95  per  cent  of  his  protein, 
and  about  60  per  cent  of  his  salts. 

The  biliary  elements  present  in  the  stool  are  hydrobilirubin,  un- 
changed bilirubin,  and  cholesterin.  The  presence  of  biliary  acids  is 
doubtful.     Mucus  is  always  present  in  considerable  quantity. 

Microscopically  there  are  seen  epithelial  cells,  chiefly  of  the  columnar 
variety,  a  few  round  cells,  mucous  corpuscles,  fat  globules  and  crystals 
of  fatty  acids,  cholesterin,  mucin,  crystalline  inorganic  salts,  some- 
times bilirubin  in  crystals,  yeast  fungi,  and  bacteria  in  immense  num- 
bers. 

If  the  infant  is  taking  a  food  containing  starch,  this  may  appear  to 
a  greater  or  less  extent  in  the  stools,  a  larger  amount  in  the  case  of  very 
young  infants. 

The  number  of  stools  of  breast-fed  infants  during  the  early  weeks  is 
from  two  to  six  daily.  After  the  first  month  two  stools  a  day  are  the 
average;  many  infants  have  three,  many  others  but  one.  With  modified 
cow's  milk  the  stools  are  seldom  more  than  one  or  two  a  day  and  there 
is  frequently  constipation. 

As  soon  as  an  infant  is  put  upon  a  mixed  diet,  the  peculiar  charac- 
ters of  the  stools  disappear,  and  they  come  to  resemble  more  closely  those 
of  the  adult,  though  remaining  softer  throughout  infancy.  They  be- 
come darker  in  color  and  assume  the  adult  odor,  while  retaining  their 
acid  reaction.  The  bacteria,  while  still  in  great  numbers,  are  more 
varied  than  are  met  with  in  milk-feees. 


HYPERTROPTTTC  STEXOSTS  OF  THE  PYLORUS  .321 


MALPOSITIONS  AND  MALFORMATIONS  OF  THE  STOMACH 

The  stomach  is  sometimes  in  the  thoracic  cavity  in  cases  of  diaphrag- 
matic hernia.  It  may  he  found  in  a  vertical  (fetal)  position,  variously 
adherent  to  the  colon  and  small  intestine.  Malformations  are  much  less 
frequent  than  those  of  other  parts  of  the  alimentary  tract.  There  may 
be  atresia  or  stenosis  at  either  orifice,  and  very  rarely  a  constriction  is 
found  near  the  middle  of  the  organ,  dividing  it  into  compartments.  The 
symptoms  of  atresia  at  either  orifice  are  persistent  regurgitation  or 
vomiting,  and  death  in  a  few  days  from  inanition. 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS 

This  condition  known  also  as  congenital  sie7io!<is  of  iJie  pylorus,  or 
simply  as  pyloric  stenosis  of  infancy,  is  not  an  uncommon  one.  It  is 
characterized  by  persistent  vomiting,  constipation,  wasting,  marked  visi- 
ble gastric  peristalsis,  and  usually  a  palpable  tumor.  It  is  a  serious 
condition,  and  unless  recognized  early  and  properly  treated  it  has  a 
high  mortality.  It  is  seen  in  early  infancy,  usually  in  the  first  two 
months  of  life  but  seldom  in  the  first  two  weeks.  Fully  four-fifths 
of  the  cases  occur  in  malajnfants.  It  has  no  relation  to  feeding,  the 
large  proportion  of  recorded  cases  having  been  seen  in  nursing  in- 
fants. 

The  pathology  of  stenosis  of  the  pylorus  in  early  iiifancy  is  some- 
what obscure  and  at  the  present  time  quite  diverse  views  are  held.  It 
is  believed  by  some  that  the  primary  and  essential  pondition  is  one  of 
spasm;  that  the  hypertrophy  when  it  is  present  is  secondary;  that  in  a 
very  considerable  proportion  of  the  cases  there  is  only  pylorospasm  with- 
out hypertrophy;  that  with  proper  medical  treatment  most  cases  recover, 
and  that  surgical  intervention  is  rarely  called  for.  The  other  view  and 
that  which  seems  to  harmonize  best  with  the  clinical  symptoms  apd  the 
pathological  findings  is  that  the  primary  condition  is  one  of  hypertrophy 
which  is  congenital;  that  to  this,  spasm  is  added;  that  in  all  cases  both 
factors — hypertrophy  and  spasm — are  present ;  that  while  the  cases  differ 
in  degree  they  are  the  same  in  kind;  that  while  many  of  the  milder  ones 
may  recover  without  operation  the  severer  ones  should  be  treated  sur- 
gically. Spasm  certainly  plays  an  important  part  in  the  production  of 
symptoms;  but  to  regard  this  condition  as  one  essentially  of  muscular 
spasm  seems  to  us  erroneous. 

The  appearance  of  the  pylorus  when  seen  at  autopsy  or  operation 
is  remarkably  uniform.    It  forms  a  hard,  whitish  tumor  about  the  size  of 


0$^ 


^ 


S22  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

a  peanut,  of  almost  cartilaginous  consistency.  Its  lumen  may  be  so  nar- 
rowed as  barely  to  admit  a  fine  probe,  while  the  normal  pylorus  will 
usually  admit  a  No.  21  sound,  French  scale.  Frequently  water  can  not 
be  forced  through  the  stenosis  owing  probably  to  the  fact  that  the  mucous 
membrane  is  thrown  into  folds.  The  walls  of  the  stomach  are  often 
hypertrophied,  especially  toward  the  pyloric  end.  Tlie  stomach  is  usually 
much  dilated;  its  lower  border  may  be  below  the  navel.  On  section 
the  pylorus  is  found  to  be  much  thickened  and  by  microscopical  exami- 
nation this  is  seen  to  be  chiefly  of  the  circular  muscle  fibers.  This  coat 
appears  to  be  two  or  three  times  the  normal  thickness.  The  other  coats 
— submucous,  mucous  and  longitudinal  muscular — are  thickened  but  to 
a  much  less  degree. 

Symptoms. — The  clinical  picture  is  a  striking  one.  Symptoms  rarely 
begin  in  the  first  week  of  life.  An  infant  who  for  the  first  two  or  three 
weeks  has  usvially  shown  no  signs  of  gastric  disorder,  and  often  has 
been  nursing  and  gaining  regularly  in  weight,  begins,  without  evident 
cause,  to  vomit ;  at  first  occasionally,  but  soon  habitually.  This  vomiting 
in  a  short  time  becomes  forcible,  projectile.  It  may  be  of  this  type 
almost  from  the  outset.  Changes  in  diet  have  but  a  temporary  effect 
upon  it,  or  none  at  all.  The  bowels  are  constipated.  The  infant  wastes 
steadily,  the  scales  often  showing  a  loss  of  one  or  two  ounces  a  day. 
There  is  no  fever  and  little  or  no  evidence  of  pain.  There  is  progressive 
failure  in  nutrition  and  death  may  occur  from  exhaustion  in  from  four 
to  six  weeks  from  the  beginning  of  marked  symptoms. 

Vomiting. — The  manner  of  vomiting  is  characteristic.  It  is  more 
^forcible  than  that  seen  under  any  other  condition.  An  infant  will  often 
fairly  shoot  out  the  contents  of  the  stomach  to  a  distance  of  three  or 
four  feet.  Food  frequently  comes  through  the  nose.  The  vomiting 
usually  has  a  relation  to  the  taking  of  food.  It  most  frequently  comes 
directly  after  feeding,  sometimes  even  while  the  child  is  still  at  the 
breast.  After  an  attack  of  vomiting,  nursing  is  sometimes  resumed  with 
avidity,  showing  a  distinct  absence  of  the  usual  symptoms  of  gastric 
indigestion.  -AlLjlJie  food  is  generally  expelled  at  one  time.  The  fre- 
quent regurgitation  of  small  amounts  is  unusual.  Generally  vomiting 
does  not  occur  at  night  unless  the  child  is  nursed  at  that  time.  The 
vomited  matters  at  first  consist  only  of  food,  often  but  little  changed. 
After  a  time  there  is  mucus,  sometimes  in  large  quantities.  The  amount 
vomited  at  one  time  is  often  considerably  greater  than  the  feeding  just 
taken,  indicating  a  considerable  retention  of  food  in  the  stomach.  Some 
of  these  children  vomit  regularly  after  every  feeding;  others  retain 
two  or  three  feedings  and  then  expel  the  whole  amount.  The  frequency 
of  vomiting  varies  from  once  or  twice  to  six  or  eight  times  a  day.  Owing 
to  the  loss  of  fluid  by  vomiting  the  urine  is  usually  very  scanty.     There 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS  3-2.3 

is  no  imiform  chang-e  in  tlie  gastric  secretions,  but  tliere  is  frequently 
hyperacidity  present. 

Bo'wels. — Obstinate  constipation  is  the  rule.  It  ii\  due  to  the  fact 
that  so  much  of  the  food  taken  is  vomited.  If  the  pyloric  obstruc- 
tion is  complete  the  stools  resemble  meconium. 

Wasting. — Progressive  wasting  is  one  of  the  striking  symptoms,  and  a 
close  observation  of  the  weight  one  of  our  best  guides  to  the  progress  of 
the  case.  If  the  loss  amounts  to  two  or  three  ounces  a  day  the  condition 
should  be  considered  most  critical.  The  rate  of  the  loss  depends  naturally 
upon  the  completeness  of  the  obstruction  and  it  is  proportionate  to  the 
amount  of  vomiting  and  the  degree  of  constipation. 

General  Appearance. — At  first  nothing  abnormal  is  seen,  but  soon 


Fig.  31. — Gastric  Peristalsis  in  Pyloric  Stenosis.    (Thomson.) 
Patient  eight  weeks  old. 

all  the  evidences  of  rapid  malnutrition  are  present,  without,  however,  the 
other  usual  symptoms  of  indigestion,  such  as  might  be  expected  with  the 
vomiting.  The  tongue  is  usually  clean ;  the  appetite  often  voracious ; 
there  are  no  eructations  of  gas ;  the  breath  is  sweet,  and  the  color  usually 
good. 

Perisfalds. — On  examination  of  the  abdomen  the  epigastrium  is  usu- 
ally full  and  the  lower  half  of  the  abdomen  may  be  sunken.  If  the  skin 
is  bared  and  the  patient  placed  in  a  good  light  the  characteristic  peristal- 
tic waves  are  seen  which  are  the  most  diagnostic  feature  of  the  disease. 
One  should  not  expect  to  see  them  if  the  stomach  is  empty;  they  are 
best  seen  immediately  after  taking  food  or  water.  When  not  appearing 
spontaneously  they  may  often  be  excited  by  slight  friction  or  tapping  of 
the  epigastrium.  There  is  seen  a  slowly  moving  wave  from  left  to  right. 
First  a  ball-like  tumor  appears  just  below  the  ribs  on  the  left  side  (see 
Fig.  31).  It  is  usually  about  one  and  a  half  to  two  inches  in  diameter 
and  slowly  moves  toward  the  right.     It  usually  disappears  Just  beyond 


324  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  median  line.  Sometimes  one  wave  is  quickly  followed  by  another. 
Peristalsis  of  the  intestine,  in  rare  cases,  may  somewhat  resemble  these 
movements;  but  typical  gastric  contractions  can  hardly  be  mistaken  for 
anything  else.      A-Pf*^ '""'^'^^''^^l  ppri^taki-;  vomitino-  frpgnentlv  or-r-nrs. 

Tumor. — The  hardened  pylorus  can  with  experience  Ijg  felt  in  mast 
cases.  It  may  be  obscured  by  distention  of  the  stomach  or  the  colon  or  by 
enlargement  of  the  liver.  The  pylorus  may  be  displaced.  The  position 
of  the  tumor  is  therefore  of  less  importance  in  diagnosis  than  its  char- 
acter. It  is  usually  felt  about  one  and  a  half  to  two  inches  below  the 
free  border  of  the  ribs,  just  inside  of  the  right  mammary  line.  It  may  be 
f  I ,  felt  only  during  active  peristalsis.  It  appears  somewhat  smaller  than  the 
little  finger  and  about  three-fourths  of  an  inch  long. 

GastricJietention. — The  prolonged  retention  of  food  in  the  stomach 
is  one  of  the  characteristic  features  of  pyloric  stenosis.  In  healthy 
nursing  infants  the  stomach  is  regularly  found  empty  at  the  end  of  three 
hours,  often  at  the  end  of  two  hours.  But  if  stenosis  is  present,  food 
in  considerable  amount  is  almost  invariably  found  after  three  hours  and, 
unless  vomiting  has  occurred,  usually  after  four  hours.  Sometimes  tliis 
is  also  the  case  when  there  has  been  vomiting.  This  retention  varies  in 
amount,  but  when  there  has  been  no  vomiting  for  several  hours  a  larger 
amount  may  be  removed  than  the  last  feeding  taken,  sometimes  twice 
as  much.  Early  in  the  morning  after  fasting  eight  or  ten  hours  the 
stomach  may  contain  three  to  four  ounces  of  partly  digested  food.  Ab- 
normal gastric  retention  is  one  of  the  diagnostic  features  of  pyloric 
stenosis.  Gastric  retention  is  best  estimated  by  the  removal  of  the  stom- 
ach contents  by  means  of  suction.  By  this  it  can  be  determined  how 
rapidly  the  food  leaves  the  stomach  quite  as  accurately  as  by  the  X-ray 
and  in  a  much  m(jre  convenient  way.  Xot  only  is  the  X-ray  unnecessary 
for  diagnosis,  but  the  administration  of  the  large  doses  of  bismuth  for 
diagnostic  jDurposes  is  objectionable  and  may  even  be  dangerous  in  these 
\"ery  young  patients.  We  have  known  of  two  instances  in  which  its  use 
was  apparently  the  factor  which  determined  the  fatal  result. 

Course  of  the  Disease. — Two  types  of  cases  are  seen:  (1)  the  severe 
form,  in  which  the  peristalsis  and  vomiting  are  but  little  influenced  by 
medical  treatment;  the  loss  of  weight  is  continuous  and  often  amounts 
to  two  or  three  ounces  a  day;  there  is  very  little  fecal  matter  in  the 
stools;  the  constipation  is  very  marked,  and,  unless  relieved  by  opera- 
tion, the  condition  generally  proves  fatal  in  from  two  to  four  weeks; 
(2)  the  mild  form,  in  which  the  symptoms,  though  characteristic,  are 
all  much  less  marked,  gastric  peristalsis  and  tumor  are  present,  l)ut 
the  vomiting  is  only  occasional,  fecal  stools  are  passed,  the  loss  of  weight 
is  not  so  marked  and  progress  may  alternate  with  periods  of  improvement 
in  which  there  is  gain  in  weight.     Yerv   manv  of  these  cases  recover 


HYPERTROPHIC  STENOSIS  OF  THE  PYLOlirS  ?,2r, 

without  surgical  aid,  the  chief  danger  being  that  the  feeble  infant  is  cut 
off  by  intercurrent  disease.  Whether  there  is  a  chronic  form  of  infantile 
stenosis  which  persists  into  later  childhood  seems  probable,  but  is  not  yet 
established. 

Diagnosis. — The  diagnosis  of  pyloric  stenosis  of  infancy  is  usually 
easy  after  a  few  days  of  observation,  but  may  be  impossible  at  the  first 
examination.  The  time  of  onset  and  nature  of  the  vomiting  are  strongly 
suggestive  but  not  quite  conclusive.  The  abrupt  development  in  a  nurs- 
ing infant  from  two  to  four  weeks  old  of  severe  vomiting  without  as- 
signable cause  and  its  persistence  in  spite  of  all  treatment,  should  always 
lead  to  the  suspicion  of  pyloric  stenosis.-  The  diagnostic  features  of 
this  condition  are  three :  waves  of  ^astrielperistalsis.,  abnoShal  ^stric 
retention  and  a  tu^T.  The  existence  of  a  tumor  may  be  a  matter  of 
some  uncertainty  in  many  cases,  but  its  presence  is  of  considerable  posi- 
tive value.  The  condition  has  been  mistaken  for  cerebral  disease  on 
account  of  the  projectile  vomiting  and  chronic  constipation;  for  renal 
disease,  because  of  the  vomiting  and  scanty  urine.  Usually,  however, 
the  only  difficulty  is  to  distinguish  between  the  vomiting  of  gastric 
indigestion  and  that  of  pyloric  stenosis.  Gastric  indigestion  is  an  ex- 
ceedingly common  symptom  in  infancy;  but  it  is  not  very  common  in 
nursing  infants  and  rarely  develops  suddenly.  The  vomiting  is  apt  to  be 
in  small  quantities  and  many  times  repeated  and  generally  occurs  at  a 
longer  period  after  feeding.  There  are  undoubtedly  some  cases  of 
gastric  indigestion  in  early  infancy  in  which  a  temporary  pylorospasm 
occurs,  but  this  condition  is  quite  different  from  the  one  we  have  under 
consideration.  The  existence  of  persistent  spasm  of  the  pylorus  without 
hypertrophy  has  yet  to  be  proven. 

Impairment  of  motility  is  a  symptom  of  gastric  indigestion  but  in  this 
condition  the  food  seldom  remains  in  the  stomach  for  so  long  a  time  or 
in  such  amount  as  in  stenosis.  Besides  it  is  unaccompanied  by  gastric 
peristalsis  or  a  tumor. 

Congenital  obstruction  of  the  duodenum  or  other  part  of  the  small 
intestine  may  lead  to  persistent,  forcible  vomiting  and,  if  the  obstruction 
is  high  up,  even  to  visible  gastric  peristalsis.  But  in  these  cases,  whether 
due  to  stenosis,  atresia,  twisting  or  pressure  from  bands,  the  symptoms 
appear  soon  after  birth  and  the  severe  forms  are  fatal  in  a  few  days.  The 
vomited  matters  consist  of  bilious  material. 

Prognosis. — Statements  regarding  prognosis  will  depend  much  upon 
M'hat  cases  are  included  under  the  diagnosis.  Limiting  tlie  term  to  the 
cases  defined  in  the  beginning  of  this  article,  the  condition  nnist  lie 
considered  a  serious  one,  often  ending  fatally  unless  properly  treated. 
By  older  methods  of  treatment,  fully  50  per  cent  of  the  cliildron  died. 
Of  the  last  50  operations  done  at  the  Babies'  Hospital,  the  mortality  was 


L^i 


.",26  DT8EASK.S  OF  THE  DTCESTTVE  SYSTEAE 

28  per  cent,  but  these  figures  include  a  considerable  number  of  cases 
admitted  very  late  in  the  disease  in  which  the  patients'  condition  was 
apparently  hopeless  when  operated  upon.  With  a  fairly  early  diagnosis 
and  resort  to  surgical  treatment,  the  mortality  in  skilled  hands  should 
not  be  over  10  or  15  per  cent.  In  any  given  case  the  unfavorable  symp- 
toms are,  rapid  and  continuous  loss  in  weight,  i.  e.,  one  to  three  ounces 
a  day,  continued  vomiting  and  meconium-like  stools,  both  showing  that 
little  or  nothing  passes  the  pylorus.  The  lower  the  body  weight  has 
fallen  before  operation,  the  worse  the  prognosis,  although  we  have  seen 
a  child  recover  whose  weight  at  the  time  of  operation  was  only  four  and 
a  quarter  pounds. 

In  cases  not  operated  on  complete  recovery  may  result,  though  the 
tumor  and  active  gastric  peristalsis  may  persist  for  seven  or  eight 
months.  Whether  this  condition  may  give  trouble  in  later  life  cannot 
yet  be  definitely  stated.  The  hypertrophy  is  certainly  very  slow  in  dis- 
appearing. A  tumor  has  been  found  at  autopsy  in  children  dying  of 
intercurrent  disease  as  long  as  six  months  after  recovery  from  all 
symptoms. 

Of  122  cases  which  have  come  under  our  observation,  chiefly  in  the 
Babies'  Hospital,  the  general  mortality  was  43  per  cent.  But  these  fig- 
ures include  a  very  large  proportion  of  severe  cases,  and  many  that  were 
admitted  very  late  and  were  in  a  hopeless  condition. 

Treatment. — The  treatment  adopted  will  depend  upon  the  type  of 
case  with  which  we  have  to  deal.  With  all  cases,  medical  treatment 
should  be  given  a  faithful  trial.  If  the  patient  is  seen  early  this  may 
safely  be  continued  for  a  period  of  at  least  one  or  two  weeks.  With 
a  large  proportion  of  those  previously  classed  as  belonging  to  the  mild 
type,  medical  treatment  will  be  successful.  The  cases  which  are  likely 
to  recover  usually  show  decided  improvement  in  a  few  days, — less  vomit- 
ing, fecal  stools,  diminished  peristalsis  and  a  stationary  or  slight  gain 
in  weight.  If,  however,  when  first  seen,  symptoms  have  already  lasted 
three  or  four  weeks  without  material  improvement,  or  if  there  has  been 
a  steady  though  not  rapid  loss  in  weight,  operation  should  be  advised. 
Though  some  of  these  cases  might  recover  without  it,  the  risks  of  waiting 
are  greater  than  the  risks  of  the  operation.  Again,  operation  should  be 
resorted  to  early  in  all  cases  classed  as  the  severe  type  which  show  no 
improvement  by  medical  treatment  in  a  few  days.  If  the  child's  con- 
dition is  bad,  no  delay  is  admissible. 

Medical  Treatment. — This  is  carried  out  on  the  theory  that  the 
pyloric  spasm  to  which  symptoms  are  chiefly  due  will  gradually  subside 
if  nutrition  can  be  maintained.  It  consists  in  diet  and  stomach  washing. 
If  a  child  is  nursing  and  the  milk  is  normal,  weaning  is  not  advisable. 
Small  meals,  not  too  near  together,  are  essential.     The  breast  should 


HYPEETROPHIC  STENOSIS  OF  THE  PYLORUS  327 

be  given  at  four-hour  intervals,  and  the  nursing  period  varied  from  two  to 
five  minutes,  according  to  the  amount  obtained.  It  is  often  advantageous 
to  pump  the  breasts  and  give  a  measured  amount  of  breast-milk.  Usually 
for  a  child  a  month  old  not  more  than  two  ounces  should  be  allowed  at 
one  feeding.  On  no  account  should  an  infant  be  weaned  immediately 
because  of  the  development  of  the  symptoms  of  pyloric  stenosis.  For 
some  infants  who  have  been  artificially  fed  nothing  succeeds  as  well  as 
a  wet-nurse.  The  chief  objection  to  the  breast-milk  is  its  high  fat  which 
sometimes  increases  the  vomiting. 

For  infants  who  are  artificially  fed  a  few  general  principles  arc  pretty 
well  established.  In  all  milk  formulas  the  fat  should  be  low,  usually 
less  than  that  in  formulas  from  wliole  milk.  The  formulas  from  skimmed 
milk  usually  succeed  best.  Feeding  should  be  regular  and  not  oftener 
than  every  three  hours,  and  in  many  cases  a  four-hour  inter \al  is  better. 
The  amount  given  at  one  time  should  be  from  one  and  a  half  to  three 
ounces. 

Stomach  washing  is  useful  to  empty  the  organ  of  food  and  mucus 
and  seems  to  have  some  effect  in  allaying  spasm.  Water  used  should 
have  a  temperature  of  108°  to  110°  F.  and  be  rendered  alkaline  by  the 
addition  of  one  per  cent  of  bicarbonate  of  soda.  The  washing  should 
be  done  about  two  and  a  half  hours  after  feeding,  and  repeated  twice  in 
twenty-four  hours.  It  should  be  continued  for  a  considerable  period. 
In  cases  which  recover  it  has  often  been  found  necessary  for  six  to  eight 
weeks,  twice  daily,  and  for  three  or  four  months  once  daily.  Hot  appli- 
cations over  the  epigastrium  are  of  little  value  in  relaxing  spasm.  The 
administration  of  drugs,  especially  preparations  of  opium,  is  not  to  be 
relied  upon. 

In  the  milder  cases  the  effect  of  stomach  washing  and  careful  feed- 
ing is  to  bring  about  a  gradual  lessening  in  the  vomiting  and  gastric 
peristalsis,  though  it  is  usually  some  weeks  before  any  material  gain 
in  weight  is  seen,     Eelapses  are  not  uncommon. 

Surgical  Treatment. — Several  different  operations  have  been  pro- 
posed, but  only  two  have  been  frequently  performed :  gastro-enterostomy 
and  a  form  of  pyloroplasty  known  as  Bamnist^dt's  operation.  In  the 
latter  the  circular  muscular  layer  is  divided  externally  without  opening 
the  stomach.  After  this  is  done  the  pylorus  opens  and  food  passes  readily 
into  the  intestine.  It  is  as  yet  too  early  to  speak  finally  as  to  the  relative 
value  of  these  two  operations ;  but  our  observations  upon  over  fifty  cases 
treated  by  the  latter  operation  lead  us  to  prefer  it.  It  requires  but 
fifteen  or  twenty  minutes,  while  gastro-enterostomy  requires  fully  twice 
as  much  time;  it  involves  much  less  handling  of  the  abdominal  viscera;  it 
is  followed  by  much  less  shock;  there  is  less  subsequent  vomiting;  con- 
valescence has  been  more  rapid ;  fluids  pass  directly  through  the  natural 


328  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

chanuel,  and  diarrhea  has  been  seen  much  less  frequently  than  after  the 
other  operation.  While  few  of  our  cases  have  as  yet  been  followed  longer 
than  a  year  and  a  half,  up  to  the  present  time  all  the  advantages  seem 
to  be  with  this  operation. 

The  after-treatment  is  exceedingly  important  and  the  outcome  de- 
pends almost  as  much  upon  this  as  upon  the  operation  itself.  Feeding 
may  be  begun  as  soon  as  the  child  has  recovered  from  the  anesthetic. 
The  food,  if  possible,  should  be  breast  milk.  By  all  possible  means 
should  the  mother's  milk  be  conserved.  Beginning  with  one  or  two 
teaspooufuls,  it  may  be  given  every  two  hours,  alternating  with- the  same 
amount  of  water,  the  amount  bemg  gradually  increased  and  the  interval 
lengthened  so  that  the  child  at  the  end  of  forty-eight  hours  is  usually 
taking  one  ounce  of  milk  every  three  hours,  and  the  same  quantity  of 
AA-ater  between  the  feedings.  At  the  end  of  a  week  or  ten  days  the  infant 
may  in  most  cases  be  put  back  to  the  breast,  but  the  amount  taken  at 
one  time  should  be  limited  and  the  nursing  closely  watched.  In  the 
beginning  not  over  one  or  two  minutes'  nursing  should  be  permitted. 
Unless  the  bowels  move  freely,  from  one-half  to  one  teaspoonful  of  castor 
oil  should  be  given  twent^'-four  hours  after  operation.  The  vomiting 
which  not  infrequently  occurs  occasionally  for  one  or  two  days  may 
sometimes  be  relieved  by  keeping  the  head  of  the  child's  crib  consid- 
erably elevated,  or  supporting  him  in  a  semi-sitting  posture  and  by 
putting  him  over  the  nurse's  shoulder  from  time  to  time  to  enable  him 
to  get  rid  of  the  gas  in  the  stomach,  or  by  the  occasional  introduction 
of  the  stomach  tube. 

Hypodermoclvsis  is  a  procedure  of  much  value,  sometimes  before 
and  nearly  always  after  operation,  since  these  infants  are  usually  suf- 
fering greatly  from  the  lack  of  water.  From  150  to  240  c.  c.  of  a 
normal  saline  solution  may  be  given,  and  in  bad  cases  repeated  daily 
for  three  or  four  days.  It  is  often  advantageous  to  add  to  the  saline 
3  per  cent  of  glucose. 

The  shock  of  operation  with  most  of  these  patients  is  surprisingly 
little.  With  careful  feeding  favorable  cases  begin  to  gain  weight  within 
a  few  days  after  operation  and  in  a  few  weeks  are  apparently  as  well 
as  ever.  Cases  we  have  followed  for  three  or  four  years  do  not  suffer 
subsequently  from  digestive  disturbances  more  frequently  than  do  othor 
children. 

Operation  is  to  be  looked  upon  not  as  a  last  resort  in  a  condition 
well-nigh  hopeless,  but  as  offering  in  the  hands  of  an  experienced  surgeon 
an  excellent  prospect- of  recovery.  The  statistics  of  operation  by  the 
three  American  surgeons,  Downes,  Scudder  and  Eichter,  who  have  pub- 
lished the  largest  numl^er  of  cases,  show  a  mortality  of  but  28  per  cent 
in  122  operations.     Of  the  last  62  consecutive  cases  operated  on  in  the 


VOINITTTNG  329 


Babies'  Hospital,  nearly  all  by  Dowries,  there  were  44  recoveries.  The 
results  of  medical  and  surgical  treatment  cannot  well  be  compared,  for 
they  usually  refer  to  quite  different  groups  of  cases. 


VOMITING 

Vomiting  is  one  of  the  most  frequent  symptoms  of  disease  in  infants 
and  young  children,  and  occurs  from  a  wide  variety  of  causes.  The 
physician  must  have  in  mind  both  its  common  and  its  uncommon  causes. 
Vomiting  takes  place  with  great  facility  in  young  infants  even  from 
slight  causes,  owing  to  the  position  and  shape  of  the  stomach. 

1.  Vomiting  from  Overfilling  of  the  Stomach. — This  is  often  seen  in 
nursing  infants,  and  there  may  be  no  other  symptom  of  disease.  It 
comes  within  a  few  minutes  after  nursing,  is  easy  and  without  effort, 
and  the  food  is  but  little  changed.  It  may  be  excited  by  moving  the 
child  or  making  undue  pressure  upon  the  stomach,  and  requires  no  treat- 
ment except  to  diminish  the  quantity  of  food.  Vomiting  also  comes 
from  distention  of  the  stomach  with  gas,  most  of  i't  being  air  which  has 
been  swallowed  with  nursing  or  feeding.  It  is  relieved  by  placing  the 
child  in  an  upright  position  or  over  the  shoulder  before  he  is  put  in 
his  crib. 

2.  Vomiting  is  almost  invariably  present  in  cases  of  acute  gastric 
indigestion  and  acute  gastritis.  With  the  former  it  does  not  usually 
come  immediately  after  feeding,  and  it  may  be  delayed  for  several 
hours;  with  the  latter  it  is  usually  persistent.  The  vomited  matter 
consists  of  the  contents  of  the  stomach,  but  often  mucus,  and,  in  severe 
cases,  bile  and  traces  of  blood  may  be  vomited  for  some  time  afterward. 

3.  In  the  hypertrophic  stenosis  of  the  pylorus  of  early  infancy,  un- 
controllable vomiting  without  fever  is  the  principal  symptom.  (See 
previous  Chapter.) 

4.  In  acute  intestinal  obstruction  vomiting  is  rarely  absent,  and  in 
most  cases  it  is  persistent.  In  the  newly-born,  persistent  vomiting  is 
almost  invariably  dependent  upon  congenital  obstruction  of  the  intestine, 
which  is  most  frequently  in  the  duodenum.  In  malformations  of  the 
colon  and  rectum  it  is  less  constant  and  appears  later.  In  intussuscep- 
tion, vomiting  is  forcible,  immediately  excited  by  the  taking  of  food,  and 
is  at  first  bilious,  but  later  may  become  fecal. 

5.  Vomiting  is  a  frequent  and  almost  a  constant  symptom  of  acute 
peritonitis,  whether  localized  or  general,  of  which  appendicitis  is  llie 
usual  cause.  It  is  then  associated  with  abdominal  distention,  tenderness, 
and  fever. 

().     In  certain  nervous  diseases,  especially  tumor  oi'  the   brain,  and 


330  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

acute  meningitis,  wliether  cerebrospiual  or  tuberculous,  vomiting  is  very 
common.  Cerebral  vomiting  is  usually  forcible  or  projectile.  It  may 
have  no  relation  to  meals. 

7.  In  infants,  and  less  frequently  in  older  children,  vomiting  is  onte 
of  the  most  frequent  symptoms  to  mark  the  onset  of  acute  fehrite  dis- 
eases especially  the  beginning  of  scarlet  fever,  pneumonia,  and  malaria. 

8.  An  accumulation  in  the  blood  of  various  toxic  materials  may  pro- 
voke vomiting;  the  best  known  example  is  uremia.  In  cyclic  vomiting 
it  is  quite  probable  that  the  cause  is  the  accumulation  of  some  toxic 
substance  in  the  blood.  The  absorption  of  poisons  taken  in  with  milk 
or  other  food,  or  developing  in  the  gastro-enteric  tract,  may  excite 
vomiting.  In  some  of  these  conditions  it  is  possible  that  the  vomiting 
may  be  eliminative.  The  cases  dependent  upon  renal  disease  are  dis- 
covered by  examination  of  the  urine.  The  other  forms  are  often  exceed- 
ingly obscure,  and  recognized  only  by  the  exclusion  of  all  other  causes 
of  vomiting. 

9.  Vomiting  may  be  reflex  from  irritation  in  the  pharynx.  This  is 
frequent  in  young  infants,  who  may  induce  vomiting  by  stuffing  the 
fingers  into  the  mouth.  In  certain  cases  the  irritation  from  worms  in 
the  intestinal  tract  may  cause  vomiting,  and  it  is  possible  that  even 
dentition  may  produce  it. 

10.  Hahit  is  a  frequent  cause,  in  cases  of  chronic  vomiting,  especially 
in  children  of  a  neuropathic  constitution.  In  young  infants  a  habit 
may  be  acquired  of  regurgitating  the  food  very  much  in  the  manner 
of  the  ruminating  animals.  Soon  after  feeding  there  is  seen  a  move- 
ment of  the  mouth  and  fauces  resembling  swallowing,  then  the  food 
appears  in  the  mouth  and  is  ejected  without  force.  This  may  be  re- 
peated until  a  large  part  of  the  food  taken  is  lost.  The  habit  once 
formed  may  continue  for  months,  the  nutrition  of  the  infant  often 
suffering  to  a  serious  degree.  To  this  condition  the  name  rumination 
has  been  given.  It  is  not  difficult  of  recognition  if  the  infant  is  closely 
observed   after  feeding. 

The  most  successful  treatment  is  the  administration  of  a  food  so 
tliick  that  it  cannot  be  readily  regurgitated  by  the  infant  in  the  manner 
described :  e.  g.,  four  tablespoons  of  barley  flour  is  cooked  for  thirty 
minutes  in  one  pint  of  whole  milk.  From  one  to  two  ounces  are  given 
every  three  or  four  hours  with  a  spoon,  as  it  is  too  thick  to  go  through 
a  rubber  nipple.  AYater  should  be  given  between  feedings.  Some 
children  have  the  power  of  vomiting  at  will  anything  in  the  nature  of 
food  which  they  do  not  like,  yet  who  retain  other  food  without  difficulty. 
One  such  child  would  tolerate  large  doses  of  quinin,  to  which  he  had 
no  aversion,  without  the  slightest  disturbance.  Habit  is  a  potent  cause 
in  continuing  vomiting  wdien  from  any  cause  it  has  occurred  frequently. 


CYCLIC  VOMITING  331 

In  children  who  have  this  habit  the  most  trivial  cause  will  provoke  it. 
It  may  be  present  without  *any  other  sign  of  gastric  disease,  and  appears 
simply  to  depend  upon  exaggerated  reflex  irritability  of  the  organ.  We 
have  seen  a  number  of  children  who  up  to  the  third  or  fourth  year 
objected  so  strenuously  to  taking  solid  food  that  they  would  imme- 
diately vomit  it,  no  matter  of  what  variety  or  in  how  small  a  quantity, 
although  fluids  were  taken  and  easily  digested. 

11.  Chronic  vomiting  may  depend  upon  habit,  as  just  described,  or 
upon  chronic  indigestion;  or  it  may  be  associated  with  chronic  pulmo- 
nary disease — vomiting  here  being  excited  by  the  attacks  of  coughing,  at 
first  only  when  the  paroxysms  are  severe,  and  later  even  when  they  are 
slight. 

The  diagnosis  of  a  case  in  which  vomiting  is  the  chief  symptom 
may  be  difficult.  The  first  important  distinction  to  be  made  is  between 
cases  in  which  the  vomiting  is  of  gastric  origin,  and  those  in  which  it 
depends  iipon  other  causes.  It  is  only  by  a  careful  consideration  of  the 
associated  symptoms  that  an  accurate  diagnosis  can  be  reached. 

The  treatment  of  vomiting  is  the  treatment  of  the  cause  upon  which 
it  depends. 

CYCLIC  VOMITING 

This  is  a  frequent  condition  and  up  to  recent  times  has  attracted 
but  little  attention  except  in  this  country.  Although  the  clinical  picture 
is  a  very  clear  and  definite  one;,  its  exact  pathology  is  undetermined. 
It  has  also  been  described  under  the  names  periodical  vomiting  and 
recurrent  vomiting.  It  is  characterized  by  periodical  _attacks_jof  vomit:-, 
ing,  which  recur^at  regular  or  irregular  intervals  of  weeks  or  months, 
appaxgntly  without  any  adequate  exciting  cause^  The  usual  duration 
of  the  attacks  is  two  oFtEree  days,  during  which  all  attempts  to  control 
the  vomiting  are^sually  without  a^ail,  but  at  the  end  of  this  time  it 
generally  ceases  spontaneously. 

Etiology. — The  first  attac:ks  are  usually  seen  between  the  ages  of  two, 
and  four  years,  but  they  may  date  back  to  infancy.  The  two  sexes  seem 
to  be  almost  equally  liable.  A  few  of  the  patients  are  strong  children, 
hut  the  greaf  majority  are  rather  delicate  and  of  a  highly  nervous 
temperament.  The  cases  are  seen  chiefly  in  private  practice,  often 
occurring  among  those  who  have  the  best  surroundings.  In  most  cases 
the  antecedents  of  patients  are  of  a  neurotic  type.  The  attacks  are 
not  usually  traceabk  to  distinct  or  flagrant  erroj\s  iii^  diet,  and  yet  the 
habitual  diet  seems  to  bear  some  relation  to  the  disease.  The  exciting 
cause  is  often  a  nervous  one — great  fatigue  or  unusual  excitemenf, 
sometimes  a  railroad  journey  or  a  child's  party;  in  many  instances  it 


332  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

seems  to  be  induced  by  some  ininor  illness  having  no  relation  to  tlie 
digestive  tract,  such  as  an  attack  of  tonsillitis  or  bronchitis.  In  children 
subject  to  this  condition  serious  diseases,  such  as  scarlet  fever  or  measles, 
may  be  ushered  in  by  prolonged  and  repeated  vomiting,  -which  usually 
ceases  before  the  end  of  the  febrile  period.  General  anesthesia,  specially 
by  ether,  is  very  likely  to  precipitate  an  attack. 

Symptoms. — The  clinical  picture  presented  by  these  cases  is  very  char- 
acteristic, and  is  well  illustrated  by  the  history  of  the  following  case : 

The  patient  was  a  well-nourished  boy  of  six  years  when  he  first  came 
under  treatment.  He  belonged  to  a  neurotic  family,  and  the  attacks 
dated  back  to  infancy.  From  this  time  they  had  recurred  usually  at  in- 
tervals of  a  f CAv  months ;  occasionally  five  or  six  months  would  pass  with- 
out one.  The  symptoms  in  all  the  attacks  were  similar  in  kind,  differ- 
ing only  in  degree.  They  were  preceded  by  a  prodromal  period  lasting 
from  twelve  to  twenty-four  hours,  marked  by  languor,  dulness,  dark 
rings  under  the  eyes,  loss  of  appetite,  and  a  general  sense  of  discomfort 
in  the  epigastrium.  At  this  time  the  temperature  was  generally  slightly 
elevated.  The  vomiting  then  began  suddenly.  It  was  attended  with 
great  retching  and  distress;  it  was  often  repeated  every  half -hour  or 
hour  for  two  days.  On  one  occasion  it  occurred  seventeen  times  in  a 
single  night.  Vomiting  was  immediately  excited  by  the  taking  of  any 
food  or  drink,  but  it  occurred  also  when  nothing  was  taken.  The  vomited 
matters  consisted  of  frothy  mucus  and  watery  material,  frequently 
streaked  with  blood,  apparently  f roni  the  violence  of  the  emesis,  and  often 
containing  bile.  The  temperature  usually  fell  to  about  100°  F.  when  the 
vomiting  began,  and  continued  at  or  below  this  point  throughout  the 
attack.  By  the  end  of  the  second  day  the  exhaustion  was  very  marked — 
so  severe,  in  fact,  as  apparently  to  threaten  life.  The  child  lay  in  a 
semi-stupor,  with  eyes  half  open,  lips  and  tongue  dry,  rousing  at  times 
to  beg  for  water.  The  pulse  was  rapid  and  weak,  and  sometimes  slightly 
irregular.  There  was  no  distention  of  the  abdomen;  it  was  usually 
flattened.  By  the  third  day  the  vomiting  became  less  frequent  and 
then  ceased  entirely.  Convalescence  was  rapid,  and  by  the  end  of  the 
week  the  boy  was  almost  as  well  as  usual.  The  attacks  continued  to 
recur  at  gradually  lengthening  intervals  until  they  finally  ceased  alto- 
gether at  about  the  twelfth  year. 

A  great  number  of  these  cases  come  under  observation.  The  usual 
duration  of  the  attacks  is  one  to  three  days.  In  one  child  they  lasted 
regularly  for  five  days.  Occasionally  a  severe  attack  will  last  a  week. 
The  average  number  of  attacks  is  four  or  five  a  year. 

Prodromal  symptoms  are  present  in  most  of  them — headache,  gen- 
eral languor,  coated  tongue,  and  anorexia  are  the  most  frequent;  in 
some  there  is  marked  constipation,  with  a  history  of  very  white  stools 


CYCLIC  VOMITING  333 

for  some  time.  But  it  is  not  uncommon  for  an  attack  to  occur  in  the 
midst  of  apparently  perfect  health.  The  tongue  is  usually  coated  at  the 
beginning  of  an  attack,  and  at  its  height  it  is  often  dry  and  brown.  The 
abdomen  seems  empty  and  its  walls  sunken;  pain  and  tenderness  are 
both  rare.  The  bowels  are  usually  constipated  and  move  only  with  diffi- 
culty by  artificial  means.  Very  exceptionally  there  may  be  diarrhea 
with  foul  stools. 

There  is,  as  a  rule,  no  desire  for  food,  but  the  continual  cry  is 
for  water  to  quench  the  constant,  burning  thirst.  The  pulse  after  the 
second  day  becomes  rapid,  soft,  and  often  somewhat  irregular.  The 
respiration  is  shallow,  and  at  times  this  also  may  be  irregular.  The 
temperature  is  usually  under  100.5°  F.,  rarely  it  may  be  102°  or  103°  F. 
The  low  temperature  is  a  point  of  much  diagnostic  value.  The  patients 
are  dull,  apathetic,  and  wish  to  be  left  alone.    Headache  is  very  common. 

The  disposition  to  vomit  is  sometimes  so  great  that  patients  are 
afraid  to  move  or  even  to  talk  lest  it  may  be  provoked.  The  vomited 
matter  is  often  large  in  amount,  considering  that  the  patient  is  fasting. 
It  is  essentially  gastric  juice,  containing  free  HCl,  mucus,  serum,  many 
epithelial  cells,  and  often  traces  of  blood.  Less  frequently  vomiting  may 
occur  only  two  or  three  times  a  day.  The  urine  is  concentrated,  and 
frequently  contains  at  the  height  of  the  attack  a  trace  of  albumin,  a  few 
hyaline  casts,  and  some  blood  cells.  An  increase  in  the  renal  secretion 
may  be  the  first  sign  of  improvement.  There  is  usually  an  excess  of 
indican  both  during  and  between  attacks.  A  condition  practically  con- 
stant, and  first  pointed  out  by  Marfan,  is  the  presence  in  the  urine  of 
acetone,  diacetic  and  /8  oxybutyric  acids.  These  substances  often  appear 
in  the  urine  in  large  amounts  so  early  in  the  attack  that  they  can  not  be 
ascribed  to  starvation,  and  therefore  may  be  of  diagnostic  value.  How- 
ever, it  should  be  emphasized  that  acetonuria  is  not  the  same  as  acidosis ; 
the  latter  is  uncommon  in  cyclic  vomiting,  but  occurs  in  a  severe  form, 

The  Nature  of  the  Attacks. — These  cases  have  little  in  common  with 
the  ordinary  attacks  of  indigestion.  With  our  present  knowledge  they 
are  to  be  regarded  as  explosions  due  to  faulty  metabolism.  They  have 
much  in  common  with  attacks  of  migraine  which  in  later  life  not  infre- 
quently replace  the  attacks  of  vomiting.  The  studies  of  Hilliger  upon  a 
child  subject  to  attacks  of  cyclic  vomiting  showed  an  interesting  reaction 
to  the  withdrawal  of  carbohydrates.  When  the  carbohydrates  in  the  diet 
were  greatly  restricted  the  blood  sugar  fell  at  once  to  one  half  the  normal 
amount  and  vomiting  was  precipitated.  Normal  children  were  not  influ- 
enced by  the  temporary  withdrawal  of  carbohydrates. 

Prognosis. — Although  these  patients  very  often  seem  to  be  most 
alarmingly  ill,  the  danger  to  life  is  slight.  We  have  seen  but  three  fatal 
cases,  and  in  one  the  diagnosis  is  open  to  question,  as  no  autopsy  could 


334  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

be  obtained.  Griffith  reports  two  fatal  cases,  the  autopsy  in  one  showing 
nothing  definite.  The  probabilities  are  always  in  favor  of  a  recur- 
rence of  the  attacks.  In  most  of  the  patients  who  have  been  observed 
they  have  extended  over  a  series  of  several  years,  although  by  a  careful 
regimen  much  may  be  done  to  reduce  their  frequency  and  diminish  their 
severity.  In  a  considerable  proportion  of  cases  they  may  be  stopped  alto- 
gether. Toward  puberty  there  appears  to  be  a  strong  tendency  to  spon- 
taneous recovery. 

Diagnosis. — Organic  disease  of  the  brain  and  kidneys  must  first  be 
excluded.  The  first  attacks  witnessed  may  strongly  suggest  the  onset  of 
tuberculous  meningitis;  and  only  the  course  of  the  symptoms  may  show 
that  this  is  not  present.  Usually  a  history  of  many  previous  attacks 
may  be  obtained.  From  acute  indigestion,  cyclic  vomiting  is  differen- 
tiated by  the  fact  that  the  attacks  are  not  brought  on  by  indigestible 
food,  and  also  by  the  persistence  of  the  vomiting,  and  the  early  presence 
in  the  urine  of  the  acetone  bodies.  It  is  distinguished  from  gastritis  by 
its  severity,  the  shorter  duration  of  its  symptoms,  and  its  self-limited 
course. 

Appendicitis  is  excluded  by  the  absence  of  pain,  tenderness,  and  mus- 
cular rigidity;  intussusception  by  the  fact  that  the  symptoms  are  less 
severe,  by  the  absence  of  blood  and  mucus  from  the  stools,  and  by  the 
fact  that  intussusception  is  usually  seen  in  infancy. 

Treatment — When  the  premonitory  symptoms  appear,  starvation  and 
free  purgation  offer  the  best  prospect  of  aborting  an  attack.  If  the 
vomiting  has  once  begun,  nothing  seems  to  have  the  slightest  influ- 
ence in  controlling  it.  It  is  usually  increased  by  the  taking  of  food  or 
drink  or  by  any  medication  by  the  mouth,  and  all  should  be  withheld. 
The  patient  should  be  kept  absolutely  quiet  and  a  saline  solution  given, 
per  rectum,  at  regular  intervals,  usually  six  to  eight  ounces,  four  or  five 
times  a  day.  To  this  twenty  or  thirty  grains  of  sodium  bicarbonate  may 
be  added.  This  keeps  up  the  urinary  secretion,  allays  thirst  and  often 
restlessness,  and  when  it  is  retained  usually  adds  much  to  the  patient's 
comfort.  When  the  vomiting  has  ceased  for  several  hours  it  is  not  likely 
to  recur  if  food  is  very  Judiciously  administered,  at  first  in  small  quan- 
tities. Broth,  thin  cereals,  kumyss,  or  small  quantities  of  iced  milk  and 
lime-water  in  equal  proportions  may  then  be  given.  In  severe  or  pro- 
longed cases,  six  to  eight  ounces  of  a  5-per-cent  glucose  solution  may  be 
given  by  rectum  once  or  twice  a  day.  If  this  is  not  retained,  three  to  six 
ounces  may  be  given  subcutaneously  in  a  saline  solution. 

When  acidosis  develops  it  should  receive  its  special  treatment.  (See 
Acidosis.)  Between  the  attacks,  the  alkaline  treatment  is  to  be  recom- 
mended; it  consists  in  giving  bicarbonate  of  soda  in  doses  of  fifteen  to 
thirty  grains  three  times   daily  and  continuing   it  for   many  months. 


ACUTE  GASTRITIS  335 

Wlieu  the  prodromal  signs  of  an  attack  appear,  larger  doses,  as  much  as 
twenty  grains  every  hour,  should  be  administered.  The  diet  should  con- 
sist principally  of  meat,  vegetables,  skimmed  milk,  cereals  in  moderate 
amount,  and  stale  bread.  In  addition  to  careful  regulation  of  the  diet  the 
general  nutrition  should  be  considered,  and  the  patient's  life  so  regulated 
that  extreme  fatigue  and  exhaustion,  as  well  as  nervous  excitement,  arc 
prevented.  In  most  cases  close  attention  to  these  matters  has  resulted 
in  a  very  great  diminution  in  the  frequency  of  the  attacks. 


ACUTE  GASTRITIS 

In  comparison  with  the  frequency  of  inflammatory  diseases  of  the 
intestine,  those  of  the  stomach  are  rare,  particularly  so  in  infancy. 
Owing  largely  to  the  character  of  its  secretion  and  its  contents,  the  stom- 
ach is  much  more  resistant  to  infection  than  are  the  intestines.  Gastritis 
seldom  exists  alone,  but  is  usually  associated  with  enteritis  or  colitis. 

Etiology. — The  causes  of  gastritis  are,  in  the  main,  those  of  acute 
gastric  indigestion — improper  food  or  feeding — to  which  possibly  is 
added  infection.  Gastritis  may  also  be  ^caused  by  the  introduction  of 
irritants,  which  may  either  be  swallowed  accidentally  or  given  as  drugs. 

Lesions. — The  mucous  membrane  of  the  stomach  may  be  the  seat  of 
acute  catarrhal,  ulcerative,  or  membranous  inflammation,  all  forms  ex- 
cept the  catarrhal  being  rare.  There  is  also  seen  a  mixed  form,  which 
from  its  cause  is  usually  termed  "corrosive"  gastritis. 

Catarrhal  Gastritis. — This  is  characterized  by  hyperemia  of  the  mu- 
cous membrane,  exudation  of  cells  into  the  mucosa,  a  great  increase 
in  the  secretion  of  the  mucous  glands,  and  changes  in  the  epithelium. 
About  the  only  change  which  can  be  recognized  by  the  naked  eye  is 
congestion  and  swelling  of  the  mucous  membrane.  These  are  usually 
more  marked  toward  the  pyloric  end  and  along  the  greater  curvature. 
There  may  be  small  extravasations  of  blood  into  the  mucosa.  The  stom- 
ach contains  undigested  food  and  mucus,  which  may  be  thick  and  tena- 
cious, adhering  very  closely  to  the  mucous  membrane.  The  mucus  may 
be  stained  brown  from  the  capillary  hemorrhages.  The  stomach  may  be 
either  distended  or  contracted.  Under  the  microscope  the  changes  are 
seen  to  be  almost  entirely  in  the  mucosa.  In  some  places  there  is  loss  of 
the  superficial  epithelium,  in  others  only  degenerative  changes  in  it  are 
seen.  The  mucosa  is  infiltrated  with  round  cells,  this  process  being 
rarely  diffuse,  but  generally  occurring  in  patches.  The  blood-vessels  are 
distended  and  many  small  extravasations  are  seen.  Sometimes  there  is 
a  moderate  infiltration  of  the  submucosa.  Acute  catarrhal  gastritis 
alone  is  rarely  severe  enough  to  cause  death.     It  is  usually  seen  in  cases 


336  DISEASES  OF  THE  DICtESTIVE  SYSTEM 

which  prove  fatal  from  other  causes,  particularly  diseases  of  the  intestine. 

Gastric  softening  {gastromalacia)  is  a  condition  dependent  npon 
post-mortem  changes — probably  self-digestion  of  the  stomach.  It  is 
found  both  where  gastric  symptoms  were  present  and  where  they  were 
absent.  It  is  situated  nearly  always  in  the  posterior  wall,  and  usually 
covers  a  considerable  area,  about  one-third  or  one-fourth  of  this  wall.  It 
is  recognized  by  the  gelatinous,  translucent  appearance  of  the  walls  of 
the  stomach,  which  are  so  softened  that  the  finger  may  be  pushed  through 
them  without  force,  or  that  sometimes  the  stomach  ruptures  while  it  is 
being  removed.  This  condition  is  rarely  seen  when  the  stomach  is  empty. 
It  can  scarcely  be  mistaken  for  a  pathologicar  condition  if  its  occurrence 
is  borne  in  mind. 

Ulcerative  Gastritis. — This  was  met  with  six  times,  not  including 
tuberculous  cases,  in  390  consecutive  autopsies  upon  infants  in  the 
Babies'  Hospital.  Three  of  the  patients  were  less  than  four  months  old. 
and  all  were  females.  The  ulcers  varied  from  one  twenty-fifth  to  one 
quarter  of  an  inch  in  diameter,  and  usually  from  ten  to  fifty  were  pres- 
ent. They  seldom  extended  to  the  muscular,  and  never  to  the  peritoneal 
coat.  The  lesion  was  most  marked  in  the  posterior  wall,  toward  the 
pyloric  end  and  along  the  greater  curvature.  Evidences  of  catarrhal  in- 
flammation were  present  in  most  of  the  cases,  and  in  four,  of  mem- 
])ranous  inflammation.  Lesions  in  some  other  part  of  the  digestive  tract 
were  present  in  all  but  one  case,  in  two  there  was  thrush  in  the  esopha- 
gus; in  three  there  was  ulceration  somewhere  in  the  intestines. 

Membranous  Gastritis. — This  is  even  more  rare  than  the  varieties 
previously  mentioned.  We  have  met  with  it  but  four  times  in  infants. 
One  case  was  associated  with  a  membranous  colitis;  a  second  case  with 
a  •  streptococcus  inflammation  of  the  fauces  and  larynx  in  an  infant  but 
six  weeks  old.  The  esophagus  was  not  involved  in  this  case;  and  indeed 
it  often  escapes.  Xo  Klebs-Loeffler  bacilli  could  be  found  either  in  cover- 
slip  preparations  or  by  culture. 

To  the  naked  eye  the  membrane  appears  of  a  grayish-green  color; 
it  is  adherent,  but  can  be  detached  in  quite  large  patches.  Only  a  por- 
tion of  the  stomach  is  usually  affected.  The  microscopical  appearances 
resemble  those  of  membranous  colitis.  There  is  a  pseudo-membrane  com- 
posed of  fibrin,  granular  matter,  epithelial  cells,  and  bacteria.  The 
mucosa  shows  a  moderately  dense  infiltration  with  round  cells,  and  in 
places  superficial  ulceration.  There  is  also  infiltration  of  the  submucosa, 
and  in  some  places  even  the  muscular  coat  is  involved. 

Memljranous  gastritis  occurring  in  patients  dying  of  diphtheria  is 
not  common.  Councilman,  Mailory,  and  Pearce  noted  its  presence  in 
only,  five  of  one  hundred  and  twenty-seven  autopsies. 

Corrosive  Gastritis   {toxic  gastritis). — This  form  of  iiiflamniation  is 


ACUTE  GASTRITIS  337 

excited  by  various  irritating  and  caustic  substances,  taken  by  accident. 
The  most  frequent  are  carbolic  acid  and  caustic  alkalis. 

The  lesions  in  the  stomach  depend  upon  the  amount  of  the  substance 
swallowed,  the  degree  of  concentration,  and  whether  the  stomach  was 
full  or  empty  at  the  time.  Strong  caustics,  whether  acids  or  alkalis, 
usually  act  more  deeply  and  extensively  in  the  pharynx  and  esophagus, 
for,  owing  to  the  spasmodic  contraction  of  the  muscles  of  these  parts, 
often  but  a  small  amount  of  the  substance  reaches  the  stomach.  Concen- 
trated irritant  poisons  produce  in  the  stomach,  especially  along  the 
greater  curvature,  irregular  ulcers,  which  may  be  so  deep  as  to  cause  per- 
foration, or  they  may  affect  the  mucous  membrane  only.  In  severe  cases 
death  takes  place  early,  often  in  a  few  hours.  Dark,  ragged  ulcers  are 
found  in  the  stomach,  the  surrounding  mucous  membrane  is  the  seat  of 
intense  congestion,  and  in  places  there  are  extravasations  of  blood.  If 
death  is  delayed  there  are  evidences  of  intense  inflammation,  sometimes 
with  the  production  of  a  pseudo-membrane.  If  the  amount  of  poison  is 
not  sufficient  to  cause  death,  and  if  the  patient  recovers  from  the  re- 
sulting gastritis,  a  cicatricial  condition  of  the  stomach  results,  which 
later  may  lead  to  stenosis  of  the  pylorus  or  other  deformity  of  the 
organ. 

Symptoms. — Catarrhal  gastritis  can  not  be  distinguished  at  its  begin- 
ning from  an  attack  of  acute  indigestion.  There  is  fever,  pain,  vomit- 
ing, thirst,  loss  of  appetite,  coated  tongue,  and  prostration.  The  pres- 
ence of  inflammatory  changes  is  indicated  by  the  continuance  of  these 
symptoms,  particularly  the  pain,  vomiting,  fever,  and  thirst.  With  the 
pain  there  may  be  epigastric  tenderness.  All  food  and  liquids  are  im- 
mediately rejected,  and  even  when  nothing  is  taken  the  retching  and 
\omiting  may  continue,  nothing  but  frothy  mucus  or  serum  being 
l^rought  up,  sometimes  streaked  with  blood.  The  vomited  matters  are 
usually  very  sour;  they  may  be  bilious.  The  temperature  is  rarely  high 
except  at  the  outset.  After  the  first  or  second  day  it  usually  ranges 
between  100°  and  101.5°  F.  Thirst  is  intense,  and  all  liquids  are  taken 
Avith  avidity,  especially  if  cold,  even  though  they  are  immediately 
vomited.  The  tongue  is  thickly  coated  with  a  white  fur,  and  the  breath 
may  be  foul.  The  constitutional  symptoms  are  generally  most  severe  at 
the  outset.  The  usual  duration  of  such  attacks  is  from  four  to  seven 
days,  but  with  improper  management,  especially  injudicious  feedi'ig, 
the  disease  may  be  much  prolonged.  One  attack  may  follow  another 
until  a  chronic  condition  is  established.  In  most  of  the  cases  there  is 
some  disturbance  of  the  intestines,  usually  a  sharp  attack  of  diarrhea. 
Sometimes  the  gastric  symptoms  subside  after  a  few  days  and  those  of 
the  intestines  become  the  predominant  ones.  The  symptoms  above  given 
are  those  in  infancy.     In  older  children  there  is  less  fever,  prostration, 


338  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

and  diarrhea,  but  pain  and  vomiting  are  prominent.  The  attacks  are 
usually  shorter  and  altogether  less  severe. 

The  rare  cases  of  ulcerative  gastritis  have  nothing  by  vrhich  they 
can  be  distinguished  from  the  form  described,  except  a  more  prolonged 
course  and  a  greater  liability  to  hemorrhage. 

Membranous  gastritis  also  presents  no  peculiar  symptoms.  In  fact, 
in  the  cases  we  have  personally  seen,  the  gastric  symptoms  were  insig- 
nificant, and  the  condition  not  suspected  during  life. 

In  corrosive  gastritis  the  effects  of  the  caustic  may  be  seen  in  the 
mouth  and  phar3"nx,  the  mucous  membrane  being  usually  of  a  gray  or 
whitish  color.  Pain  and  a  sense  of  constriction  are  felt  in  the  esophagus 
and  stomach,  and  thirst  is  great.  Vomiting  follows  almost  immediately, 
and  the  matters  vomited  are  usually  bloody.  The  subsequent  course  in 
most  of  the  cases  is  the  rapid  development  of  collapse,  and  death  in  a 
few  hours  from  shock.  The  younger  the  child  the  sooner  does  the  case 
terminate.  In  irritant  poisoning  not  severe  enough  to  produce  death, 
the  symptoms  of  acute  gastritis  follow,  usually  accompanied  by  more  or 
less  enteritis  owing  to  the  passage  of  the  irritant  into  the  intestine. 
There  is  seen  a  continuance  of  the  vomiting,  pain  and  epigastric  disten- 
tion, and  diarrhea,  and  from  these  symptoms  death  may  result  in  two 
or  three  days.  It  is  extremely  rare  in  early  childhood  for  the  patient  to 
survive  both  the  stage  of  shock  and  that  of  acute  inflammation,  so  that 
the  deformities  of  the  stomach  and  the  chronic  conditions  mentioned  are 
practically  never  met  with  except  in  older  children. 

Treatment. — Cases  of  acute  catarrhal  gastritis  are  to  be  managed  very 
much  like  those  of  acute  gastric  indigestion.  Thirst  may  be  relieved  by 
swallowing  bits  of  ice.  ^Vhere  there  is  continuous  vomiting  of  acid 
mucus,  relief  is  sometimes  afforded  by  repeating  the  stomach-washing 
once  in  twelve  hours  with  a  one-per-cent  solution  of  bicarbonate  of  soda, 
at  110°  F.  In  older  children,  beneficial  results  sometimes  follow  the 
use  of  bismuth  subcarbonate  (gr.  x  every  two  hours) ;  but  in  infants 
we  have  seen  but  little  effect  from  any  form  of  medication,  the  reliance 
being  upon  rest,  careful  feeding,  and  stomach-washing. 

Cases  of  corrosive  gastritis  require  special  treatment.  The  first  indi- 
cation is  to  administer  the  proper  chemical  antidote  to  the  substance 
swallowed,  and  the  next  to  use  bland  mucilaginous  or  oily  fluids,  such 
as  milk,  albumin  water,  oils  in  large  quantities,  etc.  Especially  should 
stomach-washing  be  avoided  except  immediately  after  the  ingestion  of 
the  poison.  Opium  is  always  required,  on  account  of  pain,  and  should 
be  given  hypodermically.  The  general  symptoms  are  to  be  treated 
according  to  the  indications  of  the  individual  case. 


CHRONIC  GASTRIC  IXDIGESTIOX— CHRONIC  GASTRITIS  339 


CHBONIC  GASTRIC  INDIGESTION— CHRONIC   GASTRITIS— GASTRIC 

CATARRH 

Although  from  a  pathological  point  of  view  these  conditions  may  not 
be  identical,  from  a  clinical  standpoint  there  is  no  advantage  in  attempt- 
ing to  separate  them.  Xothing  distinguishes  chronic  indigestion  from 
chronic  gastritis  except  that  in  the  latter,  in  addition  to  contin^^ed  de- 
rangement of  function,  there  is  a  greater  increase  in  the  production  of 
gastric  mucus.  Chronic  indigestion  does  not  long  exist  without  the 
production  of  a  certain  amount  of  catarrhal  inflammation.  This  con- 
dition in  the  stomach  seldom,  if  eyer,  exists  without  more  or  less  involve- 
ment of  the  intestine,  and  in  the  majority  of  cases  the  intestinal  condi- 
tion is  the  more  important.  In  some,  however,  the  gastric  symptoms 
predominate,  and  it  is  only  those  which  are  here  considered.  What  is 
often  called  chronic  gastric  indigestion  in  infancy  has  already  been  dis- 
cussed in  the  chapter  devoted  to  Difficult  Feeding.  In  this  connection 
only  the  condition  as  it  afEects  older  children  will  be  referred  to. 

Etiology. — Chronic  gastric  indigestion  may  follow  acute  attacks,  or 
it  may  be  chronic  from  the  outset.  Etiological  factors  of  importance  are 
overfeeding,  too  large  meals,  unsuitable  food,  especially  solid  food  too 
early  and  in  too  large  amounts  for  very  young  children.  The  condition 
generally  accompanies  dilatation  of  the  stomach.  As  a  consequence  of 
imperfect  digestion,  fermentation  in  the  residuum  takes  place,  and  the 
irritating  products  of  this  fermentation  soon  cause  a  catarrhal  inflamma- 
tion with  a  production  of  mucus.  Chronic  gastric  indigestion  also  com- 
plicates many  of  the  constitutional  diseases  of  childhood,  especially 
rickets,  syphilis,  tuberculosis,  and  malnutrition.  It  may  follow  any  of 
the  acute  infectious  diseases.  In  older  children  it  is  often  due  to  the 
habit  of  rapid  eating  and  insufficient  mastication,  the  cause  of  which  is 
very  often  carious  teeth.  It  may  complicate  valvular  disease  of  the 
heart. 

Lesions. — The  changes  found  in  chronic  gastritis  are  usually  confined 
to  the  mucosa.  In  the  mild  form  there  are  degenerative  changes  of  the 
epithelium  of  the  tubules,  with  an  increased  production  of  mucus ;  there 
may  be  a  slight  infiltration  of  the  mucosa  with  round  cells.  The  more 
severe  form,  with  marked  cell  infiltration  and  the  production  of  new 
connective  tissue,  is  extremely  rare.  The  submucous  coat  may  be  thick- 
ened and  the  muscular  coat  attenuated.  The  lesion  can  not  be  recognized 
Ijy  the  naked  eye.  The  stomach  is  apt  to  be  more  or  less  dilated,  and  its 
surface  is  coated  witli  thick  and  very  adherent  mucus.  This  lesion  rarely 
exists  alone,  practically  never  in  infancy,  but  is  associated  with  similar 
lesions  in  the  intestines,  the  latter  often  being  more  severe. 


340  DISEASES  OP  THE  DIGESTIVE  SYSTEM 

Symptoms. — In  all  cases  the  most  constant  symptom  is  vomiting, 
which  may  occur  regularly  after  meals,  or  only  in  the  morning  before 
breakfast.  If  the  latter,  the  vomited  matters  consist  chiefly  of  mucus.  In 
addition  to  these  regular  attacks  there  may  be  the  frequent  regurgitation 
of  small  quantities  of  food.  There  are  present  gastric  flatulence  and 
pain,  due  to  hyperacidity  or  to  acid  fermentation.  The  appetite  is  vari- 
able— sometimes  inordinate,  sometimes  entirely  lost ;  it  may  be  capricious, 
there  being  usually  a  craving  for  highly  seasoned  food.  The  tongue  is 
constantly  furred,  and  the  breath  usually  disagreeable.  These  symptoms 
are  seen  in  all  degrees  of  severity.  Intestinal  disturbances  are  not  fre- 
quent. Constipation  is  more  common  than  diarrhea.  The  general  symp- 
toms are  those  of  malnutrition.  There  are  anemia,  wasting,  constant 
fretfulness,  disturbed  sleep,  and  various  other  nervous  disorders. 

Prognosis. — The  prognosis  depends  upon  the  age  of  the  patient,  the 
duration  of  the  disease,  the  surroundings,  and  upon  how  well  treatment 
can  be  carried  out.  There  is  little  tendency  to  spontaneous  recovery,  but 
under  favorable  conditions,  with  constant  care,  much  may  be  done  for 
all  these  patients  and  many  of  them  may  be  completely  cured. 

Treatment. — The  general  treatment  is  too  apt  to  be  ignored,  but  it  is 
just  as  important  as  measures  directed  more  specifically  to  the  stomach. 
A  large,  roomy  nursery,  and  plenty  of  fresh  air  by  night  and  by  day, 
are  very  important;  equally  necessary  are  quiet  surroundings  and  free- 
dom from  disturbing  conditions  which  sometimes  obtain  in  the  nursery. 
General  friction  of  the  body  is  useful  in  delicate  children  with  poor  cir- 
culation. Of  the  measures  directed  to  the  stomach,  two  are  chiefly  to  be 
depended  upon — stomach-washing  and  proper  feeding. 

Stomach-washing  is  useful,  first,  in  removing  the  mucus  which  is 
abundant  in  most  of  these  cases;  secondly,  in  cleansing  the  organ  thor- 
oughly at  least  once  a  day,  this  of  itself  being  most  important;  thirdly, 
as  a  stimulant  to  the  gastric  secretions,  especially  hydrochloric  acid. 
Plain  boiled  water,  or  a  weak  alkaline  solution — sodium  bicarbonate,  one 
dram  to  the  pint — may  be  employed.  In  the  early  part  of  the  treat- 
ment the  washing  should  be  done  daily ;  later,  every  second  or  third  day. 
The  time  selected  is  not  very  important,  but  it  is  better  to  make  this 
about  three  hours  after  feeding. 

With  some  children  stomach-washing  can  not  be  easily  employed,  and 
other  means  must  be  used  to  clear  the  stomach  of  mucus.  The  best  is 
undoubtedly  the  use  of  large  draughts  of  water,  as  hot  as  can  be  borne, 
an  hour  before  eating.  From  six  to  eight  ounces  should  be  taken,  pre- 
ferably slowly  by  sipping.  To  this  may  be  advantageously  added,  in 
many  cases,  fifteen  or  twenty  grains  of  bicarbonate  of  soda. 

The  diet  should  consist  of  diluted  skimmed  milk,  whey,  buttermilk, 
kumyss  or  zoolak,  beef  juice,  rare  meat,  and  a  moderate  amount  of 


DILATATION  OF  THE  STOMACH  341 

starchy  food,  preferably  dried  bread  or  zwieback.  All  fruits  should  be 
avoided.  All  pastry,  sweets,  nuts,  and  candies  should  be  absolutely  pro- 
hibited. With  improvement  in  the  symptoms  green  vegetables  may  be 
added  to  the  diet,  and  the  amount  of  starchy  food  increased.  The  amount 
of  water  taken  at  meal-time  should  be  carefully  restricted.  Beneficial  re- 
sults are  often  obtained  in  these  cases  by  the  use  of  nux  vomica  or  sim- 
ple bitters  before  meals,  and  the  regular  administration  of  hydrochloric 
acid  (gtt.  V  to  viij  of  the  dilute  acid)  shortly  after  meals.  The  general 
treatment  must  not  be  neglected.  The  patient  should  lead  an  out- 
door life  as  much  as  possible,  and  should  take  regular  but  very  moderate 
exercise.  Great  caution  is  necessary  against  overfatigue.  Iron  may  be 
given  in  most  cases  during  convalescence;  but  cod-liver  oil  should  be 
carefully  avoided  until  the  gastric  symptoms  have  quite  disappeared. 
Relapses  are  easily  excited,  and  the  most  constant  care  regarding  the 
food  must  be  maintained  for  months,  or  even  years. 


DILATATION  OF  THE  STOMACH 

Moderate  dilatation  of  the  stomach  is  quite  a  frequent  condition, 
although  it  is  not  so  large  a  factor  in  the  disorders  of  digestion  in 
infancy  and  childhood  as  many  who  have  written  upon  the  subject 
would  lead  us  to  believe.  A  very  marked  degree  of  dilatation  is  rare, 
but  in  these  cases  its  recognition  is  important  and  its  treatment  difficult. 

Dilatation  is  almost  invariably  regular  or  cylindrical;  it  is  usually 
most  marked  at  the  cardiac  extremity.  Cases  of  irregular  or  saccular 
dilatation,  except  when  associated  with  cicatricial  conditions,  are  of 
very  rare  occurrence. 

Dilatation  may  also  result  from  congenital  stenosis  of  the  pylorus. 
The  most  important  predisposing  cause,  however,  is  the  muscular  atony 
which  accompanies  rickets.  It  is  found  to  a  slight  degree  in  almost  all 
severe  cases  of  rickets.  The  principal  exciting  causes  are  continued 
distention  from  overfeeding  and  chronic  indigestion. 

In  most  cases  the  only  symptoms  are  those  of  the  chronic  indigestion 
which  almost  invariably  accompanies  dilatation.  The  vomiting  seen 
with  dilatation  is  peculiar  in  that  it  is  infrequent,  possibly  only  once  a 
day,  but  then  the  quantity  vomited  is  larger  than  the  last  meal  taken. 
In  young  infants  the  pressure  symptoms  resulting  from  acute  dilatation 
may  be  very  serious.  This  is  particularly  true  of  those  with  acute  bron- 
chitis or  bronchopneumonia,  or  atelectasis.  In  such  patients  we  have 
seen  very  grave  symptoms  accompany  the  rapid  distention  of  a  dilated 
stomach,  and  in  one  very  delicate  infant  of  three  months  this  was  appar- 
ently the  cause  of  death.     A  positive  diagnosis  of  dilatation  is  only 


342  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

made  by  the  physical  signs.  There  is  epigastric  fulness  and  distention, 
and  in  some  thin  patients  the  outline  of  the  stomach  can  be  distinctly 
seen.  Dilatation  of  the  transverse  colon,  however,  may  be  mistaken  for 
dilatation  of  the  stomach.  In  the  latter,  the  lower  outline  is  convex, 
while  in  the  former  it  is  usually  slightly  concave.  The  most  satisfactory 
means  of  diagnosis  is  by  percussion.  The  examination  should  be  made 
three  or  four  hours  after  feeding,  at  which  time  the  whole  abdomen  is 
apt  to  be  tympanitic.  The  stomach  should  then  be  filled  with  water; 
the  lower  limit  of  the  area  of  flatness  will  be  the  lower  border  of 
the  stomach.  This  is  much  more  satisfactory  than  determining  the  out- 
line after  the  generation  of  gas  in  the  stomach.  If  the  lower  border 
comes  below  the  umbilicus,  it  may  be  assumed  that  the  stomach  is 
dilated. 

In  moderate  dilatation  of  the  stomach  the  prognosis  is  good  unless 
due  to  pyloric  stenosis.  If  the  infant  has  any  acute  or  chronic  pulmo- 
nary disease,  dilatation  of  the  stomach  may  add  to  the  discomfort  and 
even  to  the  danger  from  that  condition.  The  distention  of  a  dilated 
stomach  occurring  in  the  course  of  any  acute  pulmonary  disease  should  be 
relieved  by  the  use  of  the  stomach  tube. 

In  the  management  of  these  cases  the  first  point  is  to  restrict  the 
use  of  fluids,  reduce  the  size  of  the  meals,  and  regulate  the  diet  in 
accordance  with  the  general  plan  outlined  in  the  chapter  on  Chronic 
Indigestion.  If  the  dilatation  is  marked,  the  stomach  should  be  washed 
once  a  day.  The  general  condition  of  the  patient  usually  requires  tonics. 
Eickets,  if  present,  should  receive  its  appropriate  constitutional  treat- 
ment. 

ULCER  OF  THE  STOMACH 

Ulceration  of  the  stomach  may  be  found  in  connection  with  several 
pathological  processes  which  are  quite  distinct  from  one  another : 

1.  Ulcers  in  the  Newly  Born. — These  have  already  been  referred  to  in 
the  chapters  on  Hemorrhages  of  the  Newly  Born.  The  only  character- 
istic symptom  is  hemorrhage. 

2.  Ulcers  Resulting  from  Acute  Gasttitis. — These  also  are  not  fre- 
quent. As  a  rule  they  give  no  symptoms  except  those  of  gastritis, 
although  in  several  cases  we  have  known  severe  hemorrhage  to  result 
from  them.     This  symptom  will  be  considered  later. 

3.  Tuberculous  Ulcers. — These  are  quite  rare.  We  met  with  gastric 
ulcers  five  times  in  one  hundred  and  nineteen  autopsies  on  tubercu- 
lous cases;  however,  the  evidence  was  not  conclusive  in  all  of  them 
that  the  ulcers  were  tuberculous;  but  in  three  the  tubercle  bacilli  were 
found.     Usually  there  were  several  small  ulcers;  in  one  case  but  two 


DUODENAL  ULCER  343 

were  present,  the  larger  one  being  nearly  three-fourths  of  an  inch  in 
diameter,  and  situated  on  the  posterior  wall  near  the  middle  of  the 
greater  curvature.  All  but  one  of  these  cases  were  in  infants,  one  child 
being  only  ten  months  old.  The  ulcers  gave  no  symptoms  during  life, 
and  death  took  place  from  general  tuberculosis.  This  is  the  history  of 
nearly  all  the  few  cases  on  record.  In  one,  however,  reported  by  Casin, 
a  tuberculous  ulcer  perforated  the  stomach  and  caused  death  from  peri- 
tonitis. 

4.  Simple  Perforating  Ulcers. — In  young  children  these  are  of  great 
rarity  and  uncertain  pathology.  Eotch  has  reported  a  case  in  an  infant 
but  seven  weeks  old,  and  Cade  one  in  an  infant  of  two  months. 

The  symptoms  of  ulcer  before  perforation  are  gastric  pain  and  ten- 
derness, vomiting  of  blood,  and  often  bloody  stools.  In  most  of  these 
cases  in  children  there  were  no  symptoms  until  perforation;  then  fol- 
lowed collapse,  sometimes  high  temperature,  the  rapid  development  of 
tympanites,  and  death  from  shock  or  from  peritonitis. 

The  prognosis  is  bad  in  all  forms  of  ulcer  of  the  stomach,  except  the 
small  follicular  variety.  In  this,  however,  the  diagnosis  can  not  posi- 
tively be  made  except  by  gastric  hemorrhage,  and  it  is  only  this  which 
makes  these  cases  serious. 

Treatment. — The  treatment  is  absolute  rest,  ice  by  mouth,  small  doses 
of  opium,  and  rectal  feeding;  later,  bismuth,  arsenic,  or  nitrate  of  silver. 
If  symptoms  of  perforation  occur  the  abdomen  should  be  opened  without 
delay,  as  offering  the  only  chance  of  recovery. 


DUODENAL  ULCER 

Until  recently  these  ulcers  have  been  considered  very  rare  in  infancy 
and  early  childhood,  but  the  increasing  number  of  cases  reported,  espe- 
cially since  1908,  indicates  that  it  has  formerly  been  overlooked.  From 
a  study  of  ninety-five  cases  in  infants  under  one  year  collected  from  the 
literature  by  one  of  us  in  1913,  the  conclusions  which  follow  have  been 
drawn. 

Duodenal  ulcers  are  much  more  common  than  gastric  ulcers ;  accord- 
ing to  Entz  they  outnumber  them  ten  to  one.  Not  a  single  instance  of 
peptic  ulcer  of  the  stomach  in  infancy  has  been  observed  at  the  Babies' 
Hospital  in  twenty-seven  years.  In  but  one  case  were  duodenal  and 
gastric  ulcers  found  in  the  same  patient,  even  inchuling  cases  occurring 
in  the  newly  born.  Seventy  per  cent  of  the  reported  cases  have  been  ol)- 
served  between  the  ages  of  six  weeks  and  five  months ;  about  ten  per  cent 
occur  in  the  newly  born.  The  great  majority  of  the  cases  have  been  seen 
in  infants  of  the  marasmus   (atrophic)   type.     In  most  of  thoin  there 


344  DISEASES  OF  THE  DTOESTIVE  SYSTEM 

has  been  also  a  history  of  previous  digestive  disorders.     In  several  cases 
duodenal  ulcers  have  been  associated  with  spasm  of  the  pylorus. 

The  most  frequent  site  of  the  ulcer  is  on  the  posterior  wall  of  the  duo- 
denum and  practically  all  are  above  the  papilla.  When  but  a  single  ulcer 
is  present,  as  is  true  of  about  two-thirds  of  the  cases,  it  is  nearly  always 
situated  just  below  the  pyloric  ring.  These  ulcers  are  circular  in  shape; 
they  have  shelving,  sharply  defined  edges,  usually  described  as  "punched- 
out"'  in  appearance.  At  the  base,  blood  vessels  of  considerable  size  are 
often  seen.  They  may  involve  the  mucous  membrane  only,  in  which  case 
they  may  readily  be  overlooked,  or  they  may  go  to  the  muscular  coat,  to 
the  peritoneum  or  they  may  even  perforate.  Microscopical  examination 
shows  almost  complete  absence  of  round-cell  infiltration  and  other 
evidence  of  inflammatory  reaction.  The  rest  of  the  duodenum  usually 
shows  a  normal  mucous  membrane  or  one  simply  blood  stained.  Large 
clots  or  fresh  blood  may  be  found  in  the  duodenum  or  in  any  part  of  the 
small  or  large  intestine.  The  stomach  also  may  contain  old  or  fresh  blood. 
.  The  generally  accepted  view  of  the  pathogenesis  of  duodenal  ulcers 
is  that  they  are  due  to  thrombosis  followed  by  self-digestion  of  the  mucous 
memlirane  over  a  circumscribed  area.  The  situation  of  the  ulcers,  above 
the  papilla,  indicates  that  the  lesion  is  due  to  the  action  of  the  gastric 
Juice.  Below  the  opening  of  the  common  duct  the  bile  and  pancreatic 
juice  apparently  protect  the  mucous  membrane. 

Symptoms. — In  over  one-third  of  the  recorded  cases  no  symptoms 
suggestive  of  the  condition  were  present,  the  ulcer  being  found  at  au- 
topsy in  patients  dying  from  other  causes.  In  other  cases  death  occurs 
suddenly  in  collapse,  sometimes  preceded  by  symptoms  of  an  ordinary 
gastro-intestinal  disturbance  and  sometimes  by  none  at  all.  In  such  cases 
the  autopsy  frequently  discloses  severe  concealed  hemorrhage  or  perfora- 
tion. If  life  is  prolonged  peritonitis  may  follow,  but  its  recognition 
under  these  circumstances  is  exceedingly  difficult  since  vomiting,  fever 
and  distention  may  all  be  wanting.  Localized  pain  or  tenderness  in 
patients  of  this  age  is  of  no  assistance  to  the  diagnosis,  tliough  valna])le 
symptoms  in  older  children.  The  only  definite  symptom  pointing  to  duo- 
denal ulcer  is  hemorrhage.  Blood  may  be  vomited  or  passed  in  the  stools. 
In  sixty-four  cases  of  ulcer  reported  with  good  histories,  bloody  stools  were 
observed  in  twenty-eight,  bloody  vomiting  in  ten  and  both  in  six  cases, 
four  of  these  being  in  the  newly  born.  Clear  blood  may  be  seen  or  blood 
changed  by  the  action  of  the  stomach  or  intestine.  Once  it  occurs. 
hemorrhage  is  apt  to  continue  until  the  death  of  the  patient,  usually  in 
twenty-four  to  thirty-six  hours.  The  appearance  of  blood  in  any  consifl- 
erable  amount  in  the  stools  of  a  young  infant  should  always  suggest  duo- 
denal ulcer.    Jaundice  was  a  .symptom  in  biit  one  case  in  the  series. 

The  diagnosis  is  made  mainly  by  the  presence  of  hemorrhage  from  the 


HEMORRHAGE  FROM  THE  STOMACH  345 

aiomach  or  intestine,  usually  associated  with  collapse.  Perforative  peri- 
tonitis may  be  due  to  appendicitis  as  well  as  ulcer  and  both  intestinal 
hemorrhage  and  collapse  may  occur  with  intussusception.  These  should 
be  borne  in  mind  as  two  conditions  which  may  be  confounded  with  duo- 
denal ulcer.  Polypus  and  colitis  must  also  be  excluded.  The  prognosis 
oi  duodenal  ulcer  at  present  is  very  bad.  The  finding  of  healed  ulcers 
at  autopsy  proves  that  recovery  does  sometimes  take  place,  but  it  must  be 
considered  rare. 

The  treatment  is  purely  symptomatic ;  on  account  of  the  present  unr 
certainty  of  diagnosis,  surgical  measures  are  rarely  justifiable. 

TUMORS  OF  THE  STOMACH 

Although  exceedingly  rare,  tumors  of  tlie  stomach  occur  in  child- 
liood,  and  are  seen  even  in  infancy.  A  case  of  sarcoma  of  the  stomach  in 
a  child  of  three  and  a  half  years  has  been  reported  by  Finlayson.  It  was 
apparently  primary.  The  microscopical  examination  showed  it  to  be  of 
the  spindle-celled  variety.  This  writer  could  find  no  other  recorded 
case  under  the  age  of  fifteen. 

Lymphadenoma  of  the  stomach  in  a  rachitic  infant  of  eighteen 
months  has  been  recorded  by  Eolleston  and  Lathan.  There  were  mul- 
tiple tumors  arising  from  the  mucous  membrane  in  the  pyloric  region. 
The  case  in  many  features  resembled  leukemia. 

8ix  cases  of  cancer  of  the  stomach  in  children  under  ten  years  are 
collected  in  an  article  by  Osier  and  McCrae.  Four  of  these  were  in 
young  infants  and  probably  congenital.  One  case,  in  a  child  of  eight, 
presented  the  usual  symptoms  and  lesions  of  the  adult  disease. 


HEMORRHAGE   FROM   THE   STOMACH   {Hematemesis)' 

The  most  frequent  variety  of  hemorrhage  from  the  stomach,  that 
is  seen  in  the  newly  born,  has  already,  been  considered. 

Serious  and  even  fatal  cases  of  gastric  hemorrhage  though  extremely 
rare  may  be  seen  in  older  infants.  The  source  of  the  bleeding  may  be 
small  capillary  hemorrhages  from  the  mucous  membrane,  it  may  be 
from  single  or  multiple  ulcers  of  the  stomach  or  more  frequently  from 
duodenal  ulcers. 

Hemorrhages  from  the  stomach  may  occur  in  purpura,  hemophilia, 
scurvy,  and  rarely  in  malaria.  In  young  girls  about  puberty  it  may  be  a 
form  of  vicarious  menstruation.  Occasionally  blood  may  be  vomited  in 
cases  of  hemorrhagic  measles.  Two  cases  are  reported  in  which  fatal 
hemorrhage  followed  the  swallowing  of  a  foreign  body.    In  both,  vomit- 


346  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ing  of  blood  occurred  long  after  the  original  accident.  In  one  case  two 
and  a  half  years  had  elapsed.  The  autopsy  in  this  case  showed  impac- 
tion of  the  foreign  body  and  ulceration  into  the  arch  of  the  aorta.  Spu- 
rious hemorrhages  may  occur  when  blood  has  been  swallowed  and  then 
vomited.  The  source  of  this  is  most  frequently  the  nose  or  pharynx. 
It  may  happen  in  infants  at  the  breast,  when  the  blood  is  drawn  from 
a  fissure  or  ulcer  in  the  nipple.  The  amount  of  blood  vomited  under 
these  circumstances  may  be  large  enough  to  be  quite  alarming.  It  may 
be  recognized  by  the  child's  general  condition  being  normal,  and  by  the 
presence  of  fissures  or  ulcers  upon  the  nipple.  It  may  sometimes  be 
noticed  tliat  the  vomiting  of  blood  follows  nursing  from  one  breast  and 
not  from  the  other. 

Symptoms. — There  may  he  no  symptoms  except  those  of  internal 
hemorrhage,  but  this  is  rare.  Usually  there  is  vomiting  of  blood,  and 
blood  appears  in  the  stools.  If  the  hemorrhage  is  rapid  and  vomiting 
speedily  occurs,  the  blood  may  be  of  a  bright-red  color.  If  it  has  been 
long  in  the  stomach  it  is  of  a  dark-brown  or  black  color  resembling 
coffee-grounds.  The  stools  containing  blood  from  the  stomach  are 
black  and  tarry  in  appearance.  The  general  symptoms  will  depend  upon 
the  amount  of  blood  lost. 

In  a  case  where  blood  is  vomited,  the  first  point  is  to  distinguish  spu- 
rious from  true  gastric  hemorrhage.  The  nose  and  pharynx,  especially 
its  posterior  wall,  should  be  carefully  examined.  If  the  child  is  at  the 
breast,  the  nipples  should  be  examined.  In  older  children  it  is  important 
to  distinguish  vomiting  of  blood  from  hemoptysis.  This  distinction  is 
to  be  made  in  accordance  with  the  rules  laid  down  in  text-books  on  gen- 
eral medicine.  The  prognosis  is  bad  if  the  hemorrhage  is  due  to  ulcer, 
if  it  is  very  profuse,  or  if  it  occurs  in  young  infants.  When  it  occurs  in 
connection  with  constitutional  diseases  the  prognosis  depends  upon  the 
original   disease. 

Treatment. — Altogether  the  most  efficient  remedy  is  the  suprarenal 
extract.  It  may  be  given  very  freely,  at  least  two  grains  every  half  hour 
to  a  child  of  one  year.  The  patient  should  be  kept  quiet,  preferably  upon 
the  back;  if  there  are  signs  of  collapse,  stimulants  may  be  given  hypo- 
dermically  or  by  the  rectum.  No  food  or  water  should  be  given  by  the 
stomach  for  at  least  twenty-four  hours  after  the  hemorrhage  has  ceased. 


THE  SWALLOWING  OF  FOREIGN  BODIES 

Between  the  ages  of  one  and  four  years  the  habit  of  swallowing  for- 
eign substances  is  a  very  common  one.  The  variety  of  objects  swallowed 
includes  all  those  articles  which  the  young  child  can  reach  and  put  into 


THE  SWALLOWING  OF  FOREIGN  BODIES  347 

his  month.  The  most  common  are  detached  parts  of  toys,  marbles,  peb- 
bles, buttons,  and  coins.  Not  only  are  such  smooth  articles  swallowed, 
but  also  with  equal  readiness,  sharp  ones,  such  as  pins  of  every  variety, 
bits  of  glass,  fragments  of  bone,  nails,  and  small  toy  knives  and  forks, 
etc.  At  the  time  of  swallowing,  choking  attacks,  severe  pharyngeal  pain, 
and  sometimes  slight  hemorrhage  may  occur.  Symptoms  referable  to 
the  esophagus  are  very  few.  Nor  in  the  stomach  are  symptoms  often 
excited.  While  passing  through  the  intestine  there  may  be  colicky  pains, 
but  in  the  majority  of  instances  there  are  no  symptoms  whatever  even 
with  sharp  or  angular  bodies.  Impaction  and  perforation,  while  pos- 
sible, are  surprisingly  rare.  The  usual  time  required  for  a  foreign  body 
to  traverse  the  intestinal  tract  is  from  four  to  ten  days,  but  it  may  be  con- 
siderably longer.  If  the  body  swallowed  is  a  smooth  one,  it  passes  the 
sphincter  ani  without  difficulty.  But  with  sharp  bodies  there  may  be 
severe  pain  and  sometimes  hemorrhage. 

The  diagnosis  is  often  a  matter  of  much  difficulty,  and  without  ^  an 
X-ray  examination  a  positive  diagnosis  is  impossible.  Very  often  when 
the  physician  is  called  because  this  condition  is  suspected  by  parents  the 
alarm  turns  out  to  be  a  false  one. 

It  is  most  surprising  to  see  the  size,  variety,  and  dangerous  character 
of  the  foreign  bodies  which  pass  through  the  intestinal  tract  without 
causing  any  symptoms  whatever.  The  expectant  treatment  is  therefore 
by  all  means  to  be  recommended.  No  emetics  or  cathartics  should  be 
administered.  The  diet  should  be  abundant  and  composed  of  articles  of 
food  which  leave  much  residue,  e.  g.,  coarse  cereals,  bread,  and  vegetables. 
Most  of  all,  operation  should  not  be  performed  or  even  considered  unless 
there  are  definite  local  symptoms. 

Quite  distinct  from  such  accidental  swallowing  of  foreign  substances 
as  has  just  been  described,  is  the  practice  of  pulling  off  and  swallowing 
fur  from  rugs,  m^ooI  from  toys  or  blankets,  shreds  from  clothing,  and  a 
great  variety  of  other  substances.  This  habit  is  usually  seen  in  nervous 
children,  and  often  in  those  where  some  gastric  irritation  seems  to  excite 
an  abnormal  craving.  In  infants  the  quantity  of  the  substance  is  gen- 
erally small  and  usually  it  provokes  vomiting  or  the  material  is  speedily 
passed  by  the  bowel.  In  the  Babies'  Hospital  a  colored  child  of  about 
eighteen  months  passed  in  one  day  a  large  mass  of  hair  which  she  had 
pulled  from  her  own  head.  Another  child  in  the  same  ward  pulled  into 
shreds  and  swallowed  a  large  portion  of  the  foot  of  a  cotton  stocking,  and 
passed  the  same  by  the  bowel  the  following  day.  Such  occurrences  are 
not  very  common. 

It  occasionally  happens  that  the  substance  swallowed  does  not  pass 
the  bowel  but  forms  an  intestinal  tumor  which  may  give  rise  to  obscure 
and  sometimes  to  severe  symptoms  of  long  duration.    But  more  often  the 


348  •    DISEASES  OF  THE  DIGESTIVE  SYSTEM 

tumor  forms  in  the  stomach.  These  gastric  tumors  are  usually  composed 
of  hair  from  the  patient's  own  head.  They  are  more  frequently  seen  in 
older  children  than  in  infants,  and  usually  in  girls  on  account  of  the  long 
hair.  Many  of  these  patients  are  of  the  nervous  type.  The  habit  may 
continue  until  a  tumor  of  considerable  size  may  form,  sometimes  attain- 
ing two  or  three  pounds  in  weight. 

The  symptoms  of  hair  hall  in  the  stomach  are  vague  until  the  tumor 
is  discovered.  There  are  usually  gastric  disturbances  of  a  rather  in- 
definite character.  Epigastric  pain  is  common,  but  vomiting  is  not 
especially  marked.  The  general  health  may  suffer  but  little  for  a  long 
time.  The  tumor  may  be  mistaken  for  cancer,  a  displaced  spleen  or 
kidney,  fecal  impaction,  or  a  tumor  of  the  omentum.  A  correct  diagnosis 
is  seldom  made  until  operation  is  done.  In  a  few  instances  the  tumor 
has  disappeared  after  catharsis.  If  operation  is  done  the  outcome  is 
almost  always  favorable. 


CHAPTER   VI 
DISEASES    OF    THE   INTESTINES 
MALFORMATIONS  AND  MALPOSITIONS 

Malfoematioxs  are  not  very  frequent,  but  are  of  great  variety. 
With  the  exception  of  those  situated  at  the  lower  end  of  the  intestine 
they  are  not  of  much  practical  importance,  for  the  condition  is  such 
ordinarily  as  to  be  incompatible  with  life.  Malformations  may  be  met 
with  at  any  point  in  the  canal,  but  most  frequently  in  the  rectum  and 
anus.  Aside  from  these,  malformations  of  the  large  intestine  are  much 
less  common  than  those  of  the  small  intestine. 

Malformations  of  the  Rectum. — In  Fig.  32  are  shown  the  usual  vari- 
eties of  malformation  of  the  rectum.  The  most  frequent  is  atresia  of 
the  anus  (1).  In  this  the  cutaneous  septum  has  not  been  absorbed,  but 
the  intestine  is  normal  to  its  lower  extremity.  This  form  is  readily 
curable  by  a  surgical  operation.  In  the  next  variety  (2)  the  cutaneous 
orifice  and  the  lower  part  of  the  rectum  are  normal,  but  a  membrane 
separates  this  portion  from  the  upper  part  of  the  gut;  this  is  usually 
situated  within  two  or  three  inches  of  the  anus.  The  bulging  of  the  lower 
part  of  the  distended  intestine  can  usually  be  felt  by  the  finger  in  the 
rectum,  and  a  simple  division  of  the  membrane  by  a  guarded  bistoury 
may  relieve  the  condition.  The  third  form  (3)  is  more  serious.  Here 
the  rectum  terminates  in  a  blind  pouch  at  a  variable  distance  from  the 
anus,  and  is  represented  below  by  an  impervious  fibrous  cord.     The 


MALFORMATIONS  AND  MALPOSITIONS 


349 


R 


Fig.  32. — Malformations    of    the     Rectum. 
A,  anus;  R,  rectum. 


(Iia;j,ii()sis  of  this  condition  can  not  positively  be  made  without  opening- 
the  abdominal  cavity.  The  bulging  of  the  intestine  appreciable  by  the 
finger  in  the  rectum,  is  the  only  point  which  differentiates  the  preceding 
variety  from  this  one.  Instead  of  atresia  of  the  rectum  there  may  be 
stenosis  of  varying  degrees,  which  may  give  rise  to  the  usual  symptoms 
of  stricture.     This  is  often  curable  by  dilatation. 

Malformations  of  the  Small  Intestine. — There  may  be  stenosis  or 
atresia  at  any  point,  often  at  many  points.  Obstruction  is  much  more 
frequent  in  the  upper  than 
in  the  lower  part  of  the 
small  intestine,  the  most 
common  seat  being  the  duo- 
denum. Atresia  is  more 
often  seen  than  stenosis. 
There  may  be  a  single  point 
of  obstruction,  or  the  lumen 
of  the  intestine  may  be  ob- 
literated for  a  considerable 
distance,  the  intestine  being 
represented  only  by  a  fibrous 

cord  which  connects  the  two  open  portions,  or  there  may  be  no  con- 
nection between  them.  In  all  cases  the  intestine  above  is  found  very 
greatly  distended,  while  that  below  is  empty  and  usually  atrophied.  The 
causes  of  these  multiple  deformities  are  mainly  two — fetal  peritonitis 
and  volvulus.  In  fetal  peritonitis  there  are  usually  found  bands  of 
adhesions  between  the  intestinal  coils,  and  between  the  intestine  and 
the  solid  viscera.  Syphilis  has  been  assigned  as  a  cause  in  many  cases. 
Volvulus,  or  a  twisting  of  the  intestine  during  its  development,  is  a 
more  satisfactory  explanation  of  the  majority  of  the  cases,  especially 
when  there  are  multiple  points  of  atresia.  All  these  conditions  are 
beyond  the  reach  of  surgical  treatment.  The  symptoms  appear  soon 
after  birth  and  are  those  of  intestinal  obstruction.  The  higher  the  point 
of  obstruction  the  shorter  the  duration  of  life;  it  is  rarely  more  than  a 
week  in  any  case  of  atresia;  in  stenosis  it  may  be  two  or  three  months. 

Meckel's  Diverticulum. — This  is  the  remains  of  the  omphalomesen- 
teric duct,  which  in  fetal  life  forms  a  communication  between  the  intes- 
tine and  the  umbilical  vesicle.  It  is  given  off  from  the  ileum,  usually 
about  a  foot  above  the  ileo-cecal  valve.  Most  frequently  it  exists  as  a 
blind  pouch  from  one-half  to  two  or  three  inches  long,  communicating 
with  the  intestine.  At  the  extremity  of  this  there  may  be  a  fibrous  cord, 
which  is  free  in  the  abdominal  cavity  or  attached  to  the  umbilicus.  In 
other  cases  the  duct  may  remain  pervious  quite  to  the  umbilicus,  so  that 
there  is  a  fecal  fistula.  Prolapse  of  the  mucous  membrane  of  the  duct 
13 


350  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

may  lead  to  an  umbilical  tumor,  described  elsewhere.  Meckel's  diver- 
ticulum, especially  when  present  as  a  cord  connecting  the  ileum  with  the 
umbilicus,  may  compress  a  coil  of  intestine,  leading  to  obstruction  or 
even  strangulation.     This  may  occur  in  infancy  or  later  in  life. 

Malpositions. — The  ascending  colon  may  be  found  upon  the  left  side. 
There  may  be  a  complete  transposition  of  the  abdominal  viscera.  In 
cases  of  congenital  umbilical  hernia  a  large  part  of  the  intestines  may  be 
found  in  the  tumor,  and  in  diaphragmatic  hernia  they  may  be  in  the 
thoracic  cavity. 

DIARRHEA 

The  term  diarrhea  is  used  to  include  all  conditions  attended  by  fre- 
quent loose  evacuations  of  the  bowels.  These  depend  upon  an  increase 
in  peristalsis  and  in  the  intestinal  secretions. 

The  importance  of  diarrheal  diseases  in  children  can  best  be  appre- 
ciated by  reference  to  the  following  table,  showing  the  mortality  of  diar- 
rheal disease  in  children  under  two  years,  as  compared  with  that  from, 
certain  infectious  diseases  for  all  ages. 

Deaths  in  New  York  City  for   Five  Years 

Measles,  all  ages 3,378 

Scarlet  fever,  all  ages 4,152 

Pertussis,  aU  ages 2,000 

Typhoid,  all  ages 3,523 

Diphtheria,  aU  ages 10,277  • 

Total  deaths  from  five  diseases 23,330 

Diarrheal  disease  under  two  years 26,563  . 

There  are  several  important  underlying  factors  upon  which  diarrheal 
diseases  depend.  Their  greatest  frequency  belongs  to  the  first  year  of 
life;  and  after  the  second  year  a  notable  diminution  both  in  frequency 
and  severity  is  seen,  and  a  fatal  outcome  is  relatively  rare.  The  extreme 
susceptibility  in  infancy  is  due  to  several  causes.  The  digestive  organs 
are  severely  taxed  to  provide  for  the  needs  of  the  growing  body.  The 
mucous  membrane  of  the  gastro-enteric  tract  of  all  infants  is  very  deli- 
cate in  structure,  and  even  in  those  with  good  health  is  exceedingly 
vulnerable.  This  vulnerability  is  enormously  increased  in  the  very 
young,  and  in  those  who  are  feeble,  delicate,  or  suffering  from  any  form 
of  digestive  disorder.  The  mucous  membrane  of  the  digestive  tract  is 
furthermore  constantly  exposed  to  injury,  either  mechanical  or  chemical, 
and  to  infection. 

Everything  which  lowers  the  general  vitality  increases  the  liability  to 
diarrheal  diseases.  Chronic  disorders  of  digestion,  marasmus,  malnutri- 
tion, and  rickets  are  especially  important  factors. 


DIARRHEA 


351 


The  most  striking  fact  about  diarrheal  diseases  is  their  prevalence 
during  the  summer  season.  This  is  graphically  shown  in  Fig.  33,  where 
are  given  by  months  the  mortality  records  from  this  cause  for  New  York 
City  for  ten  years. 


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Fig.  33. — Mortality  from  Diarrheal  Diseases  in  New  York  for  Ten  Years  in 
Children  Under  Five;  Compared  with  the  Mean  Temperature  for  the  Same 
Period.     .mortality; ,  mean  temperature.     (Seibert.) 


While  diarrheal  diseases  are  met  with  in  all  seasons  they  regularly 
increase  with  the  advent  of  hot  weather.  In  this  country  the  higher 
summer  temperature  of  the  inland  cities,  Philadelphia  and  Chicago,  is 
associated  with  a  higher  mortality  from  diarrheal  diseases  than  is  seen  in 
Boston  and  New  York  with  a  lower  range  of  temperature.  Thus  in 
Philadelphia  and  Chicago  32  per  cent  of  the  deaths  under  one  year  have 
been  due  to  diarrheal  diseases;  while  in  New  York  but  27  per  cent,  in 
Boston  but  19  per  cent,  and  in  London  but  13  per  cent  have  been  from 
this  cause.  The  large  cities  of  northern  Europe — London,  Paris  and 
Berlin — witness  nothing  like  the  mortality  from  diarrheal  diseases  seen 
in  the  large  cities  of  the  United  States. 

How  atmospheric  heat  acts  in  causing  diarrheal  diseases  is  not  yet 
entirely  settled.  It  was  long  \\ie  prevailing  opinion  that  it  was  the  effect 
of  heat  upon  the  infant's  food,  especially  the  bacterial  contamination  of 
cow's  milk,  that  was  the  chief  cause  of  diarrhea  in  summer.  Without 
doubt  thoroughness  pf  milk  inspection  and  the  general  use  of  sterilized 
milk  in  summer  have  materially  reduced  the  mortality  from  this  cause. 
But  notwithstanding  all  the  attention  given  to  food  there  remains  an 
enormous  summer  mortality  from  diarrhea.  From  the  most  recent  study 
of  this  question  the  conclusion  seems  irresistible  that  heat  itself  has  a 
direct,  injurious  effect  upon  the  infant,  and  that  it  is  not  so  much  the 
outdoor  temperature  which  counts  as  the  stagnant  heat  of  apartments  in 
which  the  infant  lives  night  and  day.  The  effects  of  heat  are  intensified 
by  want  of  ventilation  and  all  unhygienic  surroundings.     Heat  under 


352  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

these  conditions  acts  as  a  powerful  depressant  of  the  vital  forces,  dis- 
turbing metabolism,  causing  indigestion  and  diarrhea. 

Diarrheal  diseases  are  especially  seen  in  cities,  for  there  are  combined 
the  conditions  of  povertyL^.aeglgct,  bad  food  and  bad  hjgiejie,  sA\  of  which 
are  important  causes.  That  overcrowding  and  bad  housing  in  our  large 
cities  are  not  the  chief  factors  is  shown  by  the  fact  that  the  death  rate 
from  diarrheal  diseases  is  often  higher  in  smaller  places,  especially 
factory  towns,  than  large  cities.  Thus  in  New  York  State  it  has  been 
higher  in  Troy,  Cohoes  and  Newburgh  than  in  New  York  City;  and  in 
Massachusetts,  higher  in  Fall  Eiver  and  Lowell  than  in  Boston. 

L  Artificial  feeding  is  an  etiological  factor  of  the  first  importance.  Less 
than  5  per  cent  of  the  severe  cases  of  diarrhea  are  among  the  breast-fed, 
and  fatal  cases  among  the  exclusively  breast-fed  are  really  rare,  no  matter 
how  bad  the  surroundings  or  how  ignorant  the  mothers.  Breast-feeding 
requires  but  little  experience,  and  may  be  very  successfully  done  even  by 
those  Avith  a  very  low  grade  of  intelligence  and  among  the  poor ;  but 
artificial  feeding  is  not  successful  unless  done  with  much  intelligence 
and  experience  and  also  with  good  milk. 

It  is  in  factory  towns,  where  the  mothers  work  away  from  their  homes 
and  as  a  consequence  breast-feeding  is  either  not  practiced  at  all  or  only 
for  a  short  time,  and  where  artificial  feeding  is  usually  badly  done,  that 
we  see  the  highest  mortality  from  diarrheal  diseases.  These  conditions 
do  not  depend  upon  the  size  of  the  town  and  compared  with  them 
housing  is  of  secondary  importance.  .   ••*.'. 

f2,  •  Next  to  the  kind  of  feeding  as  a  cause  of  diarrhea  must  "be  placed 
gross  or  involuntary  neglect  or  want  of  proper  care.  Ignorance  and 
stupidity  are  large  elements  in  the  failure  of  artificial  feeding  among 
the  poor.  The  simplest  rules  of  hygiene  are  either  unknown  or  ignored. 
The  importance  of  cleanliness,  fresh  air,  regularity  and  quiet  is  not 
appreciated.  Under  such  conditions  an  infant,  though  often  strong  and 
healthy  at  birth,  soon  falls  into  a  condition  of  malnutrition  or  marasmus 
with  such  feeble  resistance  that  he  readily  succumbs  to  the  depressing 
influences  of  the  first  hot  weather,  thejntestinal  tract  being  the  most 
:vulneEable_point. 

3 '  But  all  the  other  factors  mentioned — ^artificial  feeding,  overcrowding, 
bad  hygienic  surroundings  and  neglect — exist  the  year  round,  yet  diar- 
rheal diseases  are  prevalent  only  in  summer.  We  must  therefore  consider 
the  direct  or  indirect  effects  of  atmospheric  heat  as  the  primary  exciting 
cause  of  paramount  importance,  the  other  conditions  acting  as  secondary 
or  predisposing  causes. 

n^  The  role  of  impure  milk  is  so  important  as  to  demand  further  dis- 
cussion ;  that  it  can  cause  diarrhea  in  infants  is  a  fact  that  is  established 
beyond  question.    We  have  seen  every  one  of  twenty-three  healthy  ehil- 


DIARRHEA 


3:13 


clren,  all  over  two  years  old,  occupying  one  dormitory  cottage,  attacked 
in  a  single  day  with  diarrhea,  which  was  traced  to  this  cause. 

When  the  enormous  bacterial  contamination  of  milk  began  to  be 
appreciated,  it  was  thought  that  in  this  was  to  be  found  the  real  cause 
of  the  prevalence  and  fatality  of  diarrheal  diseases  in  summer.  This" 
belief  carried  with  it  the  expectation  that  by  furnishing  to  every  arti- 
ficially-fed infant  a  clean,  fresh  milk,  or  milk  which  had  been  pasteurized 
or  sterilized,  this  great  cause  of  infant  mortality  could  largely  be 
removed.     It  is  true  that  a  great  reduction  in  infant  mortality  from 


1891  92  93  94   95  96   97  98  99  1900  01   02  03   04  05   06  07  08   09   10 


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Fig.  34. — Deaths  Under  One  Year  per  1,000  of  Population  Under  One  Year, 
New  York  City.  A  comparison  of  summer  deaths  from  all  causes  with  summer 
deaths  from  diarrheal  diseases  for  a  period  of  twenty  years. 


summer  diarrheal  diseases  has  been  effected  during  the  last  two  decades ; 
but  it  is  also  true  that  there  has  been  quite  as  great  a  reduction  in 
infant  mortality  in  other  seasons,  and,  in  summer,  from  other  causes 
than  diarrheal  diseases.  (Fig.  34.)  This  leads  us  to  question  whether 
the  bacterial  contamination  of  milk  is  the  great  cause  of  diarrheal 
diseases,  and  whether  the  lowered  mortality  in  summer  has  not  been 
brought  about  quite  as  much  by  other  conditions,  such  as  better  hygiene 
and  care  and  a  better  understanding  of  infant-feeding,  as  by  the  ex- 
clusion of  germs  from  milk  or  their  destruction  by  heat. 

In  the  years  1901  to  1903  an  investigation  ^  was  undertaken  by  The 


^  The  full  report  was  published  bj-  Park  and  Holt  in  the  Medical  News,  De- 
cember 5,  1903. 


354  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Rockefeller  Institute  and  the  Health  Department  of  New  York  to  secure 
data  regarding  the  following  points :  ( 1 )  The  results  in  infant-feeding 
obtained  with  milk  of  different  degrees  of  purity  both  in  winter  and  in 
summer,  as  shown  by  the  gain  or  loss  in  weight,  the  amount  of  gastro- 
intestinal disturbance,  and  the  death  rate;  (2)  the  relation,  if  any, 
existing  between  the  number  of  bacteria  present  in  the  milk  and  the 
frequency  of  diarrheal  disease;  (3)  whether  any  organisms  with  patho- 
genic properties  could  be  found  in  milk  to  which  diarrheal  disease  could 
be  ascribed  as  a  cause;  (4)  whether  the  practice  of  heating  milk — pas- 
teurization or  sterilization — affected  the  results  obtained  with  any  given 
milk;  (5)  to  what  degree  older  children  as  well  as  infants  were  affected 
by  bacterial  contamination  of  milk. 

Observations  were  made  upon  592  bottle-fed  infants  living  in  tene- 
ments of  New  York;  202  were  observed  in  winter  and  390  in  summer. 
The  infants  were  well  when  the  observations  were  begun,  and  were 
watched  for  a  period  of  about  three  months,  being  visited  regularly  by 
physicians.  Samples  of  milk  as  fed  were  frequently  examined  as  to  the 
number  and  character  of  the  bacteria  present.  Observations  were  pos- 
sible upon  infants  taking  (1)  condensed  milk,  (2)  the  cheapest  grade  of 
store  milk,  (3)  a  better  grade  of  milk  delivered  in  bottles,  (4)  the  best 
bottled  milk  sold  in  the  city,  all  of  tlie  above  being  prepared  at  home, 
(5)  milk  modified  at  milk  stations  and  dispensed  in  separate  feeding- 
bottles. 

During  the  winter,  the  mortality  was  but  2.5  per  cent,  and  in  but 
one  ease  was  death  due  to  disease  of  the  digestive  tract.  The  health  of  the 
infants  observed  was  not  appreciably  affected  by  the  kind  of  milk  nor 
by  the  number  of  bacteria  which  it  contained.  The  different  grades  of 
milk  varied  much  less  in  bacterial  contamination  in  winter  than  in 
summer,  the  cheap  store  milk  averaging  only  about  750,000  per  c.c. 

During  the  summer,  the  mortality  was  10.5  per  cent,  four-fifths  of  the 
deaths  being  due  to  diarrheal  disease.  The  worst  results  were  seen  in 
those  whose  food  was  either  the  cheap  grade  of  store  milk  or  condensed 
milk,  and  in  those  who  received  the  poorest  care. 

The  number  of  bacteria  which  milk  may  contain  before  it  becomes 
noticeably  harmful  to  the  average  infant  in  summer  is  not  at  all  uniform. 
Of  the  usual  varieties  present,  no  strikingly  deleterious  results  were  seen 
until  the  number  approached  the  one  million  mark.  But  much  above 
this  point  injurious  effects  were  usually  manifest.  Below  it  other  factors 
seemed  of  greater  importance  in  producing  diarrhea.  Thus  in  condensed 
milk  the  bacterial  contamination  was  relatively  small,  yet  the  results 
were  almost  as  bad  as  with  the  most  highly  contaminated  milk. 

No  relationship  could  be  discovered  between  any  special  forms  of 
bacteria  present  and  the  health  of  children  or  the  occurrence  of  diarrhea. 


DIARRHEA 


^55 


Tu  test  the  effect  of  heating  milk,  observations  were  made  durino- 
two  summers  upon  93  infants  taking  milk  prepared  at  a  milk  station.  It 
was  from  a  good  farm,  and  had  been  kept  properly  cooled.  The  infants 
were  divided  into  two  groups  as  nearly  alike  as  possible.  To  one  group 
the  milk  was  given  pasteurized  (165°  F.  for  thirty  minutes),  to  the  other 
group  the  same  milk  was  given  raw.  All  the  infants  were  well  at  the 
beginning  of  the  period  of  observation.  The  results  are  shown  in  the 
following-  table: 


Food. 

Total 

Number  of 

Infants. 

Remained 

Well  Entire 

Summer. 

Had 

Severe 
Diarrhea. 

Average 

Days 
Diarrhea. 

Deaths 

Pasteurized  milk  containing  1,000 
to  50,000  bacteria  per  c.c.  at  the 
time  of  use 

41 
51 

31 
17 

10 
•Si 

4 
IIJ2 

1 

Ihiw  milk  containing  1,200,000  to 
20,000,000  bacteria  per  c.c.   at 
the  time  of  use 

'7 

Thirteen  of  the  fifty-one  infants  on  raw  milk  were  changed  before 
the  end  of  the  season  to  pasteurized  milk  because  of  serious  diarrhea ; 
but  for  this  the  results  with  raw  milk  would  have  been  even  more  un- 
favorable. A  similar  experiment  was  made  a  third  season  with  almost 
identical  results. 

Although  the  number  of  cases  is  not  large,  the  results,  which  were 
practically  uniform  for  three  successive  seasons,  show  unmistakably  that 
in  hot  weather  raw  milk,  although  from  a  good  source,  but  at  the  time 
of  feeding  highly  contaminated  with  bacteria,  causes  illness  in  a  much 
larger  number  of  cases  than  when  it  has  been  previously  heated. 

After  the  first  two  years,  children  are  much  less  affected  by  bacteria 
in  milk.  The  observations  seemed  to  show  that  milk  from  healthy  cows, 
produced  under  cleanly  conditions  and  kept  at  a  temperature  below 
60°  F.,  although  containing  large  numbers  of  bacteria,  sometimes 
amounting  to  many  millions  per  c.c,  might  be  taken  in  considerable 
quantities  and  for  long  periods  by  children  over  three  years  old,  without 
any  appreciably  harmful  effects.  A  single  example  is  typical  of  a  number 
of  observations  made.  An  orphan  asylum,  containing  650  children  from 
three  to  fourteen  years  old,  used  during  an  entire  summer  milk  in  which 
the  bacteria  ranged  from  2,000,000  to  20,000,000  per  c.c;  yet  during 
this  period  there  occurred  no  case  of  diarrhea  of  suflficient  severity  to 
call  a  physician.  The  milk  was  kept  cold,  but  was  given  without  steriliza- 
tion. Mere  numbers  of  bacteria  certainly  appear  to  count  for  much  less 
than  was  once  supposed.  But  the  fact  should  not  be  overlooked  that 
milk  abounding  in  bacteria  because  of  careless  handling  is  also  always 


356  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

liable  to  contain  pathogenic  organisms  derived  from  human  or  animal 
sources. 

These  observations,  continued  for  three  seasons  and  giving  each 
summer  nearly  identical  results,  indicate  that  we  are  to  seek  elsewhere 
than  in  a  moderate  bacterial  contamination  of  milk  the  great  cause 
of  summer  diarrheas.  Though  it  is  clear  that  excessive  bacterial 
contamination  is  highly  detrimental  to  infants,  we  must  certainly  look 
to  the  other  factors  for  the  explanation  of  a  very  large,  possibly  the 
largest,  proportion  of  the  cases.  Of  the  other  exciting  causes,  atmospheric 
heat,  especially  the  stagnant  heat  of  houses,  is  clearly  first  in  importance. 
This  may  act  by  so  interfering  with  normal  digestion  and  metabolism 
as  to  lead  to  the  formation  within  the  body  of  injurious  substances  which 
excite  diarrhea;  or  it  may  favor  the  excessive  growth  of  bacteria  ordi- 
narily present  in  the  digestive  tract.  In  this  group  of  cases  the  role 
of  the  bacteria  seems  to  be  secondary,  though  perhaps  a  very  important 
one.  According  to  this  hypothesis,  the  exciting  cause  of  the  diarrheas 
under  consideration  is  not  something  introduced  from  without,  but  some- 
thing produced  within  the  body  itself. 

From  the  foregoing  discussion  the  measures  to  be  employed  in  the 
prevention  of  diarrheal  diseases  are  inferred.  In  the  order  of  importance 
they  are  as  follows : 

1.  Encouragement  of  maternal  nursing  and  the  adoption  of  measures 
to  make  this  possible,  particularly  during  the  summer  months. 

3.  Education  of  mothers  in  all  matters  relating  to  the  care  and 
hygiene  of  infants,  best  through  the  agency  of  the  milk  station  and  the 
visits  of  a  trained  district  nurse. 

3.  Adequate  supervision  of  the  milk  supply,  the  general  use  of  pas- 
teurized or  sterilized  milk  during  the  summer,  and  furnishing  good  milk 
to  those  too  poor  to  pay  for  it. 

4.  Instruction  of  mothers  in  regard  to  the  care  of  milk  in  the  home 
and  in  all  matters  of  artificial  feeding. 

5.  The  constant  supervision  of  artificially-fed  infants  either  in  the 
milk  station  or  by  visits  to  the  home. 

The  adoption  of  these  measures  and  their  application  on  an  extended 
scale  by  an  efficient  organization  has  resulted  in  a  very  great  reduction 
in  the  deaths  from  diarrheal  diseases  wherever  they  have  been  tried. 
Nowhere  have  such  results  been  achieved  as  in  New  York  City,  where 
the  summer  mortality  in  infants  under  one  year  has  fallen  in  the 
Boroughs  of  Manhattan  and  Bronx  from  an  average  of  1069  for  the 
three  years  1908-10  to  an  average  of  802  for  the  three  years  1912-14. 
(See  Fig.  5,  Chapter  on  Infant  Mortality.)  These  figures  represent  tlie 
actual  number  of  deaths  and  take  no  account  of  the^  increase  in  popula- 
tion. 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA  357 

Another  group  of  diarrheal  diseases  is  seen  which  may  be  due  to  in- 
fection introduced  from  without,  through  water,  milk,  or  other  food ; 
to  these  the  term  dysentery  is  more  often  applied.  These  cases  have 
been  found  to  be  associated  with  definite  bacteria  or  amebae.  It  is  likely 
that  intestinal  disease  of  this  type  may  supervene  upon  other  forms. 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA 

The  term  intestinal  indigestion  is  not  an  accurately  descriptive  one 
but  is  as  satisfactory  as  any  that  has  been  proposed  until  more  exact 
knowledge  as  to  the  etiology  and  pathology  of  the  condition  is  available. 

The  cases  included  in  this  chapter  comprise  many  types  which,  how- 
ever, are  closely  allied  and  shade  into  one  another.  Though  the  extremes 
of  the  series  differ  as  widely  as  possible,  yet  intermediate  types  of  almost 
every  grade  are  met  with.  They  are  discussed  under  a  single  heading, 
since  they  have  no  essential  anatomical  differences,  nor,  so  far  as  yet 
determined,  do  they  differ  etiologically.  Some  of  the  attacks  are  so 
mild  in  character  that  in  children  with  normal  resistance,  and  receiving 
23rompt  treatment,  they  may  last  but  a  few  hours.  On  the  other  hand, 
they  may  be  so  rapid  in  development  and  so  severe  as  tO'  result  in  death 
in  a  few  hours;  or,  beginning  with  less  intensity,  they  may  be  the  start- 
ing point  of  prolonged  functional  disorders  or  may  prepare  the  way  for 
tlie  development  of  infectious  processes. 

Etiology. — The  most  important  causes  have  been  mentioned  in  the 
foregoing  discussion  on  the  General  Etiology  of  Diarrheal  Diseases.  A 
predisposition  to  attacks  is  furnished  by  summer  weather,  a  delicate  con- 
stitution, and  any  previous  derangement  of  digestion.  The  exciting  cause 
of  an  attack  may  be  the  use  of  improper  food,  overfeeding  or  some  sudden' 
change  in  food  as  in  weaning;  but,  the  food  remaining  unchanged,  it  is 
often  other  influences  affecting  the  child,  such  as  summer  heat.  The 
most  striking  thing  about  these  cases  is  their  prevalence  during  hot 
weather.  Year  after  year  for  generations  have  been  repeated  in  New 
York  the  conditions  which  are  graphically  represented  in  Fig.  33,  viz., 
an  epidemic  which,  beginning  in  June,  rapidly  increases  in  severity, 
reaching  its  height  in  July  or  August,  from  which  time  it  diminishes 
steadily,  regularly  coming  to  an  end  in  September. 

Despite  the  fact  that  since  1886  many  series  of  bacteriological  studies 
of  the  intestinal  discharges  have  been  made  by  Booker  and  by  Park  in 
this  country,  by  Escherich,  Baginsky,  and  others  in  Germany,  our  knowl- 
edge of  this  subject  is  still  very  incomplete.  So  far  as  is  now  known, 
no  one  form  of  bacteria  can  be  assigned  as  the  cause  of  tliis  group  of 
diarrheas.     There  seems  to  be  evidence  that  the   Shiga  bacillus  may 


358  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

produce  diarrheal  disease  which  clinically  does  not  differ  from  this  type. 
But  it  is  wanting  in  so  large  a  proportion  of  cases,  that  it  can  not  be 
regarded  as  the  specific  cause.  With  existing  knowledge  it  seems  probable 
that  there  are  a  number  of  organisms  present  in  the  intestine  in  disorders 
of  digestion,  which,  under  favorable  conditions,  may  multiply  to  such  a 
degree  as  to  produce  serious  disturbances;  but  the  role  of  the  micro- 
organisms may  be  regarded  as  a  secondary  one. 

There  are  certain  cases  in  which  symptoms  of  a  severe  type  develop 
abruptly  in  children  previously  quite  well.  These  only  are  to  be  regarded 
as  examples  of  acute  milk  poisoning.  Although  the  bacteria  in  the  milk 
may  have  been  previously  destroyed  by  sterilization,  the  toxins  produced 
by  them  may  still  be  present.  This  is  doubtless  the  explanation  of  the 
simultaneous  development  of  several  cases  in  families  or  institutions. 

We  can  not  believe  that  direct  contagion  is  the  usual  way  in  which 
this  disease  is  spread.  When  occurring  in  institutions  or  in  families,  it 
usually  happens  that  a  number  of  children  are  attacked  simultaneously 
rather  than  successively,  this  indicating  a  common  ca,use,  usually  to  be 
found  in  the  food,  the  surroundings,  or  the  atmospheric  conditions. 

The  irritating  substances  producing  the  diarrhea  are  largely  the  lower 
fatty  acids.  These  are  derived  from  the  sugar  and  fat  of  the  food  prob- 
ably as  the  result  of  bacterial  action.  It  is  not  the  presence  of  abnormal 
bacteria  that  brings  about  this  result  so  much  as  the  altered  conditions 
under  which  they  multiply  and  operate.  These  altered  conditions  may 
depend  upon  changes  in  the  gastric,  biliary,  pancreatic  and  intestinal 
secretions  or  upon  other  factors  that  we  do  not  yet  understand. 

Lesions.— In  the  milder  cases  which  end  in  recovery,  the  anatomical 
changes  are  probably  negligible.  In  those  which  prove  fatal  from  the 
disease  itself,  or  from  some  associated  condition,  the  lesions  may  be 
a  superficial  catarrhal  inflammation  affecting  the  entire  gastro-enteric 
tract,  but  varying  much  in  severity  in  the  different  regions  and  in  the 
different  cases.  Even  after  the  most  severe  symptoms  no  lesions  of  con- 
sequence may  be  found. 

The  gross  appearances  may  show  but  little  that  is  abnormal.  The 
wails  of  the  stomach  may  be  coated  with  mucus,  and  the  mucous  mem- 
brane may  show  congestion,  generally  in  patches.  The  mucous  membrane 
of  the  small  intestine  may  be  pale  throughout ;  there  are  often  irregular 
areas  of  congestion.  With  this  there  may  be  redness  and  swelling  of 
Peyer's  patches  and  the  solitary  follicles.  In  the  colon  the  mucous  mem- 
brane may  be  congested.  The  solitary  follicles  are  usually  swollen.  The 
changes  described  are  not  at  all  uniform,  and  do  not  differ  very  greatly 
from  the  appearances  often  seen  in  the  intestines  when  patients  have 
died  of  other  diseases. 

In  the  cases  classed  clinically  as  cholera  infantum,  the  pathological 


ACUTE  INTESTINAL  INDIGESTION  AND  DIAREHEA  359 

changes  are  sometimes  more  characteristic.  The  greater  part  of  the  small 
intestine,  and  sometimes  the  entire  colon,  are  distended  with  gas,  and 
contain  material  of  a  grayish-white  color  about  the  consistency  of  a  thin 
gruel.  It  has  a  mawkish  odor,  but  usually  not  a  very  offensive  one.  The 
mucous  membrane  of  the  entire  intestinal  tract  is  in  most  cases  pale. 
Sometimes  this  is  only  in  the  small  intestine,  while  there  are  areas  of 
congestion  in  the  colon.  If  cholera  infantum  has  been  engrafted  upon 
some  other  pathological  process  in  the  intestines,  as  is  not  infrequent, 
there  is  found  post-mortem  evidence  of  this  in  the  form  of  severe 
catarrhal  inflammation,  sometimes  old  ulcerations. 

Unless  autopsies  are  made  very  soon  after  death — at  most  within 
four  hours — it  is  not  safe  to  draw  conclusions  from  the  couditioiis  found, 
as  post-mortem  changes  take  place  rapidly,  and  resemble  those  of  the 
disease  under  consideration.  This  applies  particularly  to  the  micro- 
scoj^ical  examination  of  the  epithelium.  The  cells  may  still  be  present, 
but  with  the  cell  protoplasm  and  nuclei  so  changed  that  they  do  not  stain 
normally.  In  more  severe  and  prolonged  cases  the  superficial  epithelium 
in  places  is  entirely  destroyed. 

The  changes  in  and  about  the  blood-vessels  are  variable.  The  small 
vessels  may  be  distended,  and  there  may  be  hemorrhages  or  an  exuda- 
tion of  leucocytes  in  their  neighborhood.  These  appearances  are  seen 
either  in  the  mucous  or  submucous  layer.  Peyer's  patches  and  the  lymph 
nodules  may  be  enlarged  from  cell-proliferation. 

The  lesions  in  other  organs  are  less  frequent  and  less  severe  than 
in  the  more  protracted  cases  of  ileocolitis.  Acute  bronchitis  and  broncho- 
pneumonia are  frequent.  Acute  degeneration  of  the  kidney  is  found  to 
some  degree  in  every  case  which  is  severe  enough  to  cause  death,  and  in 
a  few  there  is  acute  nephritis.  The  liver  may  be  much  enlarged  and 
very  fatty  or  of  normal  size,  but  degeneration  of  the  liver  cells  is  fre- 
quent. There  may  even  be  small  areas  of  necrosis.  In  rare  cases  a 
general  septicemia,  due  most  frequently  to  the  streptococcus,  is  pres- 
ent. 

Symptoms. — Clinically,  these  cases  may  be  divided  into  four  groups: 
(1)  The  mild  form,  with  definite  local  symptoms,  but  few  general  ones; 
they  may  be  of  short  duration  or  protracted;  (2)  the  severe  form  in 
which  there  are  not  only  local  but  marked  constitutional  symptoms, 
fever,  etc.;  (3)  cholera  infantum;  (4)  severe  forms  complicated  by_ 
acidosis. 

The  Mild  Form. — In  infants,  the  symptoms  are  seldom  limited  either 
to  the  stomach  or  to  the  intestine,  although  in  one  case  the  disturbance 
of  the  stomach  is  slight  and  that  of  the  intestine  serious,  and  in  another 
the  reverse  may  be  observed.  In  these  little  patients  the  intestinal  symp- 
toms are  more  frequent,  and,  as  a  rule,  more  severe  than  those  referable 


360  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

to  the  stomach.  In  older  children  it  is  not  nnconmion  to  see  the  in- 
testinal symptoms  alone.  In  infants,  if  the  attack  develops  suddenly, 
gastric  symptoms  are  usually  present ;  if  more  gradually,  they  are  usually 
absent.  The  local  ^jymptoms  are  colicky  pain,  tympanites,  and  Jater 
diarrhea.  The  constitutional  symptoms,  prostration  and  nervous  dis- 
turbances, are  slight  or  absent.  Pain  is  indicated  by  the  sharp,  piercing 
cry,  great  restlessness,  and  drawing  up  of  the  legs.  Tympanites  is  rarely 
very  marked.  The  stools  are  always  increased  in  number  and  are  from 
four  to  twelve  a  day.  If  more  frequent  they  are  very  small.  The  first 
stools  are  more  or  less  fecal,  but  this  character  is  soon  lost.  The  color 
is  at  first  yellow,  then  yellowish-green,  and  finally  often  grass-green. 
This  color  is  due  to  biliverdin.  If  the  child  has  been  taking  milk,  masses 
of  undigested  milk,  chiefly  fat,  are  present.  Tlie  reaction  of  the  stools 
is  almost  invarial^ly  acid.  The  odor  may  be  sour,  or  it  may  be  foul. 
The  stools  are  much  tliinner  than  normal,  and  often  frothy  from  the 
presence  of  gases.  Blood  is  not  present,  nor  is  much  mucus  seen,  unless 
the  symptoms  have  lasted  several  days.  The  microscope  shows,  in  addi- 
tion to  food-remains,  epithelial  cells,  usually  of  the  cylindrical  variety, 
which  are  numerous  in  proportion  to  the  severity  and  duration  of  the 
attack.     The  bacteria  are  the  ordinary  forms  found  in  the  feces. 

The  course  and  termination  of  the  disease  depend  upon  the  previous 
condition  of  the  patient,  the  nature  of  the  exciting  cause,  and  the  treat- 
ment employed.  In  a  previously  healthy  child,  if  the  cause  is  at  once 
removed  and  proper  treatment  instituted,  the  severe  symptoms  rarely 
last  more  than  a  day  or  two,  and  in  four  or  five  days  the  patient  may  be 
quite  well.  In  delicate  infants,  a  severe  attack  of  acute  intestinal  in- 
digestion in  the  hot  season  is  likely  to  prove  the  first  stage  of  a  patholog- 
ical process  which  may  continue  until  serious  organic  changes  in  the 
intestine  have  taken  place.  This  result  may  not  follow  the  first  attack, 
but  one  is  often  succeeded  by  others  until  it  occurs.  If  circumstances 
are  such  that  proper  dietetic  treatment  and  general  hygienic  measures 
can  not  be  carried  out,  this  termination  is  very  common. 

In  older  children  most  of  the  cases  seen  are  of  the  milder  type.  The 
onset  is  often  with  vomiting;  pain  is  generally  mild  and  precedes  diarj 
rhea  by  several  hours.  It  is  seldom  localized  but  is  more  often  referred 
to  the  navel.  The  stools  are  loose,  frequent^  and  contain  undigested 
food,  and  are  of  almost  every  conceivable  color  and  variety.  The  tem- 
perature, if  elevated  at  all,  is  so  only  for  a  short  time.  There  is  anorexia 
and  a  coated  tongue.  With  proper  treatment  the  attack  is  usually  over 
in  a  few  days.  It  is  very  seldom  followed  by  the  severer  types  of  diarrhea, 
as  is  so  commonly  the  case  with  infants. 

The  Severe  Form. — This  may  follow  after  several  days  of  an  ap- 
parently mild  attack,  especially  during  hot  weather  or  if  improperly 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA  ?.G1 

treated.  In  the  cases  developing  suddenly,  the  clinical  picture  is  quite  a 
definite  one. 

An  infant  is  restless,  cries  much,  sleeps  but  a  few  minutes  at  a  time, 
and  seems  in  distress.  The  skin  is  hot  and  dry,  the  temperature  rises 
rapidly  to  102°  or  103°  F.,  sometimes  to  106°  F.,  and  all  the  symptoms 
indicate  the  onset  of  some  serious  illness.  He  may  lie  in  a  djill  stupor, 
with  eyes  sunken,  weak  pulse,  and  general  relaxation,  or  there  may  be 
restlessness,  excitement,  and  even  convulsions.  There  may  be  great 
thirst,  so  that  everything  offered  is  eagerly  taken,  or  everything  may  be 
refused.  Vomiting  may  be  an  early  and  important  symptom.  It  is  first 
of  food,  often  that  which  was  taken  many  hours  before;  retching  con- 
tinues even  after  the  stomach  has  been  emptied,  so  that  mucus,  serum, 
and  sometimes  bile  may  be  ejected.  Vomiting  does  not  usually  persist 
throughout  the  attack,  and  in  many  cases  it  is  absent  altogether.  Diarj- 
rhea  is  sometimes  delayed  for  several  hours  after  the  beginning  of  the 
grave  constitutional  symptoms.  At  first  there  are  fecal  stools,  then  great 
bursts  of  flatus^  with  the  expulsion  of  a  thin  yellow  material  with  an  offen- 
sive odor.  Four  or  five  such  discharges  may  occur  in  as  many  hours.  At 
other  times  the  stools  are  gray,  green,  or  greenish-yellow,  and  sometimes 
brown.  The  characteristic  features  are  the  amount  of  gas  expelled,  the 
colicky  pains  preceding  the  discharges,  and  the  foul  odoi*.  After  the 
first  day  the  stools  may  be  almost  entirely  fluid,  varying  in  number  from 
six  to  twenty  a  day,  and  often  large  even  then ;  but  their  offensive  charac- 
ter frequently  disappears.  After  two  or  three  days  mucus  appears.  The 
microscopical  examination  of  the  stools  shows  great  numbers  of  separate 
epithelial  cells,  and  sometimes  groups  of  cells  attached  to  a  basement 
membrane.  In  addition  there  may  be  leucocytes  and  some  red  blood- 
corpuscles. 

In  many  cases  the  free  evacuation  of  the  bowels  is  followed  by  a  drop 
in  the  temperature  and  subsidence  of  the  nervous  symptoms,  and  the 
child  may  fall  asleep.  The  prostration,  though  often  great  in  the  be- 
ginning, may  not  be  of  long  duration.  In  the  most  favorable  cir- 
cumstances, after  one  or  two  days  of  severe  symptoms,  convalescence  may 
take  place.  The  stools  continue  frequent  for  five  or  six  days,  but  grad- 
ually assume  their  normal  character,  and  recovery  follows.  The  chief 
factors  contributing  to  such  favorable  results  are  a  good  constitution 
on  the  part  of  the  child,  prompt  and  intelligent  treatment  at  the  outset, 
and  proper  feeding  afterward. 

If  the  circumstances  are  not  so  favorable,  if  the  patient  is  a  very 
young  or  delicate  infant,  there  may  be  no  reaction  from  the  first  severe 
symptoms,  and  the  attack  may  terminate  fatally  in  from  one  to  three 
days.  In  such  cases  the  temperature  remains  high;  the  stomach  may 
or  may  not  be  disturbed;  but  the  diarrhea,  prostration,  and  nervous 


.362 


DISEASES  OF  THE  INTESTINES 


symptoms  continue,  and  death  occurs  from  exhaustion,  in  coma  or  con- 
vulsions. Instead  of  a  rapidly  fatal  termination,  the  severity  of  the 
early  acute  symptoms  may  abate  somewhat,  and  the  attack  assume  the 
character  of  ileocolitis,  with  a  lower  but  continuous  temperature  of  100° 
to  102°  F.,  frequent  mucous  stools,  wasting,  etc.  The  urine  is  scanty 
and  concentrated,  and  in  most  of  the  severe  cases  with  very  high  tem- 
perature contains  a  small  amount  of  albumin,  and  occasionally  a  few 

hyaline  and  granular 
casts.  These  are  the 
result  of  degenerative 
changes  in  the  renal 
epithelium.  In  rare 
cases  there  are  evi- 
dences of  acute  ne- 
Bronchopneu- 
is     sometimes 


io£ 


i 


g 


m 


'X 


i 


Fig.  35. — Severe  Intestinal  Indigestion  with  Fatal 
Relapse.  Infant  five  months  old;  early  symptoms, 
both  intestinal  and  nervous,  severe;  rapid  improve- 
ment followed  stopping  milk,  free  catharsis  and  irriga- 
tion. After  stools  had  been  nearly  normal  for  three 
days  relapse  occurred,  apparently  from  adding  milk  to 
the  diet,  although  less  than  two  ounces  a  day  were 
given.  Autopsy:  Only  mild  intestinal  lesions  were 
present;  other  organs  essentially  normal. 


phritis 
monia 
seen. 

It  not  infrequently 
happens,  after  the 
storm  of  the  acute  at- 
tack with  its  high 
temperature,  intense 
prostration,  and  grave 
nervous  symptoms  is 
passed,  and  the  stools 
are  so  much  improved 
that  the  patient  is  re- 
garded as  out  of  dan- 
ger, that  all  the 
former  symptoms  may  develop  with  such  rapidity  and  severity  as  some- 
times to  carry  off  the  patient  in  from  twelve  to  twenty-four  hours.  Such 
relapses  are  generally  excited  by  some  mistake  in  the  diet,  usually  that 
of  allowing  milk  too  soon.  The  amount  of  milk  given  may  be  small,  and 
yet  the  symptoms  follow  its  administration  so  soon  that  there  can  be 
little  doubt  regarding  the  connection  between  them  (Fig.  35).  Besides 
such  severe  cases,  many  milder  relapses  are  seen ;  the  cause  is  usually 
some  error  in  diet. 

Attacks  of  acute  intestinal  indigestion  with  severe  constitutional 
symptoms  in  which  there  is  at  first  no  diarrhea,  but  constipation  instead, 
are  most  puzzling  and  frequently  serious.  Fortunately,  they  are  not  of 
common  occurrence.  It  is  somewhat  difficult  to  explain  such  cases. 
There  seems  to  exist  for  the  time  almost  complete  intestinal  paralysis. 
The  toxic  materials  are  locked  up  in  the  small  intestine,  for  the  colon 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA  363 

is  f requantly  quite  empty.  When  one  meets  sneh  a  case  he  can  appreciate 
the  fact  that  diarrhea  is  a  conservative  process  of  the  greatest  possible 
value. 

In  children  over  two  years  old  there  are  seen  some  features  which 
differ  from  those  of  the  cases  above  described  as  occurring  in  infants. 
The  attacks  are  more  often  due  to  other  causes  than  to  milk.  Vomiting 
does  not  occur  so  readily  as  in  infants,  pain  is  a  more  prominent  symp- 
tom, and  the  temperature,  as  a  rule,  is  lower.  The  nervous  symptoms 
are  much  less  prominent.  Skin  eruptions,  however,  are  more  frequently 
seen,  particularly  urticaria,  which  is  a  feature  of  .manj_  attacks,  and  in 
obscure  cases  has  some  diagnostic  value.  Although  often  beginning  with 
severe  symptoms,  these  cases  usually  make_good^ecoveries ;  there  is  much 
less  danger  of  repeated  attacks  or  of  the  development  of  "ileocolitis  than 
in  the  case  of  infants. 

Cholera  Infantum. — This  is  only  one  type  of  the  severe  form  of  acute 
indigestion,  yet  clinically  it  differs  from  the  others  sufficiently  to  deserve 
separate  consideration.  It  is  iiot,  however,  a  frequent  form.  What  it  is 
that  determines  the  marked  and  characteristic  symptoms  in  cholera 
infantum  is  entirely  unknown. 

Cholera  infantum  rarely  occurs  in  an  infant  previously  healthy-  As 
a  rule,  there  is  some  antecedent  intestinal  disorder. _  The  development 
of  the  choleriform  symptoms  is  usually  very  rapid,  and  a  child,  who 
perhaps  has  been  regarded  as  scarcely  ill  enough  to* require  a  physician, 
may  be  brought,  in  the  course  of  five  or  six  hours,  to  death's  door. 

Usually  there  are  general  symptoms,  such  as  proatration  and  a  stead- 
ily rising  temperature,  for  a  few  hours  before  the  vomiting  and  purging,  _ 
or  these  symptoms  may  be  the  first  to  excite  alarm.  Vomiting  may  pre- 
cede diarrhea,  or  both  may  begin  simultaneously.  The  vomiting  is  very 
frequent.  First,  whatever  food  is  in  the  stomach  is  vomited,  then  serum 
and  mucus,  and  sometimes  there  is  regurgitation  from  the  small  intes- 
tine. If  vomiting  subsides  for  a  time,  it  is  almost  sure  to  begin  anew 
with  the  taking  of  food  or  drink.  The  stools  are  frequent,  large,  and 
fluid,  and  may  occur  once  or  twice 'an  hour.  They  are  of  a  pale  green, 
yellow,  or  brownish  color  iii  the  beginning,  but  as  they  become  more 
frequent  they  often  lose  all  color  and  are  almost  entirely  serous.  The 
sphincter  is  sometimes  so  relaxed  that  small  evacuations  occur  every 
few  minutes.  The  first  stools  are  usually  acid,  later  they  are  neutral, 
and  when  serous  they  are  alkaline.  In  most  cases  they  are  odorless; 
in  rare  instances  they  are  exceedingly  offensive.  Microscopically  the 
stools  show  large  numbers  of  epithelial  cells,  some  leucocytes,  and  im- 
mense numbers  of  bacteria. 

Loss  of_weight  is  more  rapid  than  in  any  other  pathological  condition 
in  chijdhood;  it  may  be  as  mjijcli_as_a  pound  a  day .^  The  fontanel  is 


364  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

degressed^  and  in  rare  instances  there  ma}'  be  overlapping  of  the  cranial 
bones.  The  general  prostration  is  great  almost  froni  the  outset.  The 
face,  better,  perhapsTthan:  any^singfe" symptom,  indicates  what  a  pro- 
found impression  has  been  made  upon  the  system.  The  eyes  are  sunken, 
the  features  sharpened^  the  angles  of  the  mouth  drawn  down,  and  a 
peculiar  pallor  with  an  expression  of  anxiety  overspreads  the  whole 
countenance,  which  becomes  almost  Hippocratic.  In  the  early  stages 
the  nervous  symptoms  are  those  of  irritation.  Later,  these  symptoms 
give  place  to  dulness,  stupor,  relaxation,  and  coma  or  convulsions. 

The  temperature  is  invariably  elevated,  and  usually  in  proportion  to 
the  severity  of  the  attack.  In  cases  recovering,  it  has  generally  been 
from  102°  to  103°  F.,  while  in  fatal  cases  it  has  risen  almost  at  once 
to  104°  or  105°  F.,  and  often  shortly  before  death  it  has  reached 
106°  or  even  108°  F.  Such  temperatures  may  occur  with  a  clammy  skin 
and  cold  extremities,  and  are  discovered  only  with  the  aid  of  a  ther- 
mometer. The  pulse_k  always  rapid,  and  very  soon  it  becomes  weak^ 
often  irregular,  and  finally  almost  imperceptible.  The  respiration  is 
irregular  and  frequent,  and  may  be  stertorous.  The  tongue  is  generally 
coated,^  but  soon  becomes  dry  and  red,  and  is  often  protruded.  The 
abdomen  is  generally  soft  and  sunken.  There  is  almost  insatiable  thirst. 
Everything  in  the  shape  of  fluids,  especially  water,  is  drunk  with  avid- 
ity, even  though  vomited  as  soon  as  it  is  swallowed.  Very^little  urine 
is  passed,  sometimes  none  at  all  for  twenty-four  hours;  this  largely 
depends  upon  the  great  loss  of  fluid  by  the  bowels. 

In  the  fatal_cases_ there  is  hyperpyrexia.^ji  cold,  clammy  skin,  absence 
of  radial  pulse_j  stupor,  coma  or  convulsions,  and  death.  The  diarrhea 
and  vomiting  may  continue  until  the  end,  or  both  may  entirely  cease  for 
some  hours  before  death  occurs.  The  patients  may  pass  into  a  condition 
resembling  the  algid  stage  of  epidemic  cholera,  and  die  in  collapse.  In 
other  cases,  after  the  flrst  day  of  very  severe  symptoms,  the  discharges 
diminish,  but  the  nervous  symptoms  become  specially  prominent.  There 
is  restlessness  and  irritability  or  apathy  and  stupor.  The  fontanel  is 
sunken ;  the  eyes  are  half  open  and  covered  with  a  mucous  film ;  respira- 
tion is  irregular  and  superficial,  sometimes  even  Cheyne- Stokes;  the 
pulse  is  feeble,  irregular,  or  intermittent ;  the  muscles  of  the  neck  drawn 
back;  the  abdomen  retracted.  The  temperature  is  not  elevated,  but 
normal  or  subnormal.  From  this  condition  recovery  may  take  place  or 
the  symptoms  may  merge  into  those  of  ileocolitis;  but  much  more  fre- 
quent than  either  of  the  foregoing  is  the  fatal  termination. 

The  nervous  symptoms  have  been  ascribed  to  cerebral  anemia,  cerebral 
hyperemia  (venous),  edema  of  the  meninges,  thrombosis  of  tlie  cerebral 
sinuses,  and  uremia.  Although  we  have  examined  the  brain  in  almost 
all  our  autopsies  upon  patients  dying  from  diarrheal  diseases,  we  have 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA  365 

never  in  such  cases  seen  sinus  thrombosis,  and  but  rarely  edema.  Cere- 
bral hyperemia  is  often  met  with  in  cases  dying  in  convulsions,  but  not 
with  any  regularity  otherwise.  Nor  have  our  observations  upon  the  kid- 
neys confirmed  those  of  Kjellberg,  whom  most  of  the  writers  since 
his  day  have  quoted,  as  to  the  great  frequency  of  nephritis.  A  scanty, 
concentrated,  and  hence  irritating  urine  is  the  rule,  and  a  small  amount 
of  albumin  and  an  occasional  hyaline  cast  not  uncommon;  but  either 
clinical  or  pathological  evidence  of  a  serious  amount  of  nephritis  has 
been,  in  our  o^^T-I  experience,  extremely  rare. 

An  infrequent  complication  of  cholera  infantum  is  sclerema.  This 
condition  is  found  associated  with  muscular  contractions,  subnormal  tem- 
perature and  other  signs  of  the  most  extreme  depression.  These  cases  are 
almost  invariably  fatal. 

Of  the  children  with  true  cholera  infantum  which  have  come  under 
our  notice,  fully  three-quarters  have  died. 

Acidosis. — In  the  course  of  the  severe  form  of  diarrhea  or  of  cholera 
infantum,  symptoms  referable  to  the  nervous  system  and  respiration  may 
appear.  There  may  be  excitement  and  sleeplessness  with  a  frequent, 
shrill,  piercing  cry.  Later  on  there  may  be  somnolence  gradually  increas- 
ing to  stupor  or  even  coma.  The  typfe  of  respiration  is  the  most  charac- 
teristic evidence  of  acidosis.  This  is  altered  so  that  there  is  an  increased 
ventilation  of  the  lungs,  i.e.,  exaggerated  inspiration_a,nd  expiration. 
This  is  often  difficult  to  recognize  in  its  early  stages,  but  frequently 
develops  into  a  marked  dyspnea  of  the  "air  hunger"  type,  without  pause 
or  cyanosis  and  without  any  evidence  of  obstruction.  Tliere  is  often  a 
polymorphonuclear  leucocytosis,  generally  between  20,000_and  30,000'. 
There  may  be  sugar  in  the  urine  which,  if  lactose  is  given  in  the  food, 
is  said  to  be  galactose  and  lactose,  or  saccharose  if  this  sugar  is  being 
taken.    There  are  in  addition  the  symptoms  of  severe  general  prostration. 

When  such  symptoms  are  present,  especially  the  nervous  and  respira- 
tory ones,  the  condition  is  very  grave.  The  majority  of  the  children 
with  manifest  hyperpnea  die,  although  life  may  be  prolonged  for  several 
days.  Though  the  hyperpnea  may  cease  as  the  result  of  treatment,  death 
usually  occurs;  for  many  abnormal  processes  at  present  not  understood 
have  undoubtedly  been  initiated  and  are  sufficient  to  cause  death. 

It  is  to  the  train  of  symptoms  just  described  that  the  name  "food 
intoxication"  (alinientare  intoxication)  has  been  given  by  Finklestein. 
He  claims  that  this  condition  is  the  result  of  the  presence  of  products 
of  intermediary  metabolism,  imperfectly  elaborated,  and  that  they  are 
directly  poisonous.     Evidence  of  their  presence  is,  however,  lacking. 

decent  studies  have  shown  that  in  tliese  cases  tliore  is  an  acidosis. 
that  the  disturbances  of  respiration  are  referable  to  this  condition,  and 
that  the  gravity  of  the  symptoms  is  probably  dependent  directly  upon 


366  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

this  acidosis.  It  lias  been  shown  that  accompanying  the  hyperpnea  there 
is  a  low  carbon  dioxid  tension  in  the  alveolar  air;  that  the  greater  the 
hyperpnea,  the  lower  the  carbon  dioxid  tension;  that  in  the  most  severe 
forms  there  is  an  increase  in  the  hydrogen-ion  concentration  of  the  blood 
serum ;  that  there  is  a  great  diminution  of  the  alkali  reserve  of  the  blood 
and  that  a  greatly  increased  quantity  of  alkali  can  be  taken  before  the 
urine  becomes  alkaline.  Soda  bicarbonate,  given  by  mouth,  intravenously 
or  subcutaneously,  causes  a  cessation  of  the  hyperpnea  and  a  return  of  the 
alkalinity  of  the  blood  to  normal.  This  furnishes  a  definite  indication 
for  treatment.  But  the  relief  of  the  acidosis  does  not  necessarily  cure 
the  diarrhea.  There  is  no  doubt  that  there  is  an  alteration  in  the 
normal  relation  between  the  acids  and  alkalies  so  that  the  former  are 
in  relative  excess.  What  causes  this  alteration  is  not  known  at  the  present 
time.  It  is  not  due,  as  a  rule,  to  an  excess  of  the  acetone  bodies.  These 
are  but  moderately  increased  in  amount. 

Diagnosis. — The  acute  gastric  and  intestinal  symptoms  which  mark 
the  beginning  of  many  febrile  diseases  in  infancy,  particularly  the  exan- 
themata and  pneumonia,  are  often  difficult  to  distinguish  from  the  more 
severe  attacks  of  acute  indigestion  with  constitutional  symptoms.  The 
question  to  decide  is  whether  the  digestive  symptoms  are  the  cause  or  the 
result  of  the  fever.  It  is  sometimes  not  until  the  case  has  been  watched 
for  some  time  that  one  can  be  certain.  Usually  when  digestive  symptoms 
are  secondary  they  diminish  after  the  first  day  or  two,  although  the 
severity  of  the  general  symptoms  may  steadily  increase.  The  character- 
istic features  of  the  primary  disease  may  also  appear.  \Yhen  the  nervous 
symptoms  of  the  severe  form  of  acute  indigestion  are  prominent  at  the 
outset,  it  is  sometimes  difficult  to  exclude  meningitis.  We  have  seen 
many  cases  where  great  doubt  existed  for  several  days.  One  should 
always  hesitate  to  make  a  diagnosis  of  meningitis  when  marked  diarrhea 
is  present. 

Progfnosis. — The  milder  forms  of  acute  intestinal  indigestion  do  not 
often  prove  fatal,  except  in  young  infants  or  those  already  suffering  from 
malnutrition.  In  all  cases  the  prognosis  depends  upon  the  previous 
health  of  the  child,  his  surroundings,  the  season  of  the  year,  and  whether 
or  not  the  case  receives  prompt  and  proper  treatment.  Severe  forms  of 
the  disease,  especially  those  associated  with  nervous  or  respiratory  symp- 
toms, are  very  serious.  A  continuously  high  fever  is  a  bad  prognostic 
sign.  The  existence  of  rickets,  pertussis,  or  any  other  disease,  greatly 
increases  the  gravity  of  the  attack.  True  cholera  infantum  is  nearly 
always  fatal. 

Prophylaxis,, — A  better  understanding  of  the  etiology  brings  with  it 
great  possibilities  in  the  prevention  of  this  disease. 

Prophylaxis  must  have  regard,  first,  to  the  hygienic  surroundings  of 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA  367 

children,  and  to  all  sanitary  conditions  of  cities.  City  children  should 
be  sent  to  the  country,  whenever  it  is  possible,  for  the  months  of  July 
and  August.  Where  a  long  stay  is  impossible,  day  excursions  do  much 
good.  The  fresh-air  funds  and  seaside  homes  have  done  much  in  New 
York  to  diminish  the  moi'tality  from  diarrbeal  diseases. 

The  second  part  of  prophylaxis  relates  to  food  and  feeding.  Mater- 
nal nursing  should  be  encouraged  by  every  possible  means.  Nothing  is 
better  established  than  the  close  relation  existing  between  artificial  feed- 
ing and  diarrheal  diseases.  Yet,  as  stated  elsewhere,  it  is  not  artificial 
feeding  per  se  but  ignorant  and  improper  feeding.  Among  infants  in 
private  practice  who  are  properly  fed  these  attacks  are  not  common. 

Overfeeding  is  particularly  to  be  avoided  during  days  of  excessive 
heat.  It  is  at  such  times  an  excellent  rule  with  infants  to  diminish  each 
feeding  by  at  least  one-half,  making  up  the  deficiency  with  water,  and  to 
give  water  very  freely  between  the  feedings.  In  summer  all  water  given 
to  infants  or  young  children  should  be  boiled.  Children,  like  adults, 
require  less  food  in  very  hot  weather,  but  more  water.  Infants  cry  more 
from  thirst  and  heat  than  from  hunger,  and  even  those  at  the  breast  are 
likely  to  be  given  too  much  food.  Infants  should  never  be  fed  more  fre- 
quently, but  always  less  frequently,  during  hot  weather. 

A  very  important  work  in  practical  philanthropy  among  the  poor  of 
our  large  cities  in  summer  is  to  provide  means  for  supplying  pure  milk 
to  infants.  This  has  been  done  on  a  large  scale  in  many  American 
cities,  and  it  is  one  of  the  important  agencies  that  have  eiiected  a  decided 
reduction  in  the  death-rate  from  diarrheal  disease.  It  is  not  enough  to 
furnish  to  the  poor  a  pure,  clean  milk  in  bulk,  or  even  in  sealed  quart 
bottles.  The  advantages  of  such  milk  may  be  entirely  lost  by  the  way 
in  which  it  is  cared  for  in  the  home  or  the  way  in  which  it  is  fed  to 
infants.  Since  the  milk  must  usually  be  kept  at  home  without  ice,  steril- 
ization is  advisable.  When  milk  is  distributed  from  milk  stations,  a 
physician  should  be  in  charge  who  can  keep  a  general  supervision  over 
the  children,  and  advise  as  to  the  quantity  of  food,  number  of  feedings, 
and  the  formula  to  be  used.  His  work  should  be  supplemented  by  visits 
of  nurses  to  the  homes  of  patients.  An  essential  feature  is  to  keep  sucli 
close  supervision  over  the  infants  as  to  recognize  at  once  and  promptly 
treat  slight  disturbances  of  digestion. 

But  even  more  important  than  pure  milk  is  the  education  of  the 
poor  in  all  matters  relating  to  infant  feeding  and  hygiene.  In  no  way 
can  this  educational  work  better  be  done  than  in  connection  with  milk 
distribution. 

Hygienic  Treatment. — If  the  attack  is  a  severe  one  and  occurs  in  tho 
excessive  heat  of  midsummer,  and  does  not  readily  yield  to  treatment, 
the  child  should,  if  possible,  be  sent  to  a  cooler  place.     Convalescent  cases 


368  DISEASES  OF  THE  mOESTIVE  SYSTEM 

should  also  be  sent  away  on  account  of  the  dangers  of  relapse.  Children 
must  not  only  be  sent  away,  they  must  be  kept  away  until  quite  recov- 
ered. In  cases  which  have  become  somewhat  chronic,  more  can  some- 
times be  accomplished  by  a  change  of  air  than  by  all  other  means. 

Fresh  air  is  of  the  utmost  importance  for  all  diarrheal  cases  in  sum- 
mer. No  matter  how  much  fever  or  prostration  there  may  be,  these 
children  do  better  if  kept  ojit_jif_dQors_the  greater  part  of  the  day. 
Children  should  be  kept  quiet,  and  especially  should  not  be  allowed  to 
walk,  even  if  they  are  oTS  enough  and  strong  enough  to  do  so. 

The  clothing  should  be  veryjight  flannel;  a  single  loose  garment  is 
preferable.  Einen.  or  cotton  may  be  put  next  the  skin  if  this  is  very 
sensitive  and  there  is  much  perspiration.  At  the  seashore  and  in  the 
mountains,  care  should  be  taken  that  sufficient  clothing  at  night  is  sup- 
plied. Bathing  is  useful  to  allay  restlessness,  as  well  as  for  the  reduction 
of  temperature.  ScrupulanrS-deanliness  should~be  secured  in  the  child's 
person  and  clothing.  Napkins,  as  soon  as  soiled,  should  be  removed  from 
the  child  and  from  the  room  and  placed  in  a  disinfectant  solution.  Ex- 
coriations of  the  buttocks  and  genitals  are  to  be  prevented  by  absolute 
cleanliness  and  the  free  use  of  some  absorbent  powder,  such  as  starch  and 
boric  acid. 

Dietetic  Treatment. — It  is  of  the  first  importance  to  remember  that 
during  the  early  stage  of  the  acute  cases,  digestion  is  practically  arrested. 
To  give  food  at  this  time,  manifestly  can  do  only  harm. 

Tn~nursing  infants  the  "sev'ere^orihs  5f  the  disease  are  extremely 
rare;  but  the  breast  should  be  withheld  so  long  as  a  disposition  to  vomit 
continues,  and  no  food  whatever  ^iven  for  at  leastJwentyrlQur  hours. 
Thirst  may  be  allayed  by  giving  frequently,  but  in  small  quantities, 
bjpiled  water  or  thin  barley  or  rice  water  or  weak_iea  sweetened  with 
saccharin.  If  these  are  refused  or  vomited,  absolute  rest  to  the  stomach 
will  do  more  than  anything  else  to  hasten  recovery.  After  the  stomach 
has  been  allowed  to  rest  for  twenty-four  hours,  it  is  generally  safe  to 
permit  a  nursing  child  to  take  the  breast  tentatively.  The  intervals  of 
nursing  should  not  be  shorter  than  four  hours,  and  the  amount  allowed 
at  one  feeding  should  not  be  more  than  one-fourth  the  usual  quantity. 
This  may  be  regulated  by  allowing  an  infant  to  nurse  at  first  only  two  or 
three  minutes.  Between  the  nursings  may  be  given  boiled  water  or 
barley  water.  Nursing  may  be  gradually  increased,  so  that  in  three  or 
four  days  the  breast  may  be  taken  exclusively. 

In  infants  who  are  being  artificially  fed,  all^food,  and  especially 
milk,  should  be  stopped  at  once.  Sweet  milk  should  not  only  be  with- 
held during  the  period  of  acute  symptoms,  but  for  several  days  there- 
after. Besides  the  articles  mentioned  above  as  suitable  for  the  period 
of  most  acute  symptoms  the  following  substitutes  for  milk  will  be  found 


ACUTE  INTESTINAL  INJ31GESTI0N  AND  DIARRHEA  369 

useful :  rice  or  barley^jstate^the  farinaceous  foods,  and  broth  or  bouillon 
made  of  veal,  chicken,  mutton,  or  beef.     Water  may  be  allowed  freely  " 
at  all  times  unless  there  is  much  vomiting. 

When  milk  is  begun  it  should  be  remembered  that  the  sugar  is  more 
likely  to  disturb  digestion  than  any  other  element  and  that  sugar  and 
fat  together  are  very  badly  borne.  For  this  reason  some  form  of  fer- 
mented milk,  buttermilk  or  protein  milk  is  to  be  preferred.  This  latter 
may  be  given  except  in  the  most  severe  forms  of  the  disease  and  except 
when  vomiting  is  marked,  almost  from  the  beginning  of  symptoms.  After 
twenty-four  hours  of  preliminary  starvation,  if  the  symptoms  are  very 
acute  and  after  cleansing  of  the  intestinal  tract  has  taken  place  either 
from  the  diarrhea  itself  or  from  cathartics  or  irrigations,  its  use  may  be 
begun.  It'Tias  a'lnarked  effect  in  couhteractrng  the  dfarrhea  and  is 
well  borne  by  almost  all  infants  except  those  under  two  or  three  months 
of  age.  At  first  the  protein  milk  should  be  given  in  jinall  amounts,  one 
or  two  ounces  ^very  four  hours,  and  to  infants  under  six  months  of  age 
diluted  with  an  eq-ual  quantity  of  water.  The  increase  in  amount  and 
in  strength  should  be  gradually  made  according  to  the  improvement  in 
symptoms.  No  sugar  should  be  added  until  a  day  or  two  after  the  stools 
have  become  quite  firm  in  consistency  and  not  more  numerous  than 
three  or  four  a  day. 

The  sugar  should  be  one  of  the  dry  preparations  containing  maltose 
such  as  dextrimaltose,  Sohxlet's  nalirzuclcer,  Liebig's  ndhrmaltose  or 
cane  sugar.  Lactose  should  not  be  used.  The  sugar  should  be  added 
very  gradually,  beginning  with  one-quarter  ounce  a  day  and  increased 
up  to  four  or  five  per  cent  of  the  food.  If  loose  stools  result  the  sugar 
should  be  discontinued.  A  return  to  sweet  milk  should  be  made  gradu- 
ally and  with  caution.  To  this  no  sugar  should  be  added  until  it  has 
been  demonstrated  that  the  diluted  milk  can  be  tolerated.  Wet-nurses 
are  not  to  be  employed  during  the  acute  symptoms,  but  during  the  period 
of  prolonged  malnutrition  which  follows  an  acute  attack  they  may  be 
of  the  greatest  service. 

The  same  general  principles  of  feeding  should  be  applied  in  older 
children.  All  food  is  to  be  withheld  until  the  vomiting  ceases,  when 
broths  and  thin  gruels  may  be  given ;  later,  buttermilk,  kumyss  and  pro- 
tein milk.  Junket  from  which  the  whey  has  been  carefully  strained  is 
very  useful  in  checking  diarrhea.  Solid  food  should  not  be  allowed  for 
several  days  after  the  stools  have  become  normal. 

Medicinal  and  Mechanical  Treatment. — It  must  be  borne  in  mind 
tliat  we  are  not  treating  an  inflammation  of  the  stomach  or  intestines, 
although  such  may  be  the  ultimate  result  of  the  process.  The  essential 
condition,  it  should  be  remembered,  is  one  of  indigestion  and  intoxica- 
tion arising  from  the  intestinal  contents — food-remains  from  arrested 


370  DISEASES  OF  THE  DIGESTIVE  SYSTEM  f 

digestion,  altered  secretions,  acids,  irritating  and  toxic  substances  pro- 
duced by  chemical  and  bacterial  action — to  which  not  only  the  constitu- 
tional but  the  local  symptoms  are  chiefly  due.  We  can  hardly  do  better 
than  to  imitate  and  assist  Xature  in  her  treatment  of  this  condition. 
Let  us  consider  Avhat  this  is.  Lest  too  much  food  be  swallowed,  appetite 
is  taken  away;  by  vomiting,  the  stomach  is  emptied;  to  neutralize  the 
acid  poisons  in  the  intestine,  an  alkaline  serum  is  poured  out  from  the 
intestinal  walls;  to  remove  irritant  poisons,  increased  peristalsis  is  ex- 
cited. 

The  first  indication  is,  therefore,  to  evacuate  the  stomach  and  the 
entire  intestinal  tract  at  the  earliest  moment.  Unless  thorough  evacua- 
tion of  the  bowels  has  taken  place,  treatment  should  not  be  begun  with 
the  use  of  measures  to  stop  the  discharges.  To  empty  the  stomach  is 
not  necessary  in  every  case,  since  the  initial  vomiting  may  have  done 
this  effectively.  If  vomiting  persists  one  may  resort  to  stomach-washing. 
A  single  washing  is  generally  sufficient,  and  if  employed  at  the  outset 
may  shorten  the  attack.  With  high  fever  and  great  thirst,  it  is  often 
advisable  to  leave  a  few  ounces  of  water  with  ten  to  fifteen  grains  of 
bicarbonate  of  soda  in  the  stomach.  As  a  substitute  for  stomach-washing 
in  children  over  two  years  old,  or  where  it  can  not  be  employed,  copious 
draughts  of  boiled  water  may  be  given.  This  is  taken  readily,  and  as  it 
is  usually  vomited  almost  at  once  it  may  cleanse  the  stomach  thoroughly. 
If  there  is  distention  with  fever  and  foul  stools,  cathartics  are  indicated, 
but  if  the  diarrhea  has  been  profuse  cathartics  should  not  be  employed. 
There  is  no  greater  mistake  than  to  think  that  the  character  of  the  stools 
is  likely  to  be  improved  by  calomel  or  castor  oil.  The  .stools  contain  little 
if  any  fecal  matter ;  what  is  passed  by  the  bowel  consists  almost  entirely  of 
intestinal  secretions. 

To  clear  out  the  small  intestine,  only  cathartics  are  available.  For 
the  colon,  we  may  in  addition  employ  irrigation.  Calomel,  castor  oil,  or 
the  salines  may  be  used  as  cathartics,  and  enough  of  any  one  of  them 
must  be  given  to  clear  out  the  intestinal  tract  thoroughly.  Calomel  has 
the  advantage  of  ease  of  administration :  one-fourth  of  a  grain  should 
be  given  every  fifteen  or  twenty  minutes  up  to  four  or  six  doses.  When 
the  stomach  is  not  disturbed,  castor  oil  is  to  be  preferred  as  it  is  not  so 
irritating,  causes  little  griping  and  is  very  certain.  Two  drams  should 
be  given  to  a  child  six  months  old,  and  half  an  ounce  to  one  of  four  years. 
Of  the  salines,  the  best  are  the  sulphate  of  soda  and  Eochelle  salts ;  from 
one  to  three  drams  may  be  given,  well  diluted,  divided  into  four  or  five 
doses,  at  twenty-minute  intervals. 

Cathartics  may  be  employed  later  in  the  disease  if  the  stools  become 
foul  or  there  is  distention,  but  care  should  be  taken  not  to  continue  to 
irritate  a  hypersensitive  intestine. 


ACUTE  INTESTINAL  INDIGESTION  AND  DIARRHEA  371 

Early  irrigation  of  the  colon  is  advisable  in  all  cases,  as  it  hastens  the 
effect  of  the  cathartic  and  removes  at  once  much  irritating  and  offensive 
material.  It  should  be  done  two  or  three  times  the  first  day,  but  after- 
ward once  daily  is  generally  sufficient.  A  saline  solution  (one  table- 
spoonful  of  salt  to  two  quarts  of  water),  at  a  temperature  of  about  100° 
F.,  is  to  be  preferred;  and  a  rectal  tube  well  inserted  should  always 
be  used.  Thorough  initial  evacuation,  no  food,  but  plenty  of  water  for 
twenty-four  hours,  and  careful  feeding  after  that  time,  are  all  the  treat- 
ment that  is  necessary  in  most  cases. 

Other  drugs  are  of  secondary  importance.  Their  value  is  certainly 
very  much  overestimated.  It  is  very  doubtful  whether  as  yet  any  proper 
antiseptic  treatment  of  the  gastro-enteric  tract  is  possible. 

Of  the  drugs  which  are  used  to  influence  the  intestinal  process,  bis- 
muth is  to  be  preferred.  It  has  the  advantage  that  it  rarely  causes  vomit- 
ing, and  that  most  of  its  preparations  can  be  given  in  large  doses.  The 
subcarbonate  is  the  safest.  It  may  be  given  in  doses  of  from  ten  to  twenty 
grains  every  two  hours,  to  a  child  of  one  year.  Like  the  subnitrate  it  is 
insoluble  and  is  best  given  suspended  in  the  food  or  in  water.  It  usually 
blackens  the  stools.  It  may  be  kept  up  throughout  the  attack.  Our 
experience  leads  us  to  place  little  reliance  upon  astringents.  They  do 
little  good,  and  often  much  harm. 

While  opium  in  some  form  is  required  in  many  cases,  it  is  capable 
of  doing  much  harm.  The  chief  indications  for  opium  are  great  fre- 
quency of  movements  and  severe  pain.  It  is  contraindicated  until  the 
intestinal  tract  has  been  thoroughly  emptied ;  also  when  the  number  of 
discharges  is  small,  particularly  if  they  are  very  offensive ;  it  is  especially 
to  be  avoided  in  the  early  stage  of  very  acute  cases,  and  never  to  be  given 
when  cerebral  symptoms  and  high  temperature  coexist  with  scanty 
discharges.  Opium  is  admissible  after  the  tract  has  lieen  thoroughly 
emptied.  It  is  particularly  indicated  when  there  is  a  persistence  of  large, 
fluid  movements  attended  by  symptoms  of  collapse,  and  in  all  cases  ap- 
proaching the  cholera-infantum  type.  Nothing  requires  nicer  discrim- 
ination than  the  use  of  opium  in  diarrhea.  It  is  wise  to  administer  it 
always  in  a  separate  prescription,  and  never  in  composite  diarrheal 
mixtures.  The  dose  should  be  regulated  according  to  its  effect  upon 
the  number  of  stools.  Enough  is  to  be  given  to  produce  a  distinct  effect 
— the  control  of  excessive  peristalsis  and  the  diminution  of  pain — l)iit 
never  enough  to  check  the  discharges  entirely,  or  to  cause  stn]ior.  Tlie 
uncertainty  of  absorption  must  also  be  remembered;  a  second  full  dose 
should  not  be  given  until  a  sufficient  time  has  elapsed  for  tlie  effect  of 
the  first  to  pass  away.  For  an  average  child  of  six  montlis,  ten  minims 
of  paregoric,  one-half  minim  of  the  deodorized  tincture,  or  one-half  grain 
of  Dover's  powder,  may  be  used  as  an  initial  dose,  to  be  repeated  every 


372  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

one,  two,  or  four  hours,  according  to  the  effect  produced.  In  severe  cases 
it  may  be  necessary  to  increase  the  dose  considerably.  When  urgently 
required  morphin  should  be  given  hypodermically,  one-sixtieth  of  a  grain 
to  an  infant  of  six  months,  to  be  repeated  in  two  hours  if  no  effect  is 
seen. 

Stimulants  are  often  required  in  severe  cases.  The  prostration  is 
great  and  develops  rapidly ;  frequently  almost  no  food  can  be  assimilated 
for  twenty-four  or  thirty-six  hours,  while  the  drain  from  the  discharges 
continues.  The  general  condition  of  the  patient  is  the  best  guide  as  to 
the  time  for  stimulation  and  the  amount  required.  Brandy  is  the  best 
preparation  for  general  use.  An  infant  a  year  old  may,  as  a  maximum, 
take  half  an  ounce  of  brandy,  well  diluted,  in  twenty-four  hours.  Caffein 
and^camphor  may  also  be  given.  While  the  use  of  stimulants  is  indicated 
in  many  cases  their  effects  are  disappointing.  Taken  by  mouth  they  are 
frequently  vomited.  It  is  then  necessary  to  give  caffein  and  camphor 
hypodermically.  In  cases  of  extreme  prostration  and  collapse  the  hot 
bath,  mustard  to  the  extremities  and  sometimes  the  mustard  pack  are 
beneficial. 

When  acidosis  is  present  as  indicated  by  dyspnea  of  the  "air  hunger 
type"  or  by  stupor,  alkalis  are  indicated,  especially  sodium  bicarbonate. 
This  may  be  given  by  mouth,  intravenously  or  subcutaneously.  Enough 
should  be  given  to  render  the  urine  alkaline  and  to  keep  it  so.  As  there 
is  a  greatly  increased  tolerance  for  alkalis  the  amount  required  may  be 
large.  With  a  normal  infant  the  administration  of  fifteen  grains  of 
bicarbonate  of  soda  is  sufficient  to  render  the  urine  alkaline.  With 
acidosis  six  or  eight  times  this  amount  may  be  required.  It  should  be 
given  in  doses  of  fifteen  to  thirty  grains  every  two  hours.  If  vomited, 
it  should  be  given  subcutaneously  or  intravenously.  The  latter  method 
is  preferable  if  the  injection  can  be  made  through  the  skin  without  expos- 
ing a  vein.  As  much  as  50  c.c.  of  a  four  per  cent  solution  of  sodium 
bicarbonate  may  be  given  at  a  time.  If  a  vein  can  not  be  found,  the  solu- 
tion may  be  injected  subcutaneously.  This  method  has  the  disadvantage 
of  requiring  a  solution  ^  which  is  somewhat  difficult  to  prepare  and  even 
with  all  precautions  sloughing  may  result  from  its  use.  The  injection 
should  be  repeated  with  sufficient  frequency  to  maintain  the  urine  alka- 
line. 

The  early  evidences  of  acidosis  are  difficult  to  recognize  clinically; 
it  is,  therefore,  safer  to  give  soda  in  all  severe  cases  of  intestinal  indiges- 

^  The  solution  is  prepared  by  sterilizing  a  four  per  cent  solution  of  carbonate 
of  soda.  This  being  irritating  it  is  necessary  to  transform  it  to  the  bicarbonate 
by  passing  carbon  dioxid  from  a  Kipp  generator  or  a  cylinder  through  the  cold 
solution  until  it  is  colorless  to  phenolphthalein.  It  may  then  be  used.  Solutions 
of  bicarbonate  cannot  be  sterilized  without  decomposing. 


ACUTE  ILEOCOLITIS  373 

tion  in  quantity  sufficient  to  maintain  an  alkaline  reaction  of  the  urine. 

With  the  severe  form  of  the  disease,  especially  in  the  cholera  in- 
fantum type,  the  great  drains  of  water  and  salts  from  the  blood  may  in 
itself  be  serious. 

Vomiting  is  usually  present  which  prevents  the  giving  of  water  by 
mouth;  enemata  are  not  retained.  It  is  therefore  necessary  in  many 
cases  to  give  water  subcutaneously.  This  may  be  given  by  hypodermocly- 
sis  as  described  elsewhere  in  amounts  varying  from  six  to  ten  ounces 
daily.  The  bicarbonate  of  soda  solution  mentioned  above  may  be  em- 
ployed or  simple  saline  solution  of  a  strength  of  eight-tenths  of  one  per 
cent.  These  injections  should  be  repeated  until  the  cessation  of  vomiting 
allows  sufficient  water  to  be  taken  by  mouth.  Their  beneficial  effect  is 
frequently  striking.  Glucose  in  three-per-cent  strength  may  be  added 
to  the  saline  solution  but  in  the  majority  of  instances  the  sugar  content 
of  the  blood  is  within  normal  limits  or  even  abnormally  high.  Except 
in  prolonged  cases  therefore  the  addition  of  glucose  does  not  seem  to  be 
indicated. 


CHAPTER  VII 
DISEASES  OF  THE  INTESTINES.— {Continued) 

ACUTE  ILEOCOLITIS— DYSENTERY 

{Enterocolitis ;  Enteritis;  Inflammatory  Diarrhea) 

The  term  ileocolitis  is  a  general  one,  embracing  those  forms  of 
intestinal  disease  in  which  true  inflammatory  lesions  are  present.  In 
the  types  of  cases  described  in  the  previous  chapter  nothing  more  than 
superficial  changes  occur,  while  in  ileocolitis  the  pathological  process  con- 
tinues until  there  have  been  produced  marked  lesions,  often  involving  all 
the  walls  of  the  intestine.  Sometimes  it  is  impossible,  by  symptoms,  to 
draw  a  line  between  them.  This  is  especially  true  of  the  cases  ter- 
minating in  follicular  ulceration  of  the  colon.  In  certain  other  forms 
of  ileocolitis  the  evidences  of  a  severe  intestinal  inflammation  are  often 
manifest  from  the  very  outset.  This  difference  is  probably  due  to  a 
difference  in  the  character  of  the  infection.  The  extent  of  the  lesions 
depends  much  upon  the  duration  of  the  process. 

Etiology. — The  predisposing  causes  of  ileocolitis  are  those  common 
to  diarrheal  diseases  in  general,  and  have  already  been  considered.  Al- 
though seen  with  especial  frequency  in  summer,  and  in  children  under 
two  years  old,  it  may  affect  those  of  any  age,  and  occurs  at  all  seasons. 


374  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Epidemics  are  not  uncommon  in  the  early  fall  months.  Wliile  nsiially 
primary,,  ileocolitis  often  follows  infectious  diseases,  especially  measles, 
diphtheria,  and  bronchopneumonia.  It  frequently  occurs,  in  institutions 
chiefly,  as  a  terminal  infection  in  infants  suffering  from  extreme  mal- 
nutrition or  marasmus.  All  other  forms  of  intestinal  disease  are  predis- 
posing causes.  The  question  of  contagion  is  unsettled;  if  at  all  com- 
municable, it  is  feebly  so.  When  it  occurs  epidemically  a  common  origin 
seems  more  probable  than  that  the  disease  spreads  from  one  patient  to 
another. 

The  only  bacterium  that  up  to  the  present  time  has  been  proven  to 
be  capable  of  producing  this  form  of  intestinal  disease  is  the  B.  dysen- 
teriae  of  Shiga.  This  organism,  or,  more  properly  speaking,  this  group 
of  closely  allied  organisms,  has  now  been  found  in  all  parts  of  the  world 
in  a  sufficient  number  of  cases  to  establish  its  etiological  connection  with 
ileocolitis.  The  B.  dysenteriae  was  shown  by  Shiga,  in  1898  and  1899, 
to  be  the  cause' of  epidemic  dysentery  in  Japan.  In  1900,  Flexner  estab- 
lished its  association  with  tropical  dysentery  in  the  Philippines,  and  in 
1903,  Duval  and  Bassett,  pupils  of  Flexner,  demonstrated  its  presence 
in  a  series  of  cases  of  diarrhea  in  children  at  Baltimore. 

This  organism  is  very  frequently  found  in  cases  showing  blood  and 
mucus,  or  much  mucus  in  the  stools.  Although  usually  the  B.  dysenteriae 
is  greatly  outnumbered  by  other  organisms,  it  is  not  uncommon  to  find 
it  in  pure  culture.  A  number  of  minor  differences  have  been  found  in 
the  bacilli  from  different  cases;  there  are,  however,  two  main  groups, 
the  division  being  made  by  reason  of  the  difference  in  reaction  with 
litmus  mannite;  one  group  is  known  as  the  "true  Shiga,"  or  "alkaline" 
type ;  the  other,  as  the  "acid"  type,^  which  has  been  most  frequently  found 
in  the  diarrheal  diseases  of  children  in  this  country,  although  the  true 
Shiga  is  occasionally  present,  and  in  rare  cases  they  may  be  associated. 

AVhether  the  B.  dysenteriae  is  present  in  normal  stools  of  healthy  chil- 
dren is  still  unsettled.  Wollstein  at  the  Babies'  Hospital  failed  to  dis- 
cover its  presence  in  the  stools  of  56  normal  infants.  The  B.  dysenteriae 
has  never  been  found  outside  the  body ;  we  are  therefore  entirely  ignorant 
both  of  its  habitat  and  its  mode  of  entry.  There  are  grounds  for  believ- 
ing that.it  appears  at  times  among  the  saprophytic  bacteria  of  the  intes- 
tinal contents. 

The  role  played  by  other  bacteria,  especially  tlie  streptococcus,  in  the 
production  of  the  deeper  lesions  of  the  intestine  may  be  an  important 
one.  This  appears,  however,  to  be  rather  in  the  nature  of  a  secondary 
invasion ;  but  the  streptococcus  is  foimd  at  times  in  such  overwhelming 
numbers  that  it  is  considered  by  some  authorities  to  play  the  chief  part 

^The  "acid"  type  includes  the  Flexner-Harris,  the  "Y"  type  of  Hiss  and  Russell 
and  the  Strong  (Manila)  subvarieties. 


ACUTE  ILEOCOLITIS  375 

in  the  production  of  the  lesions.  The  gas  bacillus  of  Welch,  the  bacillus 
pyocyaneus  and  the  other  organisms  occasionally  found  in  the  stools  are 
probably  of  accidental  occurrence. 

Lesions. —  It  is  surprising  that,  so  far 'as  is  known,  a  single  organism 
can  excite  such  a  variety  of  lesions.  The  nature  of  the  anatomical 
changes  apparently  depends  upon  other  factors,  such  as  the  intensity 
of  the  infection,  the  local  resistance,  and  still  more  upon  the  duration 
of  the  disease.  The  association  of  other  organisms  must  also  be  con- 
sidered. 

The  nature  of  the  lesions  in  ileocolitis  differs  greatly,  l)ut  their  ])osi- 
tion  is  quite  constant;  they  affect  the  lower  ileum  and  the  colon.  In 
about  half  the  cases  only  the  colon  is  affected.  The  lesions  of  the  ileum 
are  usually  limited  to  the  lower  two  or  three  feet. 

Acute  Catarrhal  Ileocolitis.— In  the  milder  cases  there  is  infiltration 
of  the  mucosa.  In  the  severer  cases  the  submucosa  is  involved,  and  the 
infiltration  of  the  mucosa  may  be  so  great  as  to  lead  to  necrosis  and  the 
formation  of  ulcers. 

While  the  lower  ileum  and  the  colon  are  most  seriously  affected,  it  is 
]iot  uncommon  to  find  quite  marked  clianges  in  a  considerable  portion  of 
the  small  intestine,  and  even  in  the  stomach.  In  the  cases  of  shoi"t 
duration,  the  lesions  are  sometimes  more  marked  in  the  small  intestine 
than  in  the  colon.  The  mucous  memljrane  is  often  coated  with  tenacious 
mucus  and  may  appear  somewhat  swollen.  Congestion  is  a  constant  fea- 
ture, and  it  may  be  simply  upon  the  folds  of  the  mucous  membrane, 
or  about  the  solitary  follicles,  or  it  may  be  intense  and  involve  the  wliole 
intestine  for  some  distance.  Small  hemorrhagic  areas  are  often  seen  here 
and  there,  widely  scattered.  In  the  most  severe  cases  there  are  marked 
tliickening  and  uniform  congestion.  The  solitary  follicles  througlunit 
the  colon  are  usually  swollen,  projecting  above  the  mucous  membrane  and 
about  the  size  of  a  pin's  head.  Peyer's  patches  may  be  normal,  or  they 
may  be  swollen  and  congested,  or,  more  rarely,  they  may  be  involved 
when  the  rest  of  the  mucosa  appears  healthy.  The  lymph  nodes  of  the 
mesentery  are  usually  swollen  and  acutely  congested. 

In  interpreting  the  microscopical  changes  found  in  the  mucosa,  the 
same  precautions  must  be  observed  as  stated  in  the  previous  chapter. 
There  is  usually  loss  of  the  superficial  epithelium  and  of  that  lining  the 
tubular  glands  at  their  orifices.  The  lumen  of  the  tubular  glands  is 
narrowed  from  pressure  due  to  the  swelling  of  the  tissue  which  separates 
them,  which  is  partly  from  edema,  and  partly  from  cell  infiltration.  A 
thick  layer  of  mucus  and  round  cells,  adhering  closely  to  the  surface, 
may  resemble  a  pseudo-membrane  (Fig.  36).  The  superficial  portion  of 
the  mucosa  may  be  infiltrated  with  round  cells  and  crowded  with  bacteria 
of  many  kinds;  the  depth  to  which  this. infiltration  extends  depends  upon 


376 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


the  severity  and  duration  of  the  process.  In  very  severe  cases  there  is 
found  a  dense  infiltration  of  the  mucosa  and  of  the  suhmucosa  also,  which 
in  places  extends  quite  to  the  muscular,  coat,  ^'he.lymijh  nodules  of  the 
colon  are  swollen,  to  a  greater  or  less  degree,  chiefly  frcjin  an  increase  in 
the  number  of  lymphoid  cells:  This,  swelling  may  be  thfe  most  prominent 
feature  of  the -lesion. ;  If  the  process  is  suffieientlyprolbnged,  the  lymph 
nodules  may  break  down', and  ulcerate.  The  changes  in  the  lymph 
nodules  of  the  small  intestine  andinPeyef's  patches  are  similar  to  those 
seen  in  the  colon,  but  are  less  marked,  and  are 'frequently  absent  alto- 
gether.   Ulceration- in-I;eyer's  patches  is  extremely,  rare.    The  small  veins 


Fig.  36. — Acute  Catarrhal  Inflammation  of  the  Ileum  ;  Severe  Form.  The  mucosa, 
C,  is  everywhere  densely  infiltrated  with  round  cells,  compressing  the  tubular  follicles, 
and  in  places,  L,  L,  almost  effacing  them.  Upon  the  surface  of  the  mucosa  is  a  thick 
layer  of  cells  and  mucus.  Beneath  this  the  epithelial  arches,  B,  B,  covering  the  villi 
can  be  seen.  The  lesions  are  almost  entirely  of  the  mucosa.  The  only  changes  in 
the  submucosa,  E,  are  groups  of  cells  about  the  small  blood-vessels,  V,  V.  History. — 
Infant  six  months  old;  moderate  diarrhea  twelve  days;  severe  symptoms  with  high 
temperature  for  ^six  days.  There  was  intense  inflammation  of  the  entire  colon  and 
lower  three  feet  of  the  ileum.  Intestine  greatly  congested  and  thickened.  Specimen 
is  from  the  ileum. 


and  capillaries -Sf  the  mucosa -and  submucosa  are  usually  distended  with 
blood;  small  extravasations  are  very  common,  and  occasionally  larger 
ones  are  seen.  .".,'''. 

Catarrhal  inflammatioh,  except  in  its  very  severe  form,  which  is  not 
frequent,  causes':.no.lesions  that 'can  not  readily  be  repaired.  The  most 
persistent  change  is  usually  the  swelling  of  the  lymph  nodules,  which 
may  last  a  long  time.  There  is  often  pigmentation  whicli  may  occur 
as  striae  in  the  mucotis  membrane  but  which  is  more  frequently  limited 
to  Peyer's  patches  and  the  solitary  lymph  nodes.  Under  the  microscope 
there  may  be  found  more  or  less  celh  infiltration  of  the  mucosa,  but  rarely 
any  destructive  changes  or  new  connective  tissue. 


PLATE  V 


C 


Extensive  Supebficial  Ulceeation  of  the  Colon 
Female  child  nine  months  old ;  symptoms  of  acute  ileocolitis  of  fifteen  days'  duration ; 

temperature,  101°  to  104.5°  F.,  and  from  six  to  eight  stools  daily — thin,  green,  and  yellow, 

but  no  blood. 

Extensive  ulceration  throughout  the  colon,  most  marked  in  descending  portion,  from 

which  specimen  is  taken. 

A  A  are  small  circular  ulcers;  B  B,  larger  ones  from  coalescence  of  several  of  these; 

G  C,  large  areas  of  ulceration,  the  mucous  membrane  being  almost  entirely  destroved. 


ACUTE  ILEOCOLITIS  377 

Catarrlial  Inflanimaiioih  with  Superficial  Ulceration.. — In  the  most 
severe  form  of  catarrhal  inflammation  which  does  not  prove  fatal  in 
the  earlier  stages,  extensive  ulceration  occasionally  takes  place;  usually 
these  ulcers  are  seen  throughout  the  entire  colon,  and  occasionally  a 
few  are  found  in  the  lower  ileum.  They  generally  begin  in  the  mucosa 
overlying  the  lymph  nodules,  and  while  they  have  a  wide  superficial  area, 
they  do  not  extend  deeper  than  the  mucosa.  The  small  ulcers  are  circular 
and  usually  show  at  the  center  a  small  granular  body — the  lymph  nodule. 
The  larger  ulcers  result  from  the  coalescence  of  several  small  ones,  and 
are  irregular  in  shape.  They  may  be  two  or  three  inches  in  diameter. 
Sometimes  for  a  considerable  distance  a  large  part  of  the  mucosa  may  be 
destroyed.  Often  the  entire  surface  presents  a  worm-eaten  appearance. 
(Plate  V).  On  microscopical  examination  there  is  seen,  in  the  greater 
part  of  the  ulcer,  complete  destructiort  of  the  mucosa,  the  submucosa 
being  densely  packed  with  round  cells  quite  to  the  muscular  coat. 

Inflammation  of  the  Lymph  Nodules — Follicular  Ulceration. — ^Follic- 
ular ulcers  are  found  at  autopsy  in  about  one-third  of  the  cases  dying 
from  diarrheal  diseases.  They  are  rarely  seen  in  those  which  have  lasted 
less  than  a  week,  and  not  often  before  the  middle  of  the  second  week. 
The  average  duration  of  the  disease  in  these  cases  is  about  three  weeks. 

In  thirty-six  cases  in  which  follicular  ulcers  were  found  at  autopsy, 
they  were  present  in  the  small  intestine  alone  in  but  three  cases;  in  the 
^mall  intestine  and  in  the  colon  in  six  cases;  in  the  remaining  twenty- 
seven  they  were  present  only  in  the  colon.  When  in  the  small  intestine 
they  were  seen  only  in  the  lower  ileum.  Ulceration  was  seen  a  few  times 
in  one  or  two  of  the  nodules  of  a  Peyer's  patch.  Ulceration  of  the  large 
intestine  involved  the  whole  colon  in  about  half  the  cases;  while  in  the 
remainder  the  process  was  limited  to  its  lower  portion.  The  deepest  and 
also  the  largest  ulcers  were  usually  in  the  descending  colon  and  sigmoid 
flexure. 

In  the  early  stage  these  ulcers  appear  as  tiny  excavations  at  the  sum- 
mit of  the  prominent  lymph  nodules.  Later,  the  whole  nodule  may  be 
destroyed,  and  a  small  round  ulcer  is  formed  from  one-twelfth  to  one- 
fourth  of  an  inch  in  diameter  (Plate  VI).  These  are  quite  deep  and 
have  overhanging  edges ;  when  closely  set  they  give  the  intestine  a  sieve- 
like appearance.  By  the  coalescence  of  several  of  them,  larger  ulcers 
may  form  which  are  an  inch  or  more  in  diameter.  At  the  bottom  of 
these  larger  ones  the  transverse  striae  of  the  circular  muscular  coat  are 
often  plainly  seen.     Perforation  is  extremely  rare. 

Microscopically  the  lymph  nodules  appear  swollen,  principally  from 
the  accumulation  within  them  of  round  cells.  This  is  followed  by  soften- 
ing, which  usually  begins  at  the  summit  of  the  nodule  and  extends 
downward;  the  reticulum  breaks  down,  and  the  cellular  contents  escape 


378 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


into  the  intestine  (Fig.  37).  Softening  may  begin  at  the  center  of  the 
nodule,  which  ruptures  like  an  abscess.  The  destruction  of  the  whole 
nodule  leaves  a  cavity,  which  is  the  follicular  ulcer.  At  first  the  ulcer 
corresponds- in  "size  to  the  nodule,  but  infiltration  of  the  adjacent  tissue 
soon  takes  place,  which  may  become  necrotic.  In  this  way  the  ulcer 
extends  chiefly  in  the  ■  submucous  coat.  The  lesion;  is  never  limited 
to  the  lymph  nodules ;  but  the  extent  of  the  other  changes  found  depends 


Fig.  37. — Lymph  Nodule  of  the  Colon  in  the  Early  Stage  of  Ulceration. — Follicu- 
lar Ulcer;  The  nodule,  F,  is  much  enlarged,  and  is  breaking  down  and  discharging 
into  the  intestine.  The  other  changes  are  not  marked.  The  superficial  epithelium 
is  gone;  the  mucOsa,  A,  shows  a  slight  increase  of  cells,  and  in  the  submucosa,  C,  are 
nests  of  .cells  about  the  small  vessels,  V,  V.  History. — Delicate  child,  thirteen  months 
old;  slight  diarrhea  four  weeks;  severe  symptoms  five  days.  The  colon  was  filled 
■with  ulcers  one-twelfth  of  an  inch  in  diameter,  one  of  which  is  shown  in  the  illustration- 

upon  the  severity  and  the  duration  of  the  process.  In  cases  fatal  after 
an  illness  of  a  week  or  ten  days,  we  usually  find  only  moderate  changes 
in  the  mucosa^  and  in  the  submucosa. 

Follicular  ulceration  of  the  intestine  in  infancy  usually  terminates 
fatally  if  the.  process  is  an  extensive  one.  In  less  severe  cases  recovery 
may  take  place^.the  ulcers  healing  by  granulation  and  cicatrization  in  the 
course  of  frorn  four  to  twelve  weeks.  It  is  very  doul;)tful  whether  stric- 
ture ever  results  from  these  ulcers  in  children.  Among  the  very  rare 
lesions  are  cysts  of:  the  colon  that  are  produced  by  dilatation  of  some  of 
tbe  tubular  glands  whose  orifices  have  been  obliterated. 

Acute  Membranous  Ileocolitis. — This  is  the  most  severe  form  of 
intestinal  inflammation  seen  among  children.     The  most  frequent  type 


PLATE  VI 


f     ^m^f'Sfs^ 


Uf 


!%*'; 


«f\ 


J^» 


Deep  Follicular  Ulcers  of  the  Colon 

A  delicate  child,  fourteen  months  old,  sick  twelve  days;  stools  green,  j^ellow,  brown, 
and  watery;  no  blood;  temperature,  100°  to  101°  F. 

The  small  intestine  was  normal;  ulcers  throughout  colon.  The  specimen  is  from 
descending  colon;  the  ulcers  are  deep,  and  most  of  them  extend  to  the  muscular  coat. 


ACUTE  ILEOCOLITIS     -  379 

of  membranous  colitis  is  that  with  severe  acute  symptoms,  both  c(jnsti- 
tutioual  and  local,  with  a  duration  of  from  six  to  fourteen  days.  In 
young  infants  its  symptoms  and  course  are  very  irregular,  and  it  may  be 
found  at  autopsy  when  no  serious  intestinal  lesion  has  been  suspected. 

(rros.s  Appearances. — There  is  visible  to  the  naked  eye  usually  very 
little  pseudo-membrane  and  no  deep  sloughing.  The  lesion  affects  the 
last  two  or  three  feet  of  the  ileum  and  the  entire  colon,  sometimes  only 
the  colon.  It  is  exceedingly  rare  to  meet  with  any  marked  lesions  higher 
in  the  small  intestine.    The  most  marked  changes  are  near  the  ileocecal 


>J/—. 


Fig.  38. — Deep  Follicular  Ulcer  of  the  Colon.  A  deep  ulcer  is  shown  at  F,  a  smaller 
one  at  F' .  The  separation  of  the  mucosa  at  H  is  accidental.  There  is  no  trace  of  the 
,  lymph  nodule  from  which  the  large  ulcer  had  its  origin.  The  destructive  process  has 
extended  laterally  in  the  submucosa,  C,  and  the  mucosa,  A,  is  falling  in  to  fill  up  the 
space.  In  the  -vicinity'  of  the  ulcers,  the  submucosa  is  densely  infiltrated  with  round 
cells  L" ,  L" ,  which  also  are  seen  in  the  lymph  spaces  between  the  bundles  of  circular 
muscular  fibers,  L' ,  L' ,  and  som.e  are  seen  in  the  longitudinal  muscular  coat,  L,  L. 
History. — Thirteen  months  old,  delicate;  continuous  diarrheal  symptoms  for  three 
weeks.  Ulcers  found  throughout  the  colon,  the  largest,  one-half  an  inch  in  diameter. 
The  illustration  shows  one  of  the  small  ones  like  those  in  Plate  VI. 

valve  or  in  the  sigmoid  flexure  and  the  rectum.  In  the  ileum  they  may 
be  quite  as  severe  as  in  the  colon  (Plate  VII).  The  intestinal  wall  is 
firm  and  stifle,  and  is  two  or  three  times  its  normal  thickness.  It  is  not 
thrown  into  deep  folds,  as  is  the  healthy  intestine  when  empty.  It  is 
very  rare  to  find  false  membrane  that  can  be  stripped  off  in  patches  of 
any  considerable  size.  When  membrane  exists,  the  color  is  a  yellowish 
or  grayish  green,  and  the  surface  is  often  fissured,  giving  a  lobulated 
ap]iearanee.  In  the  parts  where  no  pseudo-memlirane  can  be  seen,  the 
surface  is  usually  of  an  intense  red  color  and  is  rougli  and  granular,  in 
striking  contrast  to  tlio  normal  glistening  appearance.  Hero  and  there 
small  extravasations  of  Ijlood  may  be  seen.  In  the  regions  most  affected, 
the  normal  structures  of  the  mucous  meiubrane — the  villi,  Peyer's 
patches,  and  solitary  follicles — can  not  be  distinguished.    Except  in  the 


380  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

lower  ileum  the  small  intestine  shows  no  constant  clianges,  and  none  are 
usually  found  in  the  stomach. 

Microscopical  Changes. — These  (Fig.  39)  are  much  more  uniform 
than  the  gross  appearances.  The  most  characteristic  feature  is  the  exu- 
dation of  fibrin,  which  forms  a  distinct  pseudo-membrane  upon  the 
surface  of  the  intestine ;  it  may  infiltrate  the  mucosa,  and  even  the  sub- 
mucosa.  Fibrin  is  seen  under  the  microscope  in  parts  of  the  specimen, 
which  to  the  naked  eye  show  no  distinct  pseudo-membrane,  but  only  a 


e<: 


tr^^2g£i:>*"*"""~^-^-^=^"  ^"^    L-^-^-^^l^^ii^ijyii 


Fig.  39. — Membranous  Inflammation  of  the  Colon.  The  intestine  is  covered  with 
a  pseudo-membrane,  Af,  which  is  composed  chiefly  of  granular  fibrin;  the  mucosa, 
A,  is  densely  packed  with  round  cells,  and  the  tubular  follicles  have  almost  dis- 
appeared, traces  only  being  left,  at  T,  T.  The  submucosa,  C,  is  greatly  thickened, 
partly  from  cells,  but  chiefly  from  fibrin,  which  with  a  high  power  is  seen  to  be  every- 
where in  this  coat,  as  well  as  the  mucosa.  Nests  of  cells  are  seen  in  the  muscular 
coats  at  L,  L,  At  F  is  a  lymph  nodule  covered  by  pseudo-membrane,  but  breaking 
down  at  its  center.  V,  V,  are  small  blood-vessels  with  nests  of  cells  about  them. 
History. — Fourteen  months  old;  ill  nine  days;  temperature  101°  to  105°  F. ;  all  stools 
containing  blood.  Lesions  found  throughout  colon  and  in  lower  ileum.  Intestine 
greatly  thickened.  Specimen  is  from  ascending  colon,  where  lesion  was  especially 
severe. 

granular  appearance.  In  rare  cases  a  fibrinous  exudation  may  be  found 
upon  the  peritoneal  covering  of  the  intestine.  The  pseudo-membrane  is 
made  up  of  a  fibrinous  network  containing  small  round  cells,  some  red 
blood-cells,  and  numerous  bacteria.  The  mucosa,  and  usually  the  sub- 
mucosa, are  densely  infiltrated  with  small  round  cells,  which  in  places 
may  be  so  numerous  as  to  efface  the  normal  elements  of  the  intestine. 
The  tubular  follicles  are  in  some  places  quite  destroyed,  not  a  vestige  of 
tliem  remaining.  In  other  places  they  are  compressed  and  distorted  by 
the  accumulation  of  cells.     The  great  thickening  of  the  intestine  is  due  ~ 


ACUTE  ILEOCOLITIS  381 

partly  to  the  cell  infiltration,  partly  to  the  fibrinous  exudation,  and 
partly  to  edema.  All  the  blood-vessels,  both  in  the  mucosa  and  sub- 
mucosa,  are  gorged  with  blood,  and  many  small  extravasations  are  seen. 
A  necrotic  process  with  the  formation  of  deep  ulcers  we  have  never  seen 
associated  with  membranous  colitis. 

Associated  Lesions  of  Ileocolitis. — The  most  important  one  is  broncho- 
pneumonia. It  is  found  in  quite  a  large  proportion  of  the  protracted 
cases,  and  not  infrequently  it  is  the  cause  of  death.  There  is  no  evidence 
that  it  is  due  to  an  infection  from  the  intestine,  although  such  a  thing  is 
possible  in  septicemic  cases.  Pulmonary  tuberculosis  is  not  infrequently 
met  with  in  hospital  cases,  having  no  relation  to  the  intestinal  disease. 
Peritonitis  is  infrequent.  We  have  met  with  it  but  once  or  twice,  and 
then  it  was  localized  and  of  the  plastic  variety.  Inflammations  of  the 
other  serous  membranes — pleurisy,  pericarditis,  and  meningitis — are  all 
very  rare. 

The  renal  lesions  of  ileocolitis  have  been  the  subject  of  considerable 
discussion,  some  observers  holding  that  nephritis  is  a  "frequent  compli- 
cation of  the  severer  forms  of  diarrhea,  while  others  have  held  it  to  be 
rare.  The  lesions  that  we  have  usually  found  coincide  with  those  de- 
scribed by  others,  and  consist  in  marked  degeneration  of  the  epithelium 
of  the  tubes  with  but  few  glomerular  or  interstitial  changes.  Acute 
diffuse  nephritis  is  a  very  infrequent  though  sometimes  a  most  serious 
complication.  The  lesions  mentioned  as  usually  present  are  properly 
classed  as  acute  degeneration  rather  than  as  inflammation  of  the  kidney. 
Degenerative  changes  may  be  found  also  in  the  heart  muscle,  the  liver, 
spleen,  and  even  in  the  central  nervous  system. 

Considerable  attention  has  been  given  to  a  study  of  the  blood  in 
intestinal  inflammations,  to  determine  how  frequently  and  in  what 
circumstances  a  general  blood  infection  (septicemia)  from  the  intes- 
tines occurs.  In  the  great  majority  of  the  cases  studied  under  proper 
precautions  the  blood  is  sterile. 

Symptoms. —  (1)  Catarrhal  Cases  of  Moderate  Severity. — The  onset  is 
usually  sudden,  often  with  vomiting,  and  for  twelve,  sometimes  twenty- 
four  hours  the  symptoms  may  be  those  of  acute  indigestion:  vomiting, 
pain,  fever,  and  frequent,  thin,  green  or  yellow  stools,  which  are  partly 
fecal  and  contain  undigested  food.  Later  the  discharges  contain  blood 
and  mucus,  are  often  preceded  by  pain  and  accompanied  by  tenesmus. 
The  stools  are  very  frequent,  often  every  half  hour,  and  proportionately 
small,  sometimes  less  than  a  tablespoonful  being  found  upon  the  nap- 
kin after  severe  straining  efforts.  The  mucus  may  be  clear  and  jelly- 
like, or  it  may  be  mixed  with  fecal  matter.  Blood  is  seen  in  some  cases 
in  almost  every  stool,  but  rarely  in  clots,  usually  streaking  the  mucus. 
These  stools  are  almost  odorless.  After  a  few  days  the  blood  usually 
14 


382  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

disappears/or  is  seen  only  as  traces  in  an  occasional  stool;  but  mucus 
is  still  present  in  large  quantities.  The  color  of  the  discharges  now 
becomes  dark  brown  or  brownish-green.  Prolapsus  ani  is  frequent, 
and  may  occur  with  nearly  every  stool.  Abdominal  pain  is  present,  and 
is  often  quite  intense  just  before  the  stool ;  frequently  there  is  ten- 
derness along  the  colon.  For  the  first  twenty-four  hours  the  tempera- 
ture is  usually  high,  from  102°  to  104°  F.  During  the  greater  part  of 
the  attack  it  ranges  from  99°  to  102°  F.  There  is  considerable  prostra- 
tion; the  loss  in  weight  is  usually  marked  and  continuous;  appetite  is 
lost;  the  tongue  is  coated  and  the  general  appearance  of  the  children  in- 
dicates, serious  illness,  although  no  really  grave  symptoms  are  present. 
Convalescence  is  always  slow,  and  it  may  be  months  before  the  lost  weight 
is  regained. 

In  the  milder  cases  the  symptoms  point  to  inflammation  of  the  lower 
part  of  the  colon  only.  The  constitutional  symptoms  are  not  at  all 
marked.  The  temperature  may  not  be  above  101°  F. ;  the  tongue  may 
remain  clean  and  the  appetite  good;  the  child  may  be  bright  and  active, 
and  hardly  seem  at  all  ill,  and  yet  have  from  six  to  eight  mucous  and 
bloody  stools  a  day. 

The  duration  of  the  acute  symptoms  is  usually  two  weeks,  and  yet 
in  such  cases,  even  though  the  child  was  previously  in  good  condition 
and  properly  treated,  recovery  is  slow.  The  first  symptom  of  improve- 
ment is  generally  the  disappearance  of  blood  from  the  stools,  which  at 
the  same  time  become  less  frequent,  and  the  pain  and  tenesmus  oease. 
Gradually  the  stools  assume  more  of  a  fecal  character,  but  mucus  is 
likely  to  persist  for  two  or  three  weeks ;  it  may  be  seen  in  all  stools,  or 
only  occasionally.  In  some  cases  both  the  mucus  and  blood  disappear 
and  the  stools  become  thin,  brown,  or  green,  like  those  of  an  ordinary 
diarrhea.  Eelapses  are  readily  excited,  but  cases  such  as  have  been  de- 
scribed are  rarely  fatal  except  in  delicate  infants.  This  is  the  most  com- 
mon form  of  ileocolitis  which  terminates  in  recovery. 

(2)  TJie  Severe  Catarrhal  Form. — This  form  of  ileocolitis,  like  that 
just  described,  is  usually  primary.  The  symptoms  closely  resemble  those 
of  the  membranous  variety,  and  a  diagnosis  from  it  is  in  most  of  the 
cases  quite  impossible.  The  most  rapidly  fatal  case  we  have  seen  lasted 
only  three  days,  but  the  usual  duration  is  from  one  to  two  weeks.  The 
temperature  is  steadily  high;  the  stools  continue  very  frequent  and 
generally  contain  blood;  there  is  great  prostration,  dry  tongue,  sordes 
on  the  lips  and  teeth,  and  prominent  nervous  symptoms.  Death  usually 
occurs  from  exhaustion  and  profound  sepsis  while  the  acute  symptoms 
are  at  their  height.  If  the  patient  survives  this  stage,  the  case  may 
drag  on  for  four  or  five  weeks  with  a  temperature  curve  much  like  that 
of  typhoid  fever,  and  then  terminate  in  recovery  or  in  death  from  slow 


ACUTE  ILEOCOLITIS 


383 


asthenia,  bronchopneunionia,  ur  from  an  acute  exacerbation  of  the  intes- 
tinal symptoms.  The  autopsy  in  such  cases  usually  reveals  the  presence 
of  superficial  ulcers.  If  recovery  is  to  be  the  outcome,  after  the  symp- 
toms have  been  nearly  stationary  for  a  long  time,  there  is  seen  a  gradual 
improvement  first  in  the  general  and  then  in  the  local  conditions.  Con- 
valescence is  very  slow,  often  interrupted  by  relapses,  and  it  may  be 
months  before  the  patient  is  quite  well. 

(3)  Follicular  Ulceration — Ulcerative  Inflammation  of  the  Nodules. 
— Follicular  ulceration  is  often  preceded  by  other  forms  of  intestinal 
disease.  It  is  much  more  frequently  met  with  in  infants  over  six  months 
of  age.  The  great  majority  of  those  affected  are  institutional  children 
or  those  who  are  in  poor  condition  at  the  time  of  the  attack. 

To  understand  the  symptoms  of  these  cases,  it  must  be  remembered 


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Fig.  40. — Temperature  Chart  of  Ileocolitis,  Fatal  on  Thirty-fourth  Day.  Autopsy 
showed  follicular  ulcers  throughout  the  colon. 


that  follicular  ulceration  is  often  a  terminal  process  following  other  forms 
of  diarrhea.  It  may  be  preceded  by  one  or  more  acute  attacks,  or  by  a 
protracted  subacute  attack.  On  account  of  the  feeble  resistance  of  the 
child  or  the  continuance  of  the  exciting  cause,  the  pathological  process 
gradually  extends  to  the  lymph  nodules  of  the  intestine,  chiefly  the 
colon,  which,  as  already  described,  pass  successively  through  the  stages 
of  swelling,  softening,  and  ulceration.  The  onset  of  the  illness  may 
therefore  be  abrupt,  with  vomiting  and  high  fever;  or  gradual,  without 
vomiting  and  with  very  little  fever. 

Vomiting  is  not  a  feature  of  these  cases ;  but  it  is  often  present  at  the 
onset.  Throughout  the  attack  it  is  easily  excited  by  injudicious  feeding 
or  medication.  The  temperature  is  seldom  high,  except  at  first;  its  usual 
range  is  from  99°  to  101°  F. ;  toward  tlie  close,  even  of  fatal  cases,  it  may 
be  scarcely  above  the  normal.  The  accompanying  chart  (Fig.  40)  is  a 
very  good  illustration  of  the  course  of  the  temperature  in  cases  begin- 
ning abruptly  and  ending  fatally. 

The  stools  are  seldom  very  frequent,  the  number  being  from  four 
to  eight  a  day.     The  most  (constant  feature  is  the  presence  of  mucus. 


384  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

which  is  mixed  with  the  stools  and  usually  abundant.  Blood  is  not  gen- 
erally present,  and  a  large  amount  of  blood  is  extremely  rare.  Large 
hemorrhages  from  ulcers  we  have  never  seen.  The  color  of  the  stools 
is  most  frequently  dark  green  or  brown.  Fluid  stools  are  seen  only 
during  exacerbations.  The  odor  is  usually  offensive,  particularly  in  pro- 
tracted cases.  The  microscope  shows  epithelial  cells  in  great  numbers, 
and  very  often  an  abundance  of  small  round  cells,  which  may  be  looked 
upon  as  the  most  constant  sign  of  ulceration. 

The  failure  in  nutrition  and  steady  loss  in  weight  are  very  constant 
in  these  cases.  As  emaciation  goes  on,  the  skin  hangs  in  loose  folds  on 
the  thighs;  it  becomes  dry  and  scaly  and  loses  its  elasticity,  and  occa- 
sionally small  petechial  spots  are  seen  upon  the  abdomen.  The  skin  over 
the  buttocks  becomes  excoriated,  and  bed-sores  form  over  the  heels,  the 
sacrum,  or  the  occiput.  The  abdomen  may  be  moderately  distended,  or 
it  may  be  relaxed  and  soft.  Tenderness  is  not  usually  present.  The 
appetite  is  lost,  and  in  most  cases  great  difficulty  is  experienced  in  induc- 
ing children  to  take  a  proper  amount  of  nourishment.  Occasionally, 
when  there  is  fever,  fluids  are  taken  eagerly.  A  returning  appetite  is. 
always  an  encouraging  sign.  The  mouth  is  often  dry,  the  tongue  coated, 
sometimes  dry  and  brown ;  there  may  be  sordes  upon  the  lips  and  teeth. 
Superficial  ulcers  form  upon  the  mucous  membrane  of  the  mouth,  and 
often  thrush  is  seen.  The  urine  is  usually  diminished,  high-colored,  and 
loaded  with  urates.  Albumin  and  casts  are  occasionally  present.  Earely 
is  nephritis  severe  enough  to  be  a  factor  in  the  result.  Tenesmus  and 
prolapsus  ani  are  uncommon. 

The  usual  duration  of  the  fatal  cases  is  three  or  four  weeks,  but  may 
be  very  much  longer;  their  course  is  often  marked  by  exacerbations  and 
remissions.  If  recovery  takes  place,  convalescence  is  always  very  slow  and 
relapses  are  easily  excited. 

Very  few  of  these  cases  recover  completely.  Even  those  who  survive 
the  primary  illness  are  likely  to  suffer  from  intestinal  symptoms  for 
many  months.  Fatal  relapses  are  often  brought  on  by  injudicious  feed- 
ing when  the  children  are  apparently  almost  well.  The  general  health 
is  usually  so  undermined  that  the  patients  continue  to  suffer  from  all  the 
symptoms  of  malnutrition,  and  ultimately  succumb  to  an  attack  of  some 
intercurrent  acute  disease. 

The  diagnosis  of  ulceration  is  to  be  made  from  the  case  as  a  whole 
rather  than  from  any  special  symptoms.  If  a  delicate  infant,  who  has 
previously  been  prone  to  diarrheal  attacks,  has  green  mucous  stools  with 
low  fever,  and  these  symptoms  continue  with  unabated  severity  for  two 
or  three  weeks,  ulceration  is  probable.  If  such  symptoms  continue  for 
three  or  four  weeks  with  steadily  failing  strength  and  loss  of  weight,  the 
diagnosis  is  almost  certain.    If,  on  the  contrary,  after  three  or  four  days 


ACUTE  ILEOCOLITIS 


385 


of  acute  symptoms  there  is  improvement  in  the  stools  and  occasionally 
some  which  are  quite  fecal  in  character,  even  though  it  may  be  a  week 
or  more  before  the  mucus  disappears,  we  may  be  quite  certain  that  no 
ulcers  have  formed. 

(4)  The  Memhranous  Form. — This  is  the  gravest  form  of  inflamma- 
tion of  the  intestines  seen  in  children,  and  its  symptoms  are  more  often 
obscure  than  are  those  of  any  other  variety.  This  is  particularly  true 
when  it  affects  young  infants.  There  may  be  at  the  onset  and  through- 
out the  course  of  the  disease  severe  local  aiid  constitutional  symptoms; 
or  with  well-marked  constitutional  symptoms,  the  local  symptoms  may 
be  slight  or  of  very  doubtful  character, 
so  that  it  is  often  mistaken  for  some 
other  disease. 

In  the  first  form  it  closely  resem- 
bles the  most  severe  cases  of  catarrhal 
inflammation.  The  disease  begins 
abruptly  with  vomiting,  high  temper- 
ature, and  several  large,  fluid  stools. 
The  vomiting  does  not  often  continue 
after  the  first  twenty-four  hours.  The 
temperature  is  at  first  from  102°  to 
105°  F.,  and  its  course  may  be  steadily 
high  (Fig.  41),  or  remittent.  The  ab- 
domen is  often  tender  and  sometimes 
swollen.     There  is  severe  pain,  and  at 

times  tenesmus,  with  prolapse  of  the  rectum.  This  is  seen  to  be  intensely 
congested,  and  sometimes  shows  patches  of  pseudomembrane  upon  its 
surface,  thus  establishing  the  diagnosis. 

The  stools  often  resemble  those  of  the  catarrhal  variety,  except  that 
blood  is  more  constantly  present  and  usually  more  abundant,  but  the  only 
positive  point  of  difference  is  the  presence  of  shreds  or  flakes  of  pseudo- 
membrane.  If  the  stools  are  thoroughly  washed  with  water  these  may 
be  seen  as  small  gray  opaque  masses,  which  are  then  easily  distinguished 
from  the  transparent  mucus.  Large  shreds  of  membrane  are  seldom 
seen  in  children.  Both  blood  and  mucus  sometimes  disappear  from  the 
stools,  which  may  consist  only  of  dirty  water.  Under  the  microscope 
there  may  be  seen  epithelial  cells,  red  blood-cells,  and  round  cells  in 
great  numbers. 

The  presence  of  cerebral  symptoms  in  these  cases  of  membranous 
ileocolitis  may  lead  to  great  obscurity  in  the  diagnosis.  This  is  most 
frequently  true  at  the  onset.  There  may  be  high  temperature,  great 
prostration,  vomiting,  stupor,  delirium,  and  even  convulsions;  and  such 
symptoms  may  for  two  or  three  days  completely  mask  the  intestinal  eon- 


DAY 

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98° 

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Fig.  41. — Temperature      Chart      of 
Membranous  Colitis;    Fatal. 


386 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


dition.  As  the  case  progresses,  however,  the  intestinal  symptoms  come 
more  and  more  into  prominence,  and  the  cerebral  symptoms  usually  sub- 
side.   But  sometimes^  this  is  not  the  case. 

Membranous  colitis  is  also  obscure  when  it  affects  young  infants. 
The  prominent  symptoms  are,'  rather  high,  continuous  temperature, 
usually  ranging  between  101°  and  10-4°  F.,  but  following  no  distinct 
curve  (Fig.  42) ;  wasting,  which  is  not  rapid  but  progressive;  frequent 
stools,  which  have  no  -  constant  or  striking  characteristics.  They  are 
usually  thin,  yellow  or-  greenish  in  color,  often  containing  no  mucus  or 
blood.  Occasionally  for  a  day  the  stools  may  be  almost  normal  in  ap- 
pearance. In  number  they  average  five  or  six  a  day,  but  often  for  days 
only  two  or  three.     Outside  of  a  hospital  where  autopsies  are  regularly 


Day             8 

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Fig.  42. — Temperature  Chart  of  Membranous  Colitis.  Infant  fourteen  months 
old,  Babies'  Hospital.  Symptoms  for.  the  first  two  weeks  obscure.  Intestinal  sj'mp- 
toms  for  the  last  two  weeks  only,  never  very  severe ;  stools  four  to  six  daily,  generally 
green,  thin,  with  much  mucus  at  times,  and  once  or  twice  traces  of  blood.  Autopsy: 
No  lesion  of  importance  except  membranous  colitis  involving  entire  colon;  a  slight 
catarrhal  enteritis. 


made  these  cases  aie  usually  overlooked  and  considered  as  obscure  pneu- 
monia, tuberculosis,  septicemia,  typhoid,  etc. 

The  duration  of  membranous  fleocolitis  is  usually  from  one  to  three 
weeks.  Death  takes  place  from  sepsis,  exhaustion,  or  from  complica- 
tions. It  is  probable  that '.almost  every  case  of  the  severity  described 
terminates  fatally  when  it-  occurs  in  an  infant.  In  older  children  the 
prognosis  is  much  ,better  as  to  life,  but  in  them  the  acute  attack  may 
be  follow^ed  by  the  chr-onic  form  of  the  disease.     - 

Diagnosis. — Ileocolitis  is  to  be  distinguished  chiefly  from  typhoid 
fever,  intussusception,  and  meningitis.  .  Typhoid  is  distinguished  by  the 
slower  invasion, ,-mpre  constant^temperature,  enlargement  of  the  spleen, 
tympanites,  and  most  of  all  by  the  Widal  reaction  and- the  eruption. 
Acute  colitis  should  not  be  confounded  with  intussusception;  yet  the 
records  of  intussusception  show  that  a  very  large  proportion  of  the  cases 
were  regarded  in  the  beginning  as  cases  of  dysentery.  In  intussuscep- 
tion, although  there,  is  a  sudden  onset  with  acute  pain,  tenesmus,  vomit- 
ing, and  marked  prostration,  there  is  rarely  fever.     The  later  symptoms 


PLATE  VII 


Membranous  Inflammation  of  the  Ileum 
A  delicate  child,  eleven  months  old;  mild  diarrhea  for  two  weeks  without  fevor; 

acute  severe  symptoms  for  twelve  days;  temperature,  100°  to  102.5°  F.;  green  and  nuicou:s 

stools;  no  blood. 

The  lesions  involved  the  last  foot  of  ileum  and  entire  colon.     Specimen  is  from  lower 

ileum,  and  shows  the  abrupt  termination  of  the  lesion;  the  upper  part  shows  normal 

small  intestine;  A  is  a  Peyer's  patch;  B  is  the  inflamed  part  of  the  intestine;  it  has  a  rough 

granular  appearance  and  is  much  thickened. 


ACUTE  ILEOCOLITIS  387 

• — absolute  constipation,  tumor,  stercoraceous  vomiting,  and  collapse — 
have  nothing  in  common  with  colitis.  The  membranous  form  may  be 
confounded  with  meningitis,  and  in  some  cases  a  differential  diagnosis 
is  impossible  except  by  lumbar  puncture.  Marked  diarrhea,  even 
though  the  stools  are  not  characteristic,  should  always  make  one  doubt 
meningitis. 

A  diagnosis  between  the  different  varieties  of  ileocolitis  is  not  always ' 
possible.    Follicular  ulceration  is  distinguished  by  its  lower  temperature, 
rather  subacute  course,  infrequency  of  blood  in  the  stools,  and  by  the 
fact  that  it  is  usually  preceded  by  diarrheal  attacks  Which  are  often 
prolonged. 

In  the  catarrhal  form,  the  symptoms  of  an  acute  inflammation  of 
the  colon  are  usually  manifest  from  the  outset — bloody  stools,  pain, 
tenderness,  tenesmus,  and  fever.  In  the  membranous  variety  such  symp- 
toms are  sometimes  seen;  but,  as  a  rule,  the  local  symptoms  are  less 
pronounced,  while  the  constitutional  symptoms,  especially  those  relating 
to  the  nervous  system,  are  usually  marked.  The  course  is  usually  shorter 
and  more  intense  than  in  the  other  forms. 

An  agglutination  reaction  of  the  B.  dysenteriae  with  the  serum  of 
affected  children  is  usually  present.  But  for  general  use  in  diagnosis 
this  is  not  of  great  assistance.  It  is  subject  to  considerable  variation. 
Moreover,  it  is  seldom  present  until  the  end  of  the  first  week  of  the  dis- 
ease, by  which  time  the  nature  of  the  attack  is  evident  by  clinical  symp- 
toms. Agglutination  in  the  higher  dilutions  is  seen  only  with  the  par- 
ticular type  of  organism  with  which  the  infant  is  infected. 

Prognosis. — The  younger  the  patient  the  worse  the  outlook.  The 
prognosis  is  rendered  unfavorable  by  extreme  summer  heat  and  by 
prolonged  previous  attacks  of  intestinal  disturbance.  The  outlook  is 
worse  in  secondary  than  in  primary  cases.  In  a  given  case  bad  prog- 
nostic symptoms  are :  continuous  high  temperature,  the  persistence  of 
much  blood  in  the  stools,  and  severe  nervous  symptoms.  The  prognosis 
is  always  worse  in  institutions  than  in  private  practice. 

Prophylaxis. — What  has  been  said  in  a  previous  chapter  regarding 
the  general  prophylaxis  of  diarrheal  disease,  applies  equally  well  to 
cases  of  ileocolitis. 

Special  emphasis  should  be  placed  upon  the  necessity  of  energetic 
early  treatment  of  all  the  milder  forms  of  diarrhea,  and  particularly 
the  cases  of  acute  intestinal  indigestion,  in  order  that  the  process  may 
be  arrested  before  serious  anatomical  changes  have  taken  place.  Equal 
stress  should  be  laid  upon  the  importance  of  prompt  and  intelligent 
treatment  at  the  very  beginning  of  the  cases  with  a  sudden  onset. 

Hygienic  Treatment. — The  general  plan  recommended  in  the  pre- 
vious chapter  should  be  followed  here.    A  change  of  air  is  desirable  for 


388  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

most  cases  as  soon  as  the  acute  inflammatory  symptoms  have  subsided. 
In  the  protracted  cases  which  drag  on  a  subacute  course,  this  change 
will  often  do  more  than  anything  else.  Plenty  of  fresh  air  is  necessary 
in  all  cases.  The  indications  foT  bathing  are  the  same  as  in  other  cases 
of  acute  diarrhea.  It  is  undesirable  to  crowd  these  patienxs  in  institu- 
tions, as  they  always  do  better  when  separated. 

The  diet  during  the  acute  stage  should  be  the  same  as  in  other  forms 
of  acute  diarrhea.  In  the  protracted  cases  the  diet  presents  great  dif- 
ficulties, as  the  children  have  little  or  no  appetite,  and  soon  come  to 
refuse  everything  in  the  shape  of  food  that  is  offered.  In  infancy,  for 
the  first  day  or  two  onl}",  barley  or  rice  water  or  weak  tea  should  be 
given.  As  soon  as  the  vomiting  ceases  protein  milk  may  be  given  in 
the  manner  described  in  the  previous  chapter.  Buttermilk  may  be  used 
as  a  substitute  if  protein  milk  cannot  be  obtained,  but  is  not  so  effica- 
cious. Especially  to  be  avoided,  not  only  in  the  acute  stage  but  during 
convalescence,  are  cream,  all  top-milk  mixtures,  and  also  the  malted  foods. 
Infants,  when  very  ill,  are  much  more  likely  to  take  too  little  than  too 
much  food.  A  careful  record  should  be  kept  of  the  amount  actually 
taken  in  each  twenty-four  hours.  In  no  case  should  food  be  given  oftener 
than  every  four  hours,  water  and  stimulants  being  allowed  between  the 
feedings.  In  older  children  the  diet  during  the  acute  stage  should  be 
much  the  same  as  in  infants,  but  to  them  junket  from  which  the  whey 
has  been  carefully  strained  may  also  be  given  with  a  spoon.  At  a  later 
period,  rare  scraped  beef,  kumyss,  buttermilk,  skimmed  milk,  and  zoo- 
lak  will  be  found  useful,  and  during  convalescence,  eggs,  boiled  milk,  or 
milk  gruel  made  with  rice  or  barley.  Special  care  should  be  given  to 
the  diet  for  a  long  time.  For  months  after  an  acute  attack  the  intes- 
tines are  very  easily  deranged.  Eelapses  »re  excited  by  changes  in  the 
temperature,  by  great  fatigue  or  exhaustion,  but  most  of  all  by  improper 
feeding.  Especially  in  older  children  should  such  articles  as  cream, 
corn,  tomatoes,  green  vegetables,  and  all  fruits  be  withheld  for  a  long 
time. 

Medicinal  and  Mechanical  Treatment. — Cases,  the  early  stage  of 
which  is  marked  by  vomiting  and  thin  diarrheal  stools,  are  to  be  man- 
aged at  the  outset  according  to  the  plan  outlined  in  the  previous  chapter, 
viz.,  purgation,  irrigation  of  the  colon,  and  stopping  all  food.  Castor  oil, 
should  be  administered  at  the  outset — one  dram  at  six  months,  two 
drams  at  one  year,  and  half  an  ounce  at  four  years.  The  salines 
may  be  used  as  described  in  the  previous  chapter.  If  the  stomach  is  at 
all  irritable,  calomel,  one-fourth  grain  every  half-hour  for  four  doses, 
may  be  substituted.  Opium  is  usually  required  on  account  of  the  pain, 
tenesmus,  and  great  frequency  of  stools.  The  dose  should  be  regulated 
by  the  severity  of  these  symptoms.    The  deodorized  tincture  and  paregoric 


ACUTE  ILEOCOLITIS  389 

are,  we  think,  preferable  to  other  preparations.  Eepeated  small  doses  are 
better  than  a  single  large  dose.  It  is  very  important  that  opium  should 
be  withheld  for  at  least  twelve  hours  after  the  initial  purgative. 

As  the  pathological  process  is  principally  in  the  colon,  and  most 
severe  in  the  lower  half  of  the  colon,  it  can  often  be  much  more  effectively 
treated  by  injections  than  by  drugs  given  by  the  mouth.  Irrigation  of 
the  colon  is  one  of  our  most  valuable  means  of  treatment  in  these  cases. 
For  general  purposes  a  saline  solution  at  100°  to  104°  F.  should  be 
employed.  One  or  two  quarts  should  be  used  for  each  irrigation.  The 
solution  should  be  injected  high  into  the  colon  through  a  rectal  tube, 
and  early  in  the  disease  repeated  at  least  twice  a  day.  When  the  tenes- 
mus is  very  great  and  blood  abundant,  small  injections  of  either  hot 
water  (106°  to  110°  F.)  or  ice  water  may  be  used,  and  later  astringent 
injections. 

The  most  useful  astringent  is  tannic  acid  of  which  one  dram  may 
be  added  to  a  pint  of  hot  water.  Whether  injections  are  to  be  used 
regularly  or  not  will  depend  much  upon  the  patient.  If  they  are  well 
borne,  they  may  be  given  once  or  twice  a  day  during  the  attack;  but  if 
at  every  attempt  to  give  them  ihe  child  struggles,  screams,  and  resists, 
they  may  do  more  harm  than  good.  Complete  rest  is  a  very  important 
part  of  the  treatment. 

For  cases  not  influenced  by  the  measures  mentioned,  or  those  not 
seen  at  the  outset,  bismuth  should  be  tried,  but  it  is  of  no  use  whatever 
unless  large  doses  are  administered.  From  two  to  four  drams  of  the 
subcarbonate  should  be  given  in  twenty-four  hours  to  a  child  two  years 
old,  and  proportionate  doses  to  older  children.  This  may  be  suspended 
in  mucilage.  Tenesmus  and  pain  are  sometimes  relieved  by  the  injection 
of  three  or  four  ounces  of  a  starch  solution  to  which  from  five  to  ten 
drops  of  laudanum  are  added.  Severe  tenesmus,  when  not  controlled 
thus,  and  when  associated  with  prolapsus  ani,  is  sometimes  immediately 
relieved  by  a  suppository  containing  cocain.  Kot  more  than  one-fourth 
grain  should  be  used  for  a  child  of  three  years. 

Although  a  serum  has  been  produced  which  protects  animals  against 
inoculation  with  the  B.  dysenteriae  its  use  in  the  treatment  of  the  vari- 
ous forms  of  ileocolitis  in  children  has  not  been  followed  by  any  very 
striking  benefit. 

Alcoholic  stimulants  are  needed  in  many  cases.  They  are  indicated 
by  a  weak  pulse,  cold  extremities,  and  great  general  prostration,  no 
matter  at  what  stage  in  the  disease  these  symptoms  are  seen.  Brandy 
is  usually  to  be  preferred.  Generally  not  more  than  fifteen  or  twenty 
drops  every  three  hours  should  be  given  to  an  infant  of  one  year.  Brandy 
should  always  be  well  diluted. 

Ie  cases  where  symptoms  have  lasted  two  or  three  weeks,  and  the 


390  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

active  ones  have  subsided,  when  the  temperature  is  scarcely  above  100° 
F.,  and  the  stools  reduced  to  four  or  five  a  day,  it  is  wise  to  stop  all 
medication  and  attend  only  to  the  feeding,  with  irrigation  of  the  colon 
every  two  or  three  days.  One  is  often  surprised  at  this  stage  to  find 
that  patients  do  better  without  drugs  than  with  them.  The  prevailing 
tendency  is  to  overdose  cases  of  this  type.  N"o  greater  mistake  is  made 
than  to  give  these  children  week  after  week  the  various  diarrhea  mix- 
tures, with  the  expectation  that  ultimately  the  formula  will  be  found 
which  exactly  meets  the  requirements  of  the  particular  case.  The  essen- 
tial and  important  part  of  the  treatment  consists  in  injections,  careful 
feeding  and  change  of  air.  Astringent  enemata,  however,  are  of  some 
value;  they  should  not  be  given  continuously  but  from  time  to  time 
should  be  omitted  for  several  days.  Cases  are  not  infrequently  seen 
where  the  constant  use  of  such  injections  is  an  important  factor  in  keep- 
ing up  the  production  of  mucus.  The  colon  should  first  be  washed 
with  a  large  amount  of  a  tepid  salt  solution  and  then  four  or  five  ounces 
of  the  astringent  solution  injected  and  held  in  place  by  compressing  the 
buttocks  for  half  an  hour.  The  patient  should  be  placed  in  the  best 
possible  surroundings;  in  no  disease  is  a  change  of  air  more  to  be  desire  1 
than  in  this.  They  should  be  in  the  open  air  as  much  as  possible  but 
should  be  kept  warm  for  their  temperatures  quickly  fall  to  subnormal. 
The  dangers  of  relapses  and  acute  exacerbations  continue  long  after  the 
primary  attack  has  subsided. 


AMEBIC  COLITIS 

Amebic  colitis  is  rare  in  children  in  this  country ;  it  is  particularly  so 
in  infants,  probably  owing  to  the  fact  that  nearly  all  the  water  taken 
at  this  age  is  boiled.  Most  of  the  cases  in  children  thus  far  reported 
have-  been  observed  in  warm  climates,  although  Amberg  has  recorded 
five  which  occurred  in  Baltimore,  the  youngest  child  being  two  years  and 
eight  months  old. 

The  symptoms  in  the  few  cases  that  have  been  reported  in  children 
have  differed  in  no  important  particular  from  the  disease  as  seen  in 
adults.  In  exceptional  cases  the  onset  may  be  abrupt  and  the  attack 
may  run  an  acute  course,  terminating  fatally  in  two  to  three  weeks. 
Such  cases  are  characterized  by  much  abdominal  pain  and  tenderness, 
frequent  mucous  and  bloody  stools  containing  amebae,  and  some  fever, 
which,  however,  seldom  reaches  102°  P. 

More  frequently  this  acute  onset  is  followed  by  a  subacute  or  chronic 
form  of  the  disease,  or  the  disease  may  be  subacute  from  the  beginning. 
The  protracted  cases  are  those  most  frequently  seen.     They  are  very 


TUBERCULOSIS  OF  THE  INTESTINES  391 

obstinate  to  treatment.  Periods  of  constipation  and  apparent  recovery 
often  alternate  with  exacerbations  in  which  the  bloody  and  mucous 
stools  return,  with  pain,  tenesmus,  and  slight  fever.  The  duration  may 
be  from  a  few  months  to  one  or  two  years.  Death  may  finally  occur 
from  exhaustion  with  extreme  wasting,  or  from  some  complication,  such 
as  hemorrhage,  abscesses  of  the  liver  being  very  rare  in  children.  The 
diagnosis  from  other  forms  of  colitis  is  made  only  by  the  discovery  of 
pathogenic  amebae  in  a  freshly  voided  stool. 

The  general  treatment  is  the  same  as  for  other  forms  of  acute  or 
subacute  colitis.  The  special  treatment  for  the  purpose  of  destroying 
the  amebae  locally  is  the  use  of  injections  of  quinin  which  may  be  em- 
ployed in  solutions  varying  in  strength  from  1  to  5,000  to  1  to  250. 
Eecently  subcutaneous  injections  of  emetin  hydrochlorid  have  been  used 
for  amebic  colitis  with  very  favorable  results.  Emetin  should  be  given 
in  doses  of  gr.  1/13  to  gr.  1/4  depending  upon  the  age  of  the  child. 
The  dose  should  be  repeated  two  or  three  times  at  intervals  of  a  day  or 
more.    The  drug  is  a  very  powerful  one  and  is  to  be  used  with  caution. 


AMYLOID  DEGENERATION  OF  THE  INTESTINES 

This  is  rarely  met  with  in  infants.  It  is  not  so  infrequent  in  older 
children,  where  it  is  associated  with  amyloid  changes  in  the  liver,  spleen, 
and  kidneys,  usually  as  a  result  of  prolonged  suppuration  in  connection 
with  bone  tuberculosis.  It  is  sometimes  met  with  in  syphilis.  The  ileum 
is  the  part  of  the  intestine  most  affected.  The  process  begins  in  the 
walls  of  the  arterioles  and  capillaries,  particularly  of  the  villi,  and  later 
involves  the  vessels  of  the  submucosa;  subsequently  the  epithelimn  may 
be  affected.  The  mucous  membrane  in  these  cases  is  pale,  somewhat 
translucent.  The  condition  is  recognized  by  the  application  of  the  iodin 
test ;  the  affected  villi  become  of  a  brownish-red  or  mahogany   color. 

Amyloid  degeneration  produces  no  definite  symptoms.  Diarrhea  is 
frequent  but  by  no  means  constant.  The  anemia  and  waxy  cachexia 
which  are  present  are  probably  dependent  much  more  upon  the  associated 
lesions  of  the  liver  and  kidneys  than  upon  the  changes  in  the  intestines. 


TUBERCULOSIS    OF   THE   INTESTINES    AND    MESENTERIC    LYMPH 
NODES   (MESENTERIC  GLANDS) 

These  two  conditions  are  usually,  but  not  invariably,  associated,  and 
may  be  conveniently  considered  together. 

Frequency. — In  a  series  of  386  autopsies  upon  tuberculous  cases  from 


392  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

our  hospital  records,  the  intestines  were  involved  in  40  per  cent.  The 
great  majority  of  the  patients  were  nnder  three  years  of  age.  In  131 
autopsies  upon  tuberculous  cases  published  in  the  Pendlebury  Hospital 
Reports,  the  intestines  were  involved  in  50  per  cent.  These  patients 
were  mainly  between  four  and  fourteen  years  old.  In  209  autopsies 
upon  tuberculous  children,  chiefly  infants,  reported  by  Miiller,  the  intes- 
tines were  involved  in  28  per  cent.  In  1,34G  autopsies  collected  by 
Biedert  there  were  intestinal  lesions  in  31.6  per  cent.  Intestinal  tuber- 
culosis is  most  common  from  the  third  to  the  eighth  year.  The  mesen- 
teric lymph  nodes  are  more  frequently  involved  than  are  the  intestines, 
though  the  two  are  usually  associated.  They  were  tuberculous  in  59 
per  cent  of  the  Pendlebury  cases;  and  in  178  recent  autopsies  at  the 
Babies'  Hospital  upon  tuberculous  patients,  published  by  Bartlett  and 
Wollstein,  these  nodes  were  involved  in  63  j)er  cent;  in  10  per  cent  they 
were  apparently  the  oldest  tuberculous  lesions. 

Etiology. — While  it  is  no  doubt  possible  for  infection  of  the  mesen- 
teric nodes  to  occur  through  the  general  circulation,  this  is  exceptioijal. 
In  the  great  majority  of  cases  infection  takes  place  from  the  intestines; 
i.  e.,  these  are  examples  of  tuberculosis  by  ingestion  rather  than  by  in- 
halation. The  bacilli  in  the  intestinal  tract  may  be  derived  from  food 
or  from  sputum  which  has  been  coughed  up  and  swallowed.  Of  96  cases 
of  abdominal  tuberculosis  of  all  varieties  in  children  under  sixteen  years, 
studied  by  Park  and  Ivrumwiede,  the  infection  was  of  the  bovine  type  in 
52,  and  the  human  type  in  44  cases.  Of  these  children,  71  were  under 
five  years  and  25  between  five  and  sixteen  years.  The  proportion  of 
bovine  infections  was  slightly  larger  in  the  younger  group.  Primary  in- 
testinal tuberculosis  in  this  country  is  relatively  infrequent.  When  it 
does  occur,  however,  it  is  more  often  due  to  a  bacillus  of  the  bovine  than 
of  the  human  type.  The  inference  is  probably  justified  that  in  cases 
of  bovine  infection,  tuberculous  milk  was  the  source  of  the  infection. 
The  intestinal  lesions  most  often  found  in  infants  and  young  children 
are  mild  in  character  and  are  usually  associated  Math  and  secondary  to 
an  advanced  pulmonary  lesion.  They  are  doubtless  due  to  SM^allowing 
tuberculous  sputum.    In  such  cases  the  human  type  of  bacillus  is  found. 

Lesions. — Intestines. — The  usual  seat  is  the  small  intestine,  chiefly 
the  jejunum  and  lower  ileum.  With  extensive  disease  the  large  intes- 
tine may  also  be  involved,  most  frequently  the  cecum,  and  exceptionally 
it  alone  may  be  affected.  Tuberculous  ulcers  may  be  found  in  the 
appendix. 

The  early  deposits  appear  as  tiny  yellow  nodules,  not  numerous  but 
widely  scattered  and  generally  affecting  Peyer's  patches.  Usually,  how- 
ever, ulcers  are  present,  and  often  only  ulcers  are  seen.  Their  size  and 
number  vary  greatly;  there  may  be  only  five  or  six  tiny  ulcers,  or  there 


TUBERCULOSIS  OF  THE  INTESTINES  393 

may  be  forty  or  fifty,  the  largest  beipg  two  or  three  inches  in  diameter. 
They  very  frequently  involve  Peyer's  patches.  The  typical  tuberculous 
ulcer  is  of  irregular  shape,  with  rounded  borders  and  with  its  longest 
diameter  at  right  angles  to  the  intestinal  axis.  When  large,  it  may  nearly 
encircle  the  gut.  The  ulcers  are  excavated ;  they  have  overhanging,  infil- 
trated edges  of  a  deep-red  color.  The  surface  is  covered  with  granula- 
tions. In  those  which  have  partially  healed  a  distinct  puckering  of  the 
intestine  occurs,  which  is  especially  noticeable  upon  the  peritoneal  sur- 
face. The  small  ulcers  involve  the  mucosa  only ;  the  larger  and  older  ones 
the  submucosa  and  the  muscular  coats,  and  not  infrequently  also  the 
serous  coat.  Perforation  may  occur,  but  rarely  into  the  general  perito- 
neal cavity,  as  a  localized  plastic  inflammation  precedes  it.  There  may  be 
adhesions  of  adjacent  intestinal  coils,  and  fistulae  may  form,  owing  to 
ulceration  at  the  point  of  contact.  With  these  severe  cases  there  is  always 
associated  more  or  less  extensive  tuberculous  peritonitis,  frequently  of 
the  ulcerative  variety.  Like  other  tuberculous  processes,  the  infiltration 
and  ulceration  may  cease  at  any  stage,  and  cicatrization  follow.  If  the 
ulcers  have  been  large  ones,  there  is  always  some  narrowing  of  the  lumen 
of  the  intestine.  Stricture  is  rarely  seen  because  most  of  the  children  die 
from  the  general  disease  before  it  has  had  time  to  occur.  Monti  has  re- 
ported a  case  of  obstruction  at  the  ileocecal  valve,  due  to  an  old  tubercu- 
lous cicatrix,  in  an  infant  of  twenty-one  months.  One  has  come  under 
our  observation  in  a  child  of  nine  years,  in  which  the  obstruction  was  in 
the  colon,  just  beyond  the  ileocecal  valve. 

Mesenteric  Lymph  Nodes. — Usually  these  tuberculous  lymph  nodes 
are  from  half  an  inch  to  an  inch  in  diameter;  occasionally  they  may 
reach  the  size  of  a  hen's  egg.  From  a  fusion  of  several  of  them,  tumors 
of  considerable  size  may  be  formed.  We  have  seen  one  such  mass  as  large 
as  the  head  of  a  child  at  birth. 

The  process  is  the  same  as  that  which  occurs  in  other  lymph  nodes 
of  the  body.  There  is  a  tuberculous  inflammation,  followed  by  caseation, 
softening  and  abscess,  or  by  calcification.  Localized  peritonitis  is  found 
in  all  the  marked  cases;  this  is  usually  plastic,  but  may  be  suppurative 
when  due  to  the  rupture  of  an  abscess.  Pressure  upon  the  vena  cava 
may  lead  to  dropsy  in  the  lower  extremities.  Ollivier  has  reported  a  case 
in  which  thrombosis  of  the  vena  cava  occurred.  Pressure  upon  the  portal 
vein  may  lead  to  ascites  and  dilatation  of  the  superficial  abdominal  veins. 
There  may  be  pressure  upon  the  thoracic  duct. 

Symptoms,. — The  symptoms  of  intestinal  tuberculosis  are  exceedingly 
irregular.  Ulcers  are  very  frequently  found  at  autopsy  when  there  have 
been  no  marked  intestinal  sym.ptoms;  this  is  especially  true  of  the  small 
ulcers  usually  seen  in  infants.  On  the  other  hand,  diarrhea  is  not  un- 
common in  cases  of  advanced  general  tuberculosis  where  no  ulcers  are 


394  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

present.  It  is  the  most  frequent  symptom  of  ulceration,  and  may  be 
exceedingly  obstinate.  The  stools  do  not  differ  essentially  from  those  in 
protracted  cases  of  ileocolitis  except  in  the  occurrence  of  hemorrhages 
and  in  the  presence  of  tubercle  bacilli.  Hemorrhages  are  not  very  fre- 
quent, but  they  may  be  so  large  as  to  be  the  cause  of  death.  This  oc- 
curred in  one  of  our  cases,  an  infant  nine  months  old,  the  blood  coming 
from  a  single  ulcer  in  the  ileum.  Hemorrhage  is  more  common  in  older 
children.  In  some  cases  localized  abdominal  pain  or  tenderness  is  pres- 
ent. In  advanced  cases  the  symptoms  of  intestinal  ulceration  are  usually 
mingled  with  those  of  peritonitis,  and  there  are  also  present  the  en- 
larged mesenteric  lymph  nodes,  which  may  aid  in  the  diagnosis.  In  the 
majority  of  cases,  these  nodes  are  recognized  only  by  deep  palpation.  A 
rectal  examination  may  give  additional  information.  The  tumors  are 
generally  felt  as  irregular  nodular  masses,  lying  close  against  the  spine, 
not  movable,  and  sometimes  tender  on  pressure.  Other  tumors  from 
deposits  in  the  peritoneum  may  be  present  anywhere  in  the  abdomen; 
they  may  be  superficial  or  deep.  The  other  symptoms  are  due  to  the 
complications  already  mentioned  and  to  tuberculosis  elsewhere. 

Diagnosis. — The  only  positive  evidence  of  intestinal  tuberculosis  is 
the  discovery  of  the  bacilli  in  the  stools.  They  are  here  to  be  carefully 
differentiated  from  smegma  and  other  forms  of  acid-fast  bacilli.  In  the 
absence  of  such  evidence,  the  disease  is  differentiated  from  simple  ileo- 
colitis, first,  by  the  signs  of  tuberculosis  elsewhere  in  the  body,  espe- 
cially in  the  lungs,  these  being  almost  invariably  involved ;  secondly,  by 
the  slow  onset  and  gradual  development  of  the  symptoms,  while  in  ileo- 
colitis an  acute  attack  has  almost  invariably  preceded.  Large  hemor- 
rhages should  suggest  tuberculosis.  A  positive  reaction  to  the  tuberculin 
skin  test  is  of  much  assistance  in  diagnosis,  as  is  also  the  presence  of 
palpable  mesenteric  glands. 

Prognosis. — This  depends  altogether  upon  the  extent  of  the  tubercu- 
lous disease  elsewhere,  as  it  is  extremely  rare  for  the  intestinal  lesion  to 
be  the  cause  of  death.  Once  formed,  the  ulcers  probably  remain,  cica- 
trization being  very  rare,  and  then  only  partial. 

Treatment. — The  only  symptom  which  ordinarily  demands  treatment 
is  the  diarrhea.  When  severe,  this  is  to  be  managed  much  as  in  cases 
of  ileocolitis,  except  that  irrigation  of  the  colon  is,  of  course,  not  called 
for.  The  chief  reliance  must  be  upon  diet.  Bismuth  and  opium  may 
diminish  the  peristalsis  somewhat.    No  drugs  can  affect  the  process. 


CHRONIC  INTESTINAL  INDIGESTION  395 


CHAPTEE    yill 

DISEASES  OF   THE  INTESTINES— (Continued) 
CHRONIC  INTESTINAL  INDIGESTION 

The  diagnosis  of  chronic  intestinal  indigestion  is  frequently  made 
when  it  is  not  the  digestion  of  the  child  but  the  character  of  the  food 
which  is  at  fault.  The  term  should  be  reserved  for  those  cases  in  which, 
with  proper  feeding,  there  are  marked  and  persistent  evidences  of  dis- 
turbance in  intestinal  digestion,  usually  with  great  retardation  in  physi- 
cal development. 

Chronic  intestinal  indigestion  is  especially  common  in  children  from 
the  first  to  the  fifth  year.i  It  is  seldom  seen  after  that  time.  In  a  small 
proportion  of  cases  it  is  apparently  the  result  of  a  constitutional  weak- 
ness. Nursing  infants  or  infants  who  have  been  artificially  fed  during 
the  first  few  months  in  a  manner  that  cannot  be  criticized  and  who  have 
thrived  fairly  well  may,  when  the  change  to  solid  food  is  made,  be  quite 
unable  to  digest  this  or  may  even  gradually  manifest  an  inability  to 
digest  and  thrive  upon  cow's  milk  however  modified. 

Som^e  cases  are  clearly  the  result  of  improper  feeding.  With  bottle- 
fed  infants  this  is  usually  the  giving  of  too  great  proportions  of  fat. 
With  children  taking  solid  food  the  trouble  usually  arises  from  giving 
this  too  early  or  in  too  large  quantities,  especially  when  the  food  has  been 
improperly  cooked,  such  as  cereals,  vegetables,  and  especially  potato.  But 
the  most  frequent  cause  of  the  condition  is  a  previous  severe  or  pro- 
longed attack  of  diarrhea  or  dysentery  from  which  the  child  seems  never 
to  have  entirely  recovered.  Those  who  have  previously  been  delicate  or 
who  have  had  prolonged  digestive  disturbance  before  the  acute  attack  are 
particularly  liable  to  be  affected.  The  condition  is  seen  in  all  grades  of 
society  but  more  commonly  in  the  middle  or  upper  classes,  for  among 
the  very  poor  indiscretions  in  diet  are  likely  to  precipitate  attacks  of 
acute  indigestion  which  may  be  fatal. 

There  are  no  characteristic  pathological  changes  other  than  a  dilata- 
tion of  the  small  and  large  intestine,  chiefly  the  latter.  In  some  cases 
this  may  be  extreme.  Children  who  are  the  subjects  of  chronic  intestinal 
indigestion  seldom  die  from  the  condition  itself,  but  usually  from  some 
acute  process  engrafted  upon  it,  chiefly  of  the  lungs  or  gastro-intestinal 
tract.  There  are  then  found  only  the  lesions  of  the  terminal  infection 
or  condition. 

*  Prolonged  disturbances  in  intestinal  digestion  during  the  first  year  have 
been  considered  under  Difiicult  Feeding  Cases. 


396 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


Symptoms. — The  clinical  picture  which  these  cases  present  is  a  very 
common  one,  and  the  symptoms  are  quite  uniform.  The  patients  are 
generally  very  thin,  with  small  extremities,  a  small  amount  of  subcu- 
taneous fat,  and  a  large  protuberant  abdomen  (Fig.  43).  The  size 
of  the  abdomen  is  perhaps  the  most  striking  feature  of  the  condition. 
This  is  partly  due  to  dilatation  of  the  small  intestine,  but  chiefly  to'  dila- 
tation of  the  colon  which  is  regularly  present  in  this  condition.     It 

occurs  partly  as  the  result  of  an  excessive 
fermentation  of  food  and  partly  from  the  re- 
laxed condition  of  the  muscular  coats  of  the 
bowel.  There  is  no  hypertrophy  and  no  ul- 
ceration. Dilatation  of  the  intestine  is  fur- 
ther favored  by  a  similar  condition  of  the 
muscular  walls  of  the  abdomen  which  in 
marked  cases  become  extremely  attenuated, 
almost  transparent.  This  relaxation  is  to  be 
attributed  partly  to  the  poor  nutrition  and 
partly  to  the  constant  pressure  from  within. 
The  colon  is  often  dilated  to  a  diameter 
of  three  or  four  inches,  as  shown  by  X-ray 
examination,  and  sometimes  even  more  than 
this.  An  erroneous  diagnosis  of  Hirsch- 
sprung's disease  is  often  made  in  such  cases. 
The  circumference  of  the  abdomen  may  be 
several  inches  greater  than  that  of  the  chest. 
Tympanites  is  constantly  present  although 
much  gas  may  be  passed  per  rectum.  There 
is  a  marked  tendency  for  the  tympanites  to 
increase  during  the  day  time  and  to  diminish 
at  night  so  that  the  variation  in  the  circum- 
ference of  the  abdomen  is  usually  two  or 
three  inches  and  sometimes  as  much  as  four 
or  five  inches  in  twenty-four  hours.  This 
variation  is  of  assistance  in  differentiating  the  condition  from  tuber- 
culous peritonitis  with  which  it  is  frequently  confounded.  Such  chil- 
dren are  pale,  anemic,  sallow  in  complexion  and  haggard  looking;  they 
have  dark  rings  under  the  eyes;  they  are  fatigued  on  slight  exertion; 
they  are  very  cross,  irritable,  and  emotional  to  an  unnatural  degree. 
They  are  hard  to  amuse,  hard  to  control,  and  altogether  exceedingly 
difficult  patients  to  deal  with.  Their  growth  is  retarded  if  the  symp- 
toms have  lasted  long.  They  are  much  below  the  average  in  height 
and  weight,  but  mentally  often  quite  precocious.  One  of  our  patients 
at  three  years  weighed  twelve  and  a  half  pounds  and  was  twenty-nine 


Fig.  43. — Chronic  Intestinal 
Indigestion. — Patient  four 
years  old ;  symptoms  of  three 
years'  duration,  following 
attack  of  acute  ileocolitis. 
Height,  34  inches;  circumfer- 
ence of  abdomen,  22f  inches; 
weight,  24  pounds. 


CHRONIC  INTESTINAL  INDIGESTION  397 

inches  tall  and  another  patient  at  five  years  weighed  twenty-two  pounds 
and  was  thirty-three  inches  tall.  The  sleep  is  always  unnatural  and 
disturbed;  and  at  night  the  children  toss  about  their  cribs,  waking  fre- 
quently, crying  out  and  often  grinding  their  teeth.  They  perspire  very 
readily,  and  suffer  from  cold  extremities. 

The  bowels  alternate  between  constipation  and  diarrhea,  the  former 
being  more  frequently  present.  At  such  times  the  stools  are  gener- 
ally of  a  light  gray  color  or  nearly  white.  The  odor  of  the  stools  is 
usually  extremely  foul.  With  diarrhea  the  stools  are  often  not  very 
frequent,  not  exceeding  four  or  five  a  day,  but  they  are  large,  gray, 
green,  or  brown  in  color,  acid  in  reaction,  often  frothy,  offensive,  and 
always  contain  undigested  food.  A  stool  in  many  cases  is  immediately 
excited  by  the  taking  of  food.  From  time  to  time,  in  many  patients, 
large  quantities  of  mucus  are  passed;  in  some  cases  this  comes  to  be  a 
constant  feature  of  the  disease.  A  striking  feature  is  the  large  size  of 
the  stools  in  proportion  to  the  amount  of  food  taken.  The  chemical 
examination  of  these  stools  when  cow's  milk  is  taken,  shows  that  the  chief 
solid  constituent  is  fat  which  frequently  forms  as  much  as  60  to  70  per 
cent  of  the  dried  matter  of  the  stool,  as  compared  with  the  normal  of 
20  to  40  per  cent.  The  carbohydrates  which  are  taken  are  largely  broken 
down  by  the  excessive  fermentation  which  takes  place  in  the  intestinal 
tract.  Large  quantities  of  gas  are  expelled.  Pain  is  not  a  very  common 
symptom,  but  discomfort  from  the  great  tympanites  is  frequent.  The 
appetite  is  capricious  and  usually  poor,  though  some  patients  have  a 
voracious  appetite  and  will  eat  everything  offered.  The  tongue  is  usually 
clean  and  the  breath  is  not  offensive  unless  the  stomach  is  also  affected, 
when  the  tongue  may  be  coated. 

The  nervous  symptoms  which  these  patients  present  are  exceedingly 
varied,  and  often  of  the  most  puzzling  character.  In  some  cases  there 
are  from  time  to  time  attacks  in  which  they  are  so  severe  and  so  per- 
sistent as  to  lead  to  the  diagnosis  of  organic  disease  of  the  brain.  In 
addition  to  the  condition  of  general  nervous  irritability,  there  may  be 
tetany,  fainting  attacks  resembling  somewhat  the  seizures  of  petit  mal, 
exaggerated  reflexes,  attacks  of  dulness  or  sometimes  stupor,  with  irregu- 
lar pulse  and  respiration  and  other  symptoms  strongly  suggestive  of 
tuberculous  meningitis.  Convulsions  are  not  uncommon.  They  are 
usually  accompanied  by  fever,  and  may  be  repeated  at  intervals  of  a 
few  minutes.  There  is  almost  no  end  to  the  combinations  of  nervous 
symptoms  which  these  patients  may  present.  The  skin  shows  frequently 
eruptions  of  erythema  or  of  urticaria. 

Most  of  these  cases  are  without  fever;  but  in  some  a  slight  fever  is 
present  for  weeks  at  a  time,  the  temperature  usually  varying  between 
99°  and  101.5°  F.     Occasionally  it  may  rise  to  103°  or  103°  F.  during 


398  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

an  acute  exacerbation  in  the  symptoms.  The  urine  of  most  of  these 
patients  contains  a  great  excess  of  inclican  and  the  amount  present 
often  fluctuates  regularly  with  the  nervous  symptoms.  The  weight  may 
remain  stationary  or  there  may  be  a  gradual  loss  for  some  time.  When 
improvement  takes  place  the  gain  is  apt  to  be  rapid  but  very  irregular. 
Great  fluctuations  in  weight  are  characteristic  of  this  condition  and 
are  to  be  explained  by  retention  and  loss  of  water.  Attacks  of  general 
edema  with  rapid  gain  in  weight  are  occasionally  seen.  Intercurrent 
attacks  of  acute  indigestion,  with  diarrhea  and  sometimes  also  vomiting, 
are  frequent  and  easily  excited.  Occasionally  there  are  seen  attacks  of 
intercurrent  intestinal  infection  with  the  dysentery  bacillus,  or  other 
organisms. 

The  course  and  duration  of  these  symptoms  are  indefinite.  The 
milder  cases  if  recognized  early  and  promptly  treated  often  recover  in 
a  few  months,  though  careful  feeding  must  be  continued  for  a  long  time 
to  prevent  relapses.  The  severe  cases  under  the  most  favorable  cir- 
cumstances last  many  months  and  usually  several  years.  In  those  which 
progress  favorably,  improvement  is  usually  first  seen  in  the  digestive 
symptoms,  next  in  the  nervous  symptoms  and  last  of  all  in  the  weight. 
In  the  most  severe  forms,  if  untreated,  the  patients  gradually  waste 
until  they  die  from  exhaustion,  or  fall  easy  victims  to  any  acute  disease 
which  they  may  happen  to  contract.  There  is  but  little  tendency  to  spon- 
taneous recovery. 

Herter  has  called  attention  to  a  type  of  this  disease  associated  with 
marked  arrest  in  growth  to  which  he  gave  the  name  Intestinal  Infantil- 
ism. In  several  such  cases  studied  he  found  a  failure  of  retention  of 
calcium  and  magnesium  salts  over  a  prolonged  period  of  time.  To  this 
he  ascribed  the  arrested  development  of  the  skeleton.  Associated  with 
this,  there  were  present  evidences  of  excessive  intestinal  putrefaction. 
The  bacteriology  of  the  condition  he  believed  to  be  characteristic,  viz., 
a  preponderance  of  the  B.  hifidus,  with  great  diminution  or  entire  absence 
of  the  B.  coU. 

Prognosis. — This  depends  upon  the  duration  of  the  symptoms,  the 
general  condition  of  the  patient  at  the  time  treatment  is  begun,  and 
upon  how  thoroughly  it  can  be  carried  out.  The  symptoms,  in  the 
great  majority  of  cases,  have  existed  for  several  months  at  the  time  the 
case  comes  under  observation.  Generally,  the  greater  the  mistakes  in 
feeding  have  been,  and  the  greater  the  violation  of  hygienic  and  dietetic 
rules,  the  better  the  prognosis.  A  child  who  has  developed  chronic  in- 
testinal indigestion  of  a  severe  type,  in  spite  of  the  fact  that  the  hygienic 
surroundings  were  good,  and  when  the  dietetic  errors  were  not  flagrant, 
is  not  nearly  so  hopeful  a  subject  for  treatment  as  one  whose  hygienic 
surroundings  have  been  poor  and  whose  diet  has  been  especially  bad. 


CHEONIC  INTESTINAL  INDIGESTION  399 

In  cases  like  the  latter,  a  removal  of  the  causes  and  the  institution  of 
proper  methods  of  treatment  almost  invariably  result  in  immediate  and 
striking  improvement,  unless  the  general  vitality  of  the  patient  has 
been  reduced  to  a  very  low  point.  In  the  other  cases  where  the  mistakes 
have  been  less  marked  and  the  condition  is  due  more  to  constitutional 
than  to  local  causes,  the  improvement  is  slower  and  less  striking.  Thus, 
as  a  rule,  hospital  patients  improve  more  rapidly  than  those  seen  in 
private  practice. 

Treatment. — In  no  class  of  cases  that  the  physician  is  called  upon  to 
treat  are  results  more  satisfactory  than  in  many  of  those  of  chronic  in- 
testinal indigestion,  when  intelligent  cooperation  can  be  secured.  But 
the  reverse  is  also  true  and  no  cases  are  more  unsatisfactory  than  these 
when  intelligent  cooperation  cannot  be  secured.  Treatment  is  very 
difficult  at  best;  recovery  is  a  very  slow  process  and  the  periods  of  ex- 
acerbation of  symptoms  that  occur  with  almost  every  case  are  exceed- 
ingly trying  to  anxious  parents  and  relatives.  If  the  parents  themselves 
are  lax  in  discipline,  and  are  unable  to  control  the  child,  an  efficient 
trained  nurse  should  be  secured,  into  whose  hands  the  exclusive  manage- 
ment of  the  child  should  be  placed.  In  any  case  it  should  be  understood 
that  the  duration  of  the  symptoms  is  likely  to  be  from  one  to  two  years 
and  may  be  much  longer.  The  adoption  of  a  consistent  plan  of  treat- 
ment continuously  carried  out  for  a  long  period  is  indispensable  to 
success. 

The  essential  part  of  the  treatment  is  diet  and  general  manage- 
ment. It  should  be  remembered  that  the  condition  is  in  most  cases 
primarily  one  of  fat  indigestion  and  intolerance.  To  this  there  is  soon 
added  intolerance  of  carbohydrates  and  often  the  latter  becomes  the 
prominent  feature.  When  there  is  intolerance  of  both  carbohydrates 
and  fats,  it  is  apparent  that  there  can  be  no  gain  in  weight.  The  best 
that  can  be  done  with  these  patients  is  to  keep  them  for  a  long  time  upon 
a  diet  made  up  almost  entirely  of  protein  food.  On  this  one  should  be 
contfelit  if  the  weight  remains  stationary  or  if  there  is  but  a  slight  loss. 
As  the  digestive  condition  improves,  fats  or  carbohydrates,  according 
to  the  tolerance,  can  gradually  be  added  to  the  diet — at  first  only  in 
very  small  amounts.  In  most  cases  the  conditions  must  be  met  em- 
pirically and  mauy  mistakes  and  consequent  relapses  are  likely  to 
occur. 

At  the  outset  the  most  important  thing  is  to  stop  all  starchy  food 
for  a  considerable  time,  and  put  the  patient  upon  a  diet  consisting  only 
of  rare  beef,  beef  juice,  junket  without  whey,  buttermilk  or  protein  milk. 
Skimmed  milk  is  well  borne  by  only  a  limited  number.  After  some 
improvement  has  occurred  carbohydrates  may  be  added,  but  very  gradu- 
ally beginning  with  small  quantities  (not  more  than  one  tablespoonful 


400  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

a  day)  of  well-cooked  cereal.  The  number  of  feedings  should  not  be 
more  than  four  a  day  during  the  second  year,  and  three  or  four  a  day 
for  children  during  the  third  and  fourth  years.  These  should  always  be 
at  regular  intervals,  and  nothing  whatever  given  between  meals.  The 
meat  should  be  rare  scraped  beefsteak  or  lamb  chop ;  from  one  to  three 
tablespoonfuls  may  be  allowed  once  a  day.  The  white  of  egg  may  be 
given  early,  and  after  a  time,  the  whole  of  a  hard-boiled  egg  very  finely 
grated. 

After  improvement  has  been  going  on  for  two  or  three  months,  bread 
may  be  added,  at  first  in  small  quantities  and  once  a  day.  This  should 
preferably  be  stale,  cut  thin  and  dried  in  the  oven  until  it  is  crisp,  and 
given  without  butter.  Mutton,  chicken,  or  beef  broth,  without  vegetables, 
may  be  given  occasionally  in  the  place  of  one  of  the  milk  feedings.  After 
this  diet  has  been  kept  up  for  three  or  four  months,  if  improvement  con- 
tinues, one  of  the  green  vegetables  thoroughly  cooked  and  strained  may 
be  added  once  a  day.  A  striking  feature  of  these  cases  is  their  marked 
intolerance  for  sweet  cow's  milk.  This  must  be  withheld  for  a  long 
period.  This  restricted  diet  should  be  continued  for  at  least  a  year  or 
until  all  the  symptoms  have  disappeared.  Potato  should  be  forbidden 
for  a  long  time.  A  few  of  the  patients  can  take  olive  oil  when  they  can- 
not tolerate  any  other  form  of  fat.  This  may  be  tried  very  carefully, 
beginning  with  one  teaspoonful  a  day. 

Intestinal  irrigation  is  occasionally  useful  for  brief  periods  in  some 
cases  in  which  there  is  much  mucus  passed;  no  astringents,  but  only 
a  warm  saline  solution  should  be  used.  But  it  should  not  be  forgotten 
that  continued  irrigation  often  keeps  up  the  production  of  mucus,  and 
also  that  the  introduction  of  large  amounts  of  water  may  increase  the 
intestinal  distention. 

The  constipation  can  sometimes  be  controlled  by  the  diet  alone ;  but 
in  most  cases  drugs  are  needed  also.  As  laxatives  in  this  condition  prep- 
arations of  rhubarb,  or  cascara  and  the  compound  licorice  powder  are 
serviceable.  On  account  of  the  great  tendency  to  abdominal  distention 
due  to  excessive  fermentation  and  atony  of  the  intestinal  walls  the  bowels 
must  be  kept  well  emptied.  Most  patients  do  better  when  two  stools 
a.  day  are  secured,  the  second  if  necessary  by  an  enema,  but  the  frequent 
use  of  large  intestinal  injections  is  to  be  avoided.  Abdominal  massage 
is  of  much  benefit  in  most  cases. 

Drugs  directed  against  the  process  of  putrefaction  are  extremely 
unsatisfactory  even  in  older  children  and  are  not  to  be  recommended. 
Of  little  value  also  is  the  administration  of  the  various  digestive  fer- 
ments. General  tonics  are  sometimes  useful  during  convalescence  and 
apparently  assist  in  the  improvement  of  the  general  condition,  but 
during  acute  exacerbations  their  use  should  be  interdicted.    Kux  vomica 


INTESTINAL  COLIC  401 

is  the  best  combined  with  some  mild  preparation  of  iron.  Cod-liver  oil, 
particularly  in  the  early  stage,  is  badly  borne. 

EelajDses  are  easily  excited  by  indiscretions  in  diet,  and  parents 
should  be  impressed  at  the  very  beginning  with  the  necessity  of  adhering 
rigidly  to  the  diet  prescribed  for  a  long  period.  It  very  often  happens 
that  the  improvement  which  is  seen  after  one  or  two  months  of  careful 
treatment  is  so  marked  as  to  lead  the  parents  to  the  belief  that  a  cure 
has  been  accomplished,  so  that  they  relax  their  vigilance  and  allow  im- 
proper articles  of  food  which  are  almost  certain  to  induce  a  relapse. 
If  the  case  is  an  aggravated  one,  and  the  symptoms  of  long  standing,  it 
is  wise  to  tell  parents  at  the  outset  that  a  year's  treatment  is  the  mini- 
mum in  which  anything  permanent  can  be  accomplished. 

The  general  treatment  of  the  patient  must  not  be  overlooked.  Proper 
clothing,  regular  exercise  in  the  open  air,  cool  sleeping  rooms,  massage 
and,  when  the  condition  is  such  as  to  permit  it,  sponging  every  morning 
with  cool  water  are  all  of  very  great  importance.  An  elastic  abdominal 
bandage  giving  moderate  support  not  only  adds  to  the  comfort  of  these 
patients  but  to  some  degree  prevents  the  excessive  distention  likely  to 
occur  on  account  of  the  loss  of  muscular  tone  in  the  abdominal  walls. 
The  improvement  in  the  nervous  symptoms  of  the  patient  is  often  one 
of  the  first  things  noticed.  From  an  irritable,  fretful,  peevish  child  the 
patient  is  sometimes  totally  changed  in  disposition  in  a  few  weeks,  so  as 
to  become  quiet,  affectionate,  docile,  and  playful. 


INTESTINAL  COLIC 

The  term  colic  is  applied  to  any  severe  paroxysmal  pain  occurring  in 
the  intestines.  It  may  be  due  to  many  causes.  The  colic  of  lead  and 
arsenic  poisoning  are  both  very  rare  in  children;  but  colicky  pains  are 
present  in  appendicitis,  intussusception,  ileocolitis,  and,  in  fact,  in  all 
the  severe  forms  of  intestinal  inflammation.  Colic  may  be  due  to  swal- 
lowing certain  substances,  especially  foreign  bodies  and  the  seeds  of 
fruits ;  and  in  rare  cases  it  may  be  excited  by  the  presence  of  round- 
worms when  they  are  numerous.  In  all  the  conditions  mentioned,  colic 
is  only  one  of  the  symptoms,  although  it  may  be  a  very  prominent  one. 

The  peculiar  colic  of  infancy  is  clearly  caused  by  spasm  of  the  mus- 
cular wall  of  the  intestine.  It  is  a  heightened  reflex  from  irritation  of 
which  we  have  many  other  illustrations  at  this  period  of  life.  The 
cause  of  the  irritation  is  usually  the  presence  of  some  undigested  food 
in  the  intestine.  Colic  is  therefore  essentially  a  symptom  of  indigestion. 
Flatulence  and  colic  are  very  often,  but  not  always,  associated.  Colic 
is  always  increased  by  the  coexistence  of  constipation,  which  in  many 


402  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

eases  is  its  sole  cause.  Almost  any  of  the  elements  of  the  food  may  give 
rise  to  colic. 

Sugars  and  starches  produce  it  by  causing  excessive  fermentation 
and  flatulence.  Fats  are  less  frequently  at  fault;  but  the  presence  of 
large  unabsorbed  masses  in  the  intestine  may  be  a  sufficient  cause  of 
irritation.  The  actual  pain  in  colic  is  partly  from  distention,  but  chiefly 
from  muscular  spasm.  In  some  of  the  most  severe  cases  of  colic  it  is 
possible  that  the  spasm  may  be  accompanied  by  a  slight  transient  in- 
tussusception. Colic  may  follow  chilling  the  surface  of  the  body.  In 
these  cases,  also,  muscular  spasm  appears  to  be  the  principal  factor  in 
causing  the  pain.  The.  colicky  period  of  infancy  is  chiefly  the  first 
three  months;  after  this  time  the  peculiar  susceptibility  gradually 
passes  off. 

Symptoms. — These  are  in  most  cases  so  typical  as  to  be  easily  recog- 
nized. They  are  always  more  severe  in  delicate  and  highly  nervous  chil- 
dren. In  the  severe  attacks  there  is  contraction  of  the  features,  a  loud 
paroxysmal  cry,  subsiding  for  a  few  moments  and  then  beginning  with 
renewed  intensity,  drawing  up  the  lower  extremities,  and  in  male  in- 
fants contraction  of  the  scrotum.  With  these  symptoms  the  abdomen  is 
usually  found  tense  and  hard.  With  the  expulsion  of  gas,  the  symptoms 
usually  subside  at  once,  and  the  child  falls  asleep.  In  the  most 
severe  attacks  there  may  be  considerable  prostration,  cold  extremities, 
and  persj)iration.  When  the  symptoms  are  less  severe  there  is  only  con- 
tinual fretfulness,  and  the  child  can  not  sleep.  When  colic  is  habitual 
there  are  very  few  hours  in  the  twenty-four  when  the  child  seems  to  be 
entirely  comfortable.  In  nursing  infants  there  may  at  times  be  difficulty 
in  distinguishing  the  cry  of  colic  from  that  of  hunger,  as  infants  suft'er- 
ing  from  colie  will  usually  take  food  eagerly,  and  this  is  often  followed 
by  temporary  relief.  In  colic,  however,  the  pain  soon  returns,  and  often 
is  more  severe  than  before.  The  cry  of  colic  is  usually  violent  and 
paroxysmal;  that  of  hunger  is  apt  to  be  prolonged  and  continuous,  and 
is  not  accompanied  by  the  other  symptoms  mentioned  as  indicating  ab- 
dominal pain.  In  older  children  the  less  frequent  causes  of  colic  men- 
tioned at  the  beginning  of  this  article,  especially  appendicitis,  should  be 
borne  in  mind. 

Treatment — When  colic  is  due  to  flatulence  of  the  intestine,  nothing 
given  by  the  mouth  has  much  effect  in  relieving  the  symptoms.  Cer- 
tainly food  should  not  be  given.  The  purpose  of  treatment  during  the 
attack  is  to  assist  the  child  to  get  rid  of  the  gas;  as  this  is  usually  in 
the  colon,  the  most  efficient  means  is  by  massage  or  enemata.  At  first 
an  injection  of  four  or  five  ounces  of  lukewarm  Avater  should  be  used. 
If  this  is  not  successful,  two  ounces  of  colder  water  with  half  a  teaspoon- 
fur  of  glycerin  may  be  tried.     This  rarely  fails  to  start  peristalsis  and 


CHRONIC  CONSTIPATION  403 

expel  the  gas.  In  conjunction  with  these  measures,  dry  heat  should  be 
applied  to  the  abdomen  by  means  of  hot  flannels  or  a  hot-water  bag,  and 
the  feet  should  be  well  warmed.  The  treatment  between  the  attacks  and 
the  treatment  of  habitual  colic  should  be  directed  toward  the  constipa- 
tion and  the  indigestion,  upon  wliicb  tbcy  depend. 


CHRONIC  CONSTIPATION 

Constipation  may  ])e  said  to  exist  whenever  the  stools  are  less  fre- 
quent and  firmer  than  normal.  During  the  early  months  infants  usually 
have  two  movements  a  day.  Many,  however,  have  only  one;  but  if  this 
is  normal  in  character  the  child  is  not  constipated.  In  other  cases, 
although  there  are  two  and  even  three  stools  a  day,  they  may  all  be 
small,  dry,  and  hard,  having  all  the  characters  of  constipated  stools, 
and  the  case  should  be  treated  accordingly. 

Etiology. — The  causes  of  chronic  constipation  are  many  and  far- 
reaching.  It  may  be  due  to  a  diminution  in  the  secretion  of  the  intes- 
tinal glands  or  of  the  liver.  The  movements  are  then  hard,  dry,  very 
light-colored,  and  are  associated  with  much  flatulence  and  other  signs 
of  intestinal  indigestion.  Very  often  the  principal  factor  in  constipation 
is  insufficient  muscular  contraction  in  the  intestine.  The  fecal  masses 
are  then  propelled  so  slowly  and  remain  so  long  in  the  intestine  that 
the  fluid  portion  is  absorbed,  the  residue  becoming,  in  consequence,  so 
dry  and  hard  that  it  is  difficult  to  expel.  In  other  cases  constipation 
is  due  to  the  fact  that  there  is  insufficient  volume  to  the  stools,  as  may 
be  the  case  when  the  food  leaves  very  little  residue.  Constipation  may 
depend  also  upon  local  causes,  as,  for  example,  where  an  evacuation  of 
the  bowels  is  resisted  on  account  of  pain  from  fissure  of  the  anus  or  from 
hemorrhoids.  Although  not  the  primary  cause,  this  condition  may  be 
sufficient  to  keep  up  the  constipation  indefinitely.  It  may  in  rare  cases 
be  due  to  a  congenital  condition,  such  as  narrowing  or  twisting  of  the 
large  intestine  at  some  point.  Another  rare  cause  seen  especially  in 
infancy  is  tonic  spasm  of  the  anal  sphincter.  The  most  important  causes 
of  constipation  may  be  grouped  under  two  heads :  diet,  and  conditions 
giving  rise  to  muscular  atony. 

Diet. — In  breast-fed  infants  the  trouble  is  usually  low  total  solids  in 
the  milk.  In  those  who  are  artificially  fed  it  is  most  often  because  the 
sugar  is  too  low,  and  sometimes  because  all  the  solids  are  too  low,  the 
stool  lacking  volume.  In  other  cases  the  cause  of  constipation  is  indiges- 
tion, especially  of  fats,  in  still  others  the  use  of  sterilized  milk.  During 
the  second  and  third  years  the  cause  may  be  too  much  cow's  milk,  par- 
ticularly that  which  has  been  boiled,  or  the  use  of  an  excessive  amount 


404  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

of  starchy  food.  In  older  children  he  cause  may  be  an  excess  of  milk 
and  starchy  food  and  a  lack  of  green  vegetables,  coarse  cereals,  meat, 
fruit,  and  water. 

Muscular  Atony. — The  most  common  cause  of  muscular  atony  is 
habit;  in  a  large  number  of  cases  lack  of  proper  training  is  the  principal 
etiological  factor.  If  the  inclination  to  have  a  stool  is  regularly  disre- 
garded it  soon  ceases  to  be  felt.  The  ordinary  irritation  from  fecal 
masses  produces  no  response  whatever.  The  longer  such  a  condition 
continues  the  more  obstinate  does  it  become.  This  is  an  important 
factor  in  all  cases.  Another  cause  of  muscular  atony  is  rickets.  In  this 
disease  the  muscular  walls  of  the  intestine  suffer  like  the  muscles  of  the 
extremities,  and  become  incapable  of  doing  their  work.  Again,  any 
form  of  malnutrition  in  which  there  is  feeble  muscular  tone  may  cause 
or  aggravate  constipation.  It  is  often  seen  as  a  sequel  to  acute  attacks 
of  diarrheal  diseases,  particularly  when  these  have  been  prolonged. 
Want  of  sufficient  muscular  exercise  is  a  frequent  cause.  There  are 
many  children  who  rarely  suffer  from  constipation  in  summer  when 
they  have  plenty  of  outdoor  exercise,  who  very  often  do  so  in  winter 
when  such  exercise  is  wanting.  A  loss  of  muscular  tone  is  not  an  infre- 
quent result  of  the  prolonged  and  indiscriminate  use  of  purgative  drugs 
or  enemata. 

Symptoms. — In  most  children  no  symptoms  are  present  except  the 
local  ones,  the  general  health  being  excellent  and  the  nutrition  in  no  way 
disturbed.  In  some,  however,  there  are  symptoms  of  greater  or  less 
severity,  depending  somewhat  upon  the  cause  of  the  constipation. 
There  may  be  simply  flatulence  and  colicky  pains,  or  the  irritation  of  the 
hardened  fecal  masses  may  produce  a  slight  catarrhal  inflammation 
of  the  sigmoid  flexure  and  the  rectum,  so  that  mucus  and  sometimes 
traces  of  blood  may  be  passed  with  the  stool.  Hemorrhoids  may  develop 
even  in  infancy,  and  frequently  the  constant  straining  leads  to  the  pro- 
duction of  hernia.  In  many  cases  there  are  from  time  to  time  nervous 
symptoms  resulting  apparently  from  the  absorption  of  various  toxic  ma- 
terials from  the  intestine.  There  may  be  headache,  dulness,  fretfulness, 
disturbed  sleep,  and  associated  signs  of  intestinal  indigestion.  The 
urine  often  contains  indican  in  excess,  and  there  may  be  slight  fever. 

Diagnosis. — This  includes  the  discovery  of  the  cause  and  the  principal 
seat  of  the  constipation.  To  arrive  at  the  former  the  most  careful  and 
thorough  investigation  should  be  made  of  the  child's  diet  and  habits.  It 
is  desirable  to  determine  whether  the  seat  of  trouble  is  the  rectum,  the 
colon,  or  the  small  intestine.  If  a  suppository  is  almost  immediately 
followed  by  a  normal  stool,  one  may  be  sure  that  the  rectum  only  is  at 
fault,  and  that  it  needs  but  a  little  extra  stimulus  to  make  it  do  its 
work.     This  is  common  in   infants  who  are  too  young  to  make  any 


CHRONIC  CONSTIPATION  405 

voluntary  efforts.  In  such  cases  there  are  no  other  symptoms  present. 
In  others,  the  white  or  gray  stools,  marked  flatulence,  offensive  breath, 
and  general  irritability,  leave  no  doubt  of  the  fact  that  the  trouble  is 
due  to  indigestion. 

Treatment.— The  successful  treatment  of  chronic  constipation  in 
children  is  accomplished  only  by  a  careful  study  and  regulation  of  the 
child's  routine.  In  treatment,  training,  habits,  diet  and  exercise  play 
the  most  important,  and  specific  remedies  the  least  important  part. 
Cure  of  the  constipated  habit  is  always  difficult,  and  in  most  cases  treat- 
ment must  be  continued  for  a  long  time.  The  cooperation  of  an  in- 
telligent mother  or  nurse  is  absolutely  indispensable.  To  establish  the 
habit  of  regular  stools  should  be  the  first  step,  for  without  it  nothing  can 
be  done.  This  training  should  be  begun  in  infancy.  Even  in  young 
infants  regular  habits  are  formed  without  difficulty  if  the  child  is  put 
upon  the  chamber  or  chair  invariably  at  the  same  hour.  When  a  local 
stimulus  is  required  in  addition,  an  oiled  glass  rod  or  a  gluten  supposi- 
tory may  for  a  time  be  inserted.  An  older  child  must  be  taught  to  heed 
the  first  impulse  to  evacuate  the  bowel.  Eegular  habits  can  hardly  be 
formed  unless  the  same  time  each  day  is  chosen  for  the  movement. 
That  to  be  preferred  is  soon  after  the  ^norning  meal,  as  taking  food  into 
the  stomach  starts  a  peristaltic  wave  which  is  continued  throughout  the 
intestine.  This  has .  been  demonstrated  by  the  X-ray  to  occur  even  in 
the  colon.  With  older  children  breakfast  should  be  early  enough  to  allow 
ample  time  for  this  duty  before  the  other  engagements  of  the  day;  and 
nurses  should  be  impressed  with  the  importance  of  the  early  formation 
of  proper  habits  on  the  part  of  their  charges.  It  is  a  part  of  nursery 
discipline  which  should  invariably  be  insisted  upon.  Stretching  the 
sphincter  under  an  anesthetic  is  sometimes  of  great  benefit  in  infants, 
especially  when  tonic  spasm  is  present. 

Food. — With  nursing  infants  who  get  good  breast-milk  constipation 
is  not  common.  When  the  milk  is  low  in  solids,  constipation  is  frequent. 
In  feeding  cow's  milk,  constipation  is  overcome  by  giving  the  propor- 
tions of  sugar,  *protein  and  fat  which  are  best  suited  to  the  infant.  It 
is  rather  more  apt  to  occur  with  infants  when,  on  account  of  digestive 
symptoms,  modifications  of  whole  milk  or  skimmed  milk  are  given  in- 
stead of  those  from  top-milk.  But  constipation  is  also  seen  at  times  when 
the  fat  is  too  high.  The  laxative  effects  of  all  sugars,  but  especially 
maltose,  should  be  remembered  (see  Infant  Feeding).  With  infants  dur- 
ing the  first  year,  chronic  constipation  may  be  largely  prevented  by 
proper  milk  modification. 

During  the  second  year  children  who  suffer  from  constipation  are 
usually  benefited  by  reducing  the  amount  of  milk  and  giving  more  solid 
food.    Especially  valuable  are  the  coarser  cereals  thoroughly  cooked  and 


406  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

purees  of  green  vegetables, — peas,  string  beans,  spinach  or  asparagus 
tips.  Meat  broths  and  beef  juice  are  somewhat  laxative  on  account  of 
their  extractives  and  salts.  Fruits  are  valuable  in  all  these  cases;  but 
only  the  juices  should  be  given  until  a  child  is  about  fifteen  months  old. 
That  of  cooked  fruit  or  almost  any  fresh  fruit  may  be  employed.  After 
fifteen  to  eighteen  months  pulpy  fruits  may  be  given,  but  only  after 
thorough  cooking  and  straining, — apples,  prunes,  peaches,  plums  and 
pears,  in  moderate  quantities ;  but  berries  should  be  avoided.  Eaw  fruits 
should  seldom  be  given  to  children  under  three  years  old,  and  after  that 
age  in  moderate  quantities  only. 

For  older  children  who  are  on  a  mixed  diet  the  amount  of  starchy 
food  should  be  moderate.  Coarse  cereals  only  should  be  given.  Milk 
should  be  given  rather  sparingly;  it  is  sometimes  advisable  to  stop  it 
altogether.  All  bread  should  be  made  from  whole  wheat  or  unbolted 
flour.  Bran  biscuits  are  also  useful.  Meat  and  broth  may  be  allowed 
freely,  also  green  vegetables  and  vegetable  salads.  All  fruits  allowed 
infants  may  be  used,  but  in  larger  quantities,  and  in  addition  scraped 
raw  apple.  Of  the  dried  fruits,  dates,  prunes  and  figs  are  permissible, 
but  only  after  cooking.  Fresh  fruit  is  preferably  given  in  the  morn- 
ing, oranges  being  especially  useful  when  taken  on  rising.  A  caution  is 
necessary  in  the  use  of  fruits  and  coarse  foods  for  constipated  children. 
It  often  happens  that  constipation  is  only  one  of  the  symptoms  of  a 
chronic  intestinal  indigestion,  and  such  foods  as  those  mentioned,  while 
they  may  cause  the  bowels  to  move,  frequently  aggravate  the  primary 
condition.  They  produce  abdominal  pain,  fiatulence,  and  the  discharge 
of  mucus  in  the  stools.  The  administration  of  some  mild  laxative  even 
over  a  considerable  period  is  often  much  less  objectionable. 

The  laxative  effect  of  sugars  may  be  utilized  with  older  children,  but 
they  must  be  given  with  caution  not  to  disturb  digestion.  Two  or  three 
teaspoonsfuls  of  honey  may  be  given  with  the  breakfast  or  supper.  Mo- 
lasses may  be  used  upon  bread  or  may  be  added  to  cooked  foods. 

Either  hot  or  cold  water,  when  taken  an  hour  before  breakfast,  may 
be  of  considerable  benefit  to  older  children.  The  necessity  of  supplying 
sufficient  fluids  is  apt  to  be  overlooked,  especially  when  milk  is  excluded 
from  the  diet.  While  a  liberal  amount  of  water  is  indispensable,  there 
is  no  advantage  in  excessive  water  drinking.  The  sparkling  waters, 
like  Vichy  or  Apollinaris.  are  sometimes  better  than  plain  water. 

Massage,  when  properly  employed,  is  useful  in  conjunction  with  other 
measures,  but  rarely  succeeds  alone.  It  should  be  given  for  five  or. ten 
minutes  after  retiring  and  just  before  rising.  A  proper  amount  of  gen- 
eral muscular  exercise  is  necessary  and  should  be  made  a  part  of  the 
treatment  in  every  case.  Special  exercises  for  the  development  of  the 
abdominal  muscles  when  faithfully  carried  out  are  of  particular  benefit. 


CHEONIC  CONSTIPATION  407 

Posture  during  the  stool  is  of  some  importance;  in  certain  cases  9,  cure 
is  effected  simply  by  substituting  a  low  seat  on  a  nursery  chair  or  closet 
for  the  high  one  previously  used. 

Suppositories. — In  many  cases,  particularly  in  young  infants  who 
are  not  old  enough  to  initiate  the  muscular  effort,  a  slight  stimulus  to 
the  rectum  is  all  that  is  required.  The  cone  of  oiled  paper  has  a  great 
reputation  in  domestic  practice  and  is  not  objectionable.  It  may  be  of 
assistance  in  establishing  a  proper  habit.  Soap  suppositories  produce 
a  more  marked. irritation;  although  their  immediate  effect  is  quite  satis- 
factory, they  should  not  be  continuously  used.  Glycerin  suppositories  are 
even  more  objectionable.  For  occasional  use  they  are  convenient,  but 
their  frequent  use,  especially  in  infants,  is  likely  to  cause  too  much 
irritation.  Gluten  suppositories  produce  less  irritation  and  are  conse- 
quently slower  in  their  effect,  but  they  have  not  the  same  disadvantages. 
Suppositories  are  useful  only  when  the  trouble  is  in  the  rectum. 

Enemata. — Water  enemata  should  not  be  used  regularly  for  the  relief 
of  chronic  constipation.  For  immediate  relief  they  are  often  necessary. 
The  injection  of  one  or  two  drams  of  glycerin  in  a  few  ounces  of  water 
is  one  of  the  most  efficient  means  of  moving  the  bowels  at  our  command. 
Cases  of  fecal  impaction  are  rarely  met  with  in  children.  They  are 
to  be  managed  as  in  adults,  by  repeated  injections  of  soap  and  warm 
water  or  of  ox-gall,  and  soiuetimes  by  mechanical  removal.  An  injection 
of  an  ounce  or  two  of  sweet  oil  may  facilitate  the  passage  of  very  hard 
and  dry  stools,  and  a  regular  nightly  repetition  of  this,  or  a  somewhat 
larger  amoimt,  for  several  weeks  will  sometimes  break  up  a  constipated 
habit. 

Medicinal  TreaUnent. — This  is  the  least  important  part  of  the  man- 
agement of  chronic  constipation.  The  most  valuable  laxatives  are  prepa- 
rations of  cascara,  nux  vomica,  belladonna,  hyoscyamus  and  phenolphtha- 
lein. ,  Though  in  most  obstinate  cases  they  are  necessary,  they  should  be 
used  as  little  as  possible  and  the  dose  gradually  diminished.  With  most 
drugs  the  prolonged  use  of  small  doses  is  better  than  the  occasional  use 
of  large  ones.  Cascara  may  be  used  either  in  the  form  of  the  elixir  (dose 
from  one-half  to  one  dram),  or  the  fluid  extract,  from  one  to  five  drops. 
Rhubarb,  either  in  the  form  of  the  syrup  or  the  mixture  of  rhubarb 
and  soda,  may  be  given  occasionally,  but  it  is  not  adapted  to  continuous 
use.  Of  salines,  magnesia  and  phosphate  of  soda  are  best  for  continuous 
use  in  infants.  All  the  preparations  of  malt  possess  slight  laxative 
properties,  and  are  useful  in  conjunction  with  dietetic  and  other  medic- 
inal means;  any  of  the  extracts  of  malt  may  be  employed.  Olive  oil 
is  often  of  assistance  in  the  treatment  of  the  constipation  both  of  infants 
and  older  children.  To  the  former  the  usual  dose  is  one  teaspoonful 
three  times  a  day;  to  the  latter,  two  or  three  times  this  amount  should 


408  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

be  given.  Mineral  oil  (petrolatum  liquidum)  is  a  valuable  remedy,  but 
is  applicable  onh-  to  older  children,  to  whom  from  half  an  ounce  to  one 
and  a  half  ounces  daily  must  be  given.  It  should  be  administered  on 
an  empty  stomach,  or  it  is  likely  to  disturb  digestion.  As  it  is  not 
absorbed,  its  action  is  purely  local.  The  latest  investigations  indicate 
that  the  Eussian  oil  has  no  advantages  over  American  products,  pro- 
vided the  latter  have  been  suitably  refined.  Agar-agar  has  a  beneficial 
action  by  rendering  the  fecal  mass  softer  and  more  easily  expelled.  It 
should  usually  be  combined  with  some  other  laxative  such  as  phenolphtha- 
lein,  cascara  or  rhubarb.  It  should  be  broken  up  into  fine  fragments 
and  may  be  mixed  with  the  cereal,  with  thick  soup  or  simply  with 
water.     The  dose  is  two  or  four  teaspoonfuls  daily. 


HYPERTROPHY  AND  DILATATION  OF  THE  COLON 

{Hirschsprung's  Disease) 

Hirschsprung's  disease  is  characterized  by  a  great  increase  in  the 
diameter  of  the  colon  and  in  the  thickness  of  its  wall.  It  was  originally 
believed  to  be  an  idiopathic  condition  for  which  no  sufficient  anatomical 
cause  could  be  found.  Hence  it  has  been  known  as  congenital  or 
"idiopathic''  dilatation  of  the  colon.  Within  recent  years,  however,  it 
has  become  increasingly  clear  that  in  the  majority  of  cases  there  is  an 
obstruction  to  the  passage  of  the  intestinal  contents  through  the  large 
intestine,  although  when  the  intestines  are  removed  and  laid  open,  no 
evidence  of  obstruction  can  be  found.  The  dilatation  and  hypertrophy 
are  greatest  in  the  sigmoid,  and  in  about  one  third  of  the  cases,  this 
alone  is  affected.  In  the  majority  of  instances,  however,  all  of  the 
colon  is  involved;  very  rarely  only  the  colon  above  the  beginning  of 
ths  sigmoid  is  affected.  The  degree  which  the  dilatation  and  hypertrophy 
may  reach  is  enormous.  The  colon  may  fill  the  greater  part  of  the 
much  dilated  abdominal  cavity.  There  may  be  pressure  upon,  with  a 
certain  amount  of  atrophy  of,'  the  rest  of  the  abdominal  contents  and 
the  capacity  of  the  thorax"  may  even  be  encroached  upon,  the  diaphragm 
being  displaced  upward  to  a  marked  extent.  The  inspissated  contents 
of  the  colon  may  be  many  pounds  in  weight.  The  hypertrophy  is  chiefly 
due  to  an  increase  in  the  circular  musc^^la^  fibers  of  the  affected  portion 
of  the  large  intestine.  The  mucous  membrane  may  be  normal  or  there 
may  be  large  and  oftentimes  deep  ulcers  which  usually  do  not  extend 
beyond  the  muscular  coat  but  may  involve  this  and  even  lead  to  perfora- 
tion of  the  intestines  with  the  consequent  lesions  of  peritonitis. 

At  operation  and  at  autopsy,  when  attention  is  especially  directed 


HYPERTROPHY  AND  DILATATION  OF  THE  COLON  409 

to  the  obstruction,  it  is  found  that  this  is  usually  the  result  of  an 
abnormally  long  sigmoid  and  mesosigmoid  which  allows  the  lower  por- 
tion of  the  sigmoid  flexure  to  fall  forward  and  downward,  thus  pro- 
ducing an  angulation  at  its  junction  with  the  rectum.  With  the  forma- 
tion of  this  angle,  the  tendency  is  for  the  obstruction  to  increase  and  as 
the  result  of  the  effort  of  the  portion  of  the  large  intestine  proximal  to 
it  to  overcome  this  obstruction,  hypertrophy  and  dilatation  take  place. 
This  is  the  factor  which,  in  a  majority  of  the  more  recently  studied 
cases,  has  evidently  been  the  determining  one.  In  a  small  number  of 
instances,  hypertrophy  of  the  transverse  striations  of  the  rectum  have 
been  found  sufficiently  marked  to  cause  some  obstruction.  Other  causes, 
such  as  spasm  of  the  intestine,  deficient  innervation  and  congenital 
dilatation  and  hypertrophy,  have  been  used  to  explain  the  condition 
when  no  anatomical  basis  for  it  has  been  found  but  they  lack  any 
convincing  proof. 

The  symptoms  may  appear  soon  after  birth  or  may  be  delayed 
months  or  even  years,  depending  upon  the  severity  of  the  meclianical 
disturbance.  The  most  striking  symptom  is  the  increase  in  the  size  of 
the  abdomen;  this  may  develop  rapidly  or  slowly.  The  distention  may 
reach  an  extraordinary /extent,  the -abdomen  being  almost  spherical. 
The  greatest  circumference  is  usually  just  above  the  navel.  The  dis- 
tention is  chiefly  due  to  gas,  although  there  may  be  a  sufficient  accumu- 
lation of  fecal  material  to  cause  circumscribed  dulness  and  marked 
resistance  over  the  colon. 

The  constipation  is  more  marked  than  is  seen  in  any  other  condition. 
Days,  even  weeks  may  pass  by  without  an  evacuation  from  the  bowels. 
The  feces  are  then  usually  dry,  dark  brown  or  greenish  and  very  foul. 
Occasionally  mucus  and  blood  are  passed  and  in  the  late  stages  of  the 
disease  there  may  even  be  diarrhea,  the  .result  of  ulceration.  Marked 
peristaltic  waves  are  almost  always  seen;  they  are  usually  in  the  lower 
part  of  the  abdomen  and  on  the  right  as  well  as  on  the  left  side.  Pres- 
sure upon  the  abdomen  is  seldom  painfi;il  and  only  to  a  slight  extent 
unless  some  complication  such  as  peritonitis  is  present.  By  rectal 
examination  an  obstruction  to  the  finger  is  frequently  encountered. 
This  may  be  at  times  oyercome  and  not  infrequently  a  rectal  tube  may 
be  passed  beyond  it.  It  is  then  frequently  found  that  water  may  be 
injected,  which  is  only  expelled  after  a  considerable  length  of  time. 
The  urine  is  usually  normal  except  for  the  presence  of  indican  in  large 
amount. 

Attacks  of  vomiting  from  time  to  time  are  not  unusual,  but  in  gen- 
eral the  digestion  is  good.  The  condition  may  last  for  many  years  and 
may  not  be  incompatible  with  normal  growth.  Very  occasionally  spon- 
taneous recovery  apparently  occurs.    Usually  the  condition  becomes  gradu- 


410  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ally  worse,  the  nutrition  fails,  there  may  be  attacks  of  diarrhea  witli 
fever,  or  death  may  be  due  to  some  intercurrent  infection,  frequently 
of  the  lungs.    Perforative  peritonitis  is  an  occasional  fatal  complication. 

The  two  conditions  most  likely  to  be  confounded  with  Hirschsprung's 
disease  are  tuberculous  peritonitis  and  chronic  intestinal  indigestion. 
Chronic  intestinal  indigestion  is  a  relatively  common  condition.  It 
occurs  frequently  as  the  result  of  some  frank  intestinal  disease,  usually 
between  the  first  and  second  year.  There  are  frequent  attacks  of 
diarrhea  alternating  with  constipation  which  is  never  so  marked  as  in 
Hirschsprung's  disease.  The  distention  is  of  the  small  and  large  in- 
testine as  well  and  is  seldom  accompanied  by  peristaltic  waves  which 
are  never  very  marked.  Chronic  intestinal  indigestion  is  seldom  seen  at 
the  early  age  at  which  Hirschsprung's  disease  is  often  found  and  the 
general  condition  of  the  child  is  always  bad,  while  with  Hirschsprung's 
disease  the  general  health  may  be  excellent  for  a  long  time. 

Tuberculous  peritonitis  is  characterized  by  a  more  rapid  onset,  by 
the  presence,  oftentimes,  of  fluid  in  the  abdominal  cavity  and  of  ab- 
dominal tumors,  by  evidence  of  tuberculosis  elsewhere  and  by  the  pres- 
ence of  the  von  Pirquet  reaction.  Compared  with  the  frequency  of  these 
two  diseases,  Hirschsprung's  disease  is  a  very  rare  condition. 

The  treatment  of  Hirschsprung's  disease  is  palliative  so  long  as 
the  general  health  remains  good  and  without  evidence  of  increase  in  the 
distention.  It  consists  in  careful  feeding,  occasional  enemata  and  by 
the  attempt,  which  is  sometimes  successful,  of  overcoming  the  angulation 
of  the  intestine  by  preventing  fecal  retention.  In  case  the  symptoms 
become  more  severe  and  the  general  health  undermined,  it  is  evident 
that  obstruction  is  becoming  more  marked  and  operative  procedure 
should  be  considered.  Many  different  operations  have  been  suggested; 
the  only  one  wliic-h  can  be  successful  is  one  that  involves  the  entire 
removal  of  the  obstruction  wherever  this  may  be.  In  the  past  the  results 
have  not  been  very  satisfactory,  but  with  increasing  knowledge  and 
experience,  operative  treatment  has  become  more  successful. 


INTUSSUSCEPTION 

Intussusception  consists  in  the  invagination  of  one  jDortion  of  the 
intestine  into  another.  It  occurs  most  frequently  in  infancj',  being  at 
this  age  the  most  common  cause  of  acute  intestinal  obstruction.  The 
accident  is  not  a  common  one,  but  the  life  of  the  patient  generally  de- 
pends upon  its  prompt  recognition. 

Varieties. — Usually  the  upper  part  of  the  intestine  is  invaginated  into 
file  lower,  altliough   the  reverse  is  occasionally  seen.     Intussusceptions 


INTUSSUSCEPTION  4 1 1 

may  occur  at  any  point  in  the  intestinal  tract.  Those  of  the  small  intes- 
tine are  called  enieric;  those  of  the  colon,  coHc;. and  those  occurring  at 
the  ileocecal  valve,  ileocecal  (Fig.  44).  Of  90  cases  under  ten  years 
of  age,  in  which  the  variety  was  determined  by  autopsy  or  operation,  75 
were  ileocecal,  9  colic,  and  6  enteric.  In  the  ileocecal  form  a  few 
inches  of  the  ileum  pass  through  the  ileocecal  valve,  and  then  invagina- 
tion of  the  colon  occurs.     Cases  in  which  the  ileum  passes  through  the 


Fig.  44. — Ileocecal  Intussusception.     A  specimen  removed  from  a  child  in  the  New 

York  Infant  Asylum. 


valve,  but  without  invagination  of  the  colon,  are  sometimes  classed  sepa- 
rately as  an  ileocolic  variety. 

Intussusceptions  of  the  dying,  as  they  have  been  called,  are  met  with 
in  about  eight  per  cent  of  all  autopsies  made  upon  infants ;  they  are  not 
often  found  in  children  over  two  years  of  age.  They  are  descending, 
enteric,  easily  reducible,  and  multiple — usually  from  eight  to  twelve 
invaginations  being  present.  They  are  more  frequently  in  the  jejunum 
than  in  the  ileum.  They  usually  involve  but  two  or  three  inches  of 
the  intestine,  but  may  include  ten  or  twelve  inches.  They  are  found 
in  autopsies  upon  patients  dying  of  all  varieties  of  disease,   and  are 


412  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

probably  produced  in  the  death  agony.  Such  intussusceptions  are  with- 
out symptoms,  and  are  of  no  clinical  importance. 

Etiology. — Of  358  collected  cases  under  ten  years,  the  following  are 
the  ages  reported :  under  four  months,  28  eases ;  from  four  to  six  months, 
113;  seven  to  nine  months,  71;  ten  to  twelve  months,  18;  one  to  two 
years,  32;  two  to  ten  years,  96.  Three-fourths  of  the  cases  which  occur 
in  childhood  are,  therefore,  in  the  first  two  years,  and  one-half  of  them 
between  the  fourth  and  ninth  months.  The  greater  frequency  in  infancy 
is  attributed  to  the  thinness  of  the  intestinal  walls,  the  greater  mobility 
of  the  cecum  and  ascending  colon,  and  the  presence  of  other  intestinal 
derangements  at  this  age. 

Males  are  more  often  affected  than  females.  Of  268  cases  in  which 
the  sex  was  mentioned,  there  were  174  males  and  94  females.  For  this 
fact  there  is  no  explanation.  The  exciting  causes  of  an  attack  are  ex- 
^tremely  obscure.  The  great  majority  of  cases  occur  in  children  who  are 
apparently  in  perfect  health.  Some  previous  intestinal  disorder  was 
present  in  about  three  per  cent  of  the  cases  we  have  collected — diarrhea, 
dysentery,  colic,  chronic  indigestion,  and  constipation,  all  being  men- 
tioned. In  four  cases  the  intussusception  was  ascribed  to  injury  of  the 
abdomen. 

Lesions. — Nothnagel's  animal  experiments  have  shown  conclusively 
that  intussusceptions  are  formed  by  the  irregular  action  of  the  muscular 
walls  of  the  intestine.  They  can  be  produced  or  released  at  will  by  vary- 
ing the  application  of  the  electrical  current.  In  the  artificial  intussus- 
ception there  is  first  a  contraction  of  a  certain  part  of  the  intestine,  and 
if  this  ceases  abruptly  the  normal  gut  below  this  point  turns  upward'  and 
folds  over  upon  the  contracted  portion,  thus  forming  a  minute  intus- 

^^ susception    (Fig.    45,    A).      When 

once  begun,  the  intussusception  in- 
creases solely  at  the  expense  of  the 
Fig.  45,  A.  external  layer  (Fig.  45,  B) .    Thus, 


Fig.  45,  B. — Mechanism  of  Intussusception.     (Treves.) 

while  the  apex  of  the  tumor  D  remains  unchanged,  the  part  of  the 
sheath  at  A  passes  to  B  and  then  to  C,  so  that  the  lower  part  of  the 
intestine  is  drawn  over  the  upper,  rather  than  the  upper  crowded  into 
the  lower.  The  mechanism  of  the  invagination  was  apparently  the  same 
when  a  part  of  the  intestine  was  first  paralyzed  by  crushing,  as  in  the 
case  in  which  a  spasm  of  the  intestine  was  first  produced. 

There  is  little  doubt  that  pathological  intussusceptions  are  produced 


INTUSSUSCEPTION  413 

in  the  same  way  as  in  these  experiments.  As  the  invagination  takes 
place,  the  mesentery  is  drawn  in  with  the  bowel,  and  always  lies  between 
the  sheath  and  the  inner  layer.  To  allow  intussusception  to  occur,  the 
mesentery  must  be  unduly  long,  stretched,  or  lacerated.  Its  attachment 
to  the  spine  causes  the  intussusception  to  describe  an  arc  of  a  circle,  the 
concavity  of  which  is  always  toward  the  spine.  It  also  causes  a  puckering 
of  the  tumor.  Invagination  does  not  necessarily  produce  either  ob- 
struction or  strangulation,  but  usually  both  are  present,  and  are  the 
chief  causes  of  the  symptoms.  Traction  upon  the  mesentery  leads  to 
obstruction  in  its  vessels,  causing  congestion,  edema,  hemorrhages,  and 
even  gangrene.  Obstruction  is  chiefly  due  to  swelling.  It  may  be  due 
to  dragging  of  the  mesentery,  which  brings  the  apex  of  the  tumor  against 
the  side  of  the  gut,  or  to  bending  of  the  intussusception.  Intussusception 
is  usually  of  all  the  coats  of  the  intestine.  We  have,  however,  seen  one, 
the  exact  nature  of  which  was  determined  by  operation,  in  which  only 
the  mucosa  and  submucosa  were  involved.  The  invagination  was  at  the 
ileocecal  valve.  The  symptoms  were  characteristic  except  for  the  ab- 
sence of  tumor. 

The  great  cause  of  irreducibility  in  the  first  two  or  three  days  is 
swelling.  We  have  several  times  seen  at  autopsy  or  operation  an  intus- 
susception easily  reduced,  except  the  last  two  or  three  inches  of  the 
cecum  or  ileum,  which  was  swollen  to  the  thickness  of  from  a  fourth 
to  half  an  inch.  Adhesions  may  prevent  reduction,  but  rarely  before  the 
fourth  day;  they  are  often  absent  as  late  as  the  sixth  or  seventh  day. 
They  are  usually  between  the  internal  and  middle  layers  of  the  intus- 
susceptum,  and  are  due  to  local  peritonitis.  In  chronic  cases,  however, 
they  form  the  principal  obstacle  to  reduction.  Other  causes  of  irreduci- 
bility  are  twisting  of  the  tumor  and  pinching  of  the  prolapsed  intestine, 
especially  the  ileum  by  the  ileocecal  valve. 

Gangrene  and  sloughing  of  the  gangrenous  portion  of  the  intestine 
occur  much  more  often  in  acute  than  in  chronic  cases.  Portions  of 
intestine  were  passed  per  anum  in  24  of  363  cases  under  ten  years,  or 
about  six  per  cent;  but  only  two  of  these  were  in  infants.  Toward  the 
end  of  the  second  week  is  the  time  when  the  separation  of  the  sloughs  is 
to  be  looked  for.  The  amount  of  intestine  discharged  varies  from  a  few 
inches  to  several  feet.  Two  cases  are  on  record  in  which  the  entire  colon 
was  passed,  the  patients  recovering,  but  dying  several  months  later  from 
other  causes.  At  the  autopsies  the  ileum  was  found  attached  to  the  lower 
part  of  the  rectum  just  above  the  anus.  In  acute  cases  gangrene  occurs 
about  the  upper  end  of  the  tumor,  and  the  intestine  usually  comes  away 
in  one  large  mass.  In  chronic  cases  shreds  of  intestine  may  be  dis- 
charged for  several  weeks. 

Symptoms.— The  clinical  picture  of  a  case  of  intussusception  is  a 
15 


414  DISEASES  OF  TTTE  DTflESTIVE  SYSTEM 

striking  one,  and  when  acute  the  s3'mptoms  are  so  uniform  that,  once 
seen,  it  can  scarcely  be  overlooked  a  second  time.  The  patient,  usually 
between  six  and  twelve  months  of  age,  is  taken  suddenly  ill  with  severe 
pain  and  vomiting;  the  pain  recurs  paroxysmally  every  few  minutes, 
and  the  vomiting  is  first  of  the  contents  of  the  stomach,  and  after- 
ward bilious.  There  may  be  one  or  two  loose  fecal  stools,  then  only 
blood  or  blood  and  mucus  are  passed  Avithout  any  admixture  of  feces. 
The  general  symptoms  are  those  of  great  prostration,  or  even  collapse — 
pallor,  feeble  pulse,  apathy,  and  normal  or  subnormal  temperature.  The 
abdomen  is  relaxed.  A  tumor  is  usually  present  in  the  epigastrium  or 
the  left  iliac  fossa,  or  it  may  be  felt  per  rectum.  Later  there  is  tym- 
panites ;  the  vomiting  and  pain  continue ;  there  is  a  steady  increase  in  the 
prostration,  and  toward  the  end  a  rapidly  rising  temperature  which  may 
reach  105°  or  106°  F.  before  death  occurs  from  collapse.  If  the  s^-mp- 
toms  continue  longer  the  signs  of  peritonitis  are  added.  In  subacute 
cases  the  onset  is  less  abrupt,  and  pain,  vomiting,  and  constipation  less 
constant  and  less  severe ;  but  the  same  symptoms  are  present.  In  chronic 
cases  the  onset  is  with  vague,  indefinite  intestinal  symptoms ;  pain,  vom- 
iting and  bloody  discharges  are  usuallf  wanting;  there  is  progressive 
wasting  and  more  or  less  diarrhea,  but  only  the  presence  of  the  tumor 
leads  to  the  recognition  of  the  condition. 

Onset. — Of  193  cases  under  ten  years  in  which  data  upon  this  point 
could  be  obtained,  the  onset  was  sudden  in  181  and  gradual  in  12  cases. 
By  far  the  most  frequent  symptoms  of  onset  are  pain  and  vomiting.  In 
a  smaller  number  of  cases  the  initial  symptom  is  diarrhea  or  a  dis- 
charge of  blood  and  mucus. 

Pdin. — This  is  rarely  continuous,  but  is  intermittent,  recurring  in 
paroxysms  like  those  of  ordinary  colic,  but  of  great  severity.  Few  pains 
in  infancy  are  to  be  compared  with  it.  The  child  sometimes  shrieks  so  as 
to  be  heard  all  over  the  house.  Pain  is  a  prominent  symptom  in  over 
three-fourths  of  the  cases,  and  is  very  rarely  absent.  It  is  generally  more 
^marked  for  the  first  two  days,  but  may  continue  throughout  the  attack. 
In  a  few  cases  the  pain  is  localized,  being  usually  referred  to  the  region 
of  the  umbilicus. 

Vomiting  is  more  marked  at  the  onset,  but  may  continue  throughout 
the  attack.  Like  the  pain,  it  is  more  frequent  in  the  acute  cases.  It  is 
due  to  intestinal  obstruction.  Vomiting  is  i^resent  in  fully  four-fifths 
of  all  cases.  Usually  it  is  persistent  and  often  projectile.  If  food  is 
given,  vomiting  often  occurs  as  soon  as  it  reaches  the  stomach.  Stercora- 
•ceous  vomiting  occurs  in  about  fifteen  per  cent  of  the  cases  in  children 
under  ten  years,  but  is  not  common  in  infancy.  It  is  rarely  present 
before  the  third  or  fourth  day.  Although  a  bad  sign,  it  is  not  by  any 
means  a  fatal  one,  as  nearly  one-half  the  cases  in  which  it  has  been  noted 


INTUSSUSCEPTION 


415 


have  recovered;  it  is  to  be  regarded  as  indicating  complete  intestinal 
obstruction  rather  than  strangulation. 

Tumor. — This  is  one  of  the  most  important  symptoms  for  diagnosis 
because  of  its  frequency  and  its  peculiar  character.  It  is  present  early  in 
the  disease,  often  in  a  few  hours  after  the  initial  symptoms.  The  follovs^- 
ing  table  shows  the  frequency  with  which  a  tumor  was  present  in  the 
different  varieties,  and  the  position  which  it  occupied  in  each.  The 
anatomical  variety  was  determined  either  )jy  autopsy  or  operation.      >^>^. 


The  lielation  hekveen  the  Tumor  and  the  Different  Varieties  of  Intnssus- 
ception  in  188  Cases  under  Ten  Years. 


Seat  of  Tumor. 

Seat  of  Intussusception 

Ileocecal. 

neocolic. 

CoHc. 

Enteric. 

Not  Stated. 

Total. 

Region  of  cecum 

1 

3 
3 

4 

25 

9 

i 

3 

'l      ^ 

1 

7 
1 

1 

1 
1 

7 
12 
13 
18 

8 
28 
12 

'2 

11 

"       "  ascending  colon 
"       "  transverse  colon 
"       "  descending  colon 
"       "  sigmoid  flexure. 
Rectum 

13 
16 
21 
13 
61 

Protruding  from  anus .... 
Umbilical  region 

22 
1 

Movable 

Site  unknown 

3 
1 

Total    

46 
10 

4 
2 

9 

3 
1 

100 
13 

162 

No  tumor  felt 

26 

Tumor  was  thus  made  out  during  life  in  eighty-six  per  cent  of  the 
cases;  and  in  the  great  majority  of  these  it  was  discovered  at  the  first 
careful  examination. 

It  will  be  noted  that  in  nearly  half  of  the  cases  the  tumor  was  either 
felt  in  the  rectum  or  protruded  from  the  anus,  and  that  in  over  two- 
thirds  it  had  advanced  as  far  as  the  descending  colon  or  beyond.  The 
tumor  may  reach  the  rectum  in  a  surprisingly  short  time,  even  when 
the  invagination  begins  at  the  ileocecal  valve.  In  one  of  our  cases  it 
was  felt  in  the  rectum  in  less  than  twelve  hours  from  the  onset.  The 
usual  description,  '"sausage-shaped,'"  is  accurate  when  the  invagination 
is  large,  the  tumor  then  being  from  four  to  six  inches  long  and  about 
an  inch  and  a  half  in  diameter.    It  is  often  curved. 

During  manipulation,  or  during  an  attack  of  pain,  the  tumor  may 
become  more  prominent  and  may  be  distinctly  erectile.  To  the  touch 
the  rectal  tumor  closely  resembles  the  os  uteri,  the  central  opening  being 
the  apex  of  the  intussusception.  When  protruding  from  the  body,  the 
tumor  is  rarely  more  than  two  inches  long.     It  is  usually  of  a  deep- 


416  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

purplish  color,  and  may  be  gangrenous.  It  has  been  mistaken  for 
prolapsus  ani,  polypus,  and  even  hemorrhoids. 

Condition  of  the  Bowels. — Bloody  stools  are  a  very  constant  symp- 
tom. Of  186  cases  under  ten  years  in  which  the  condition  of  the  bowels 
was  noted,  blood  in  the  stools  was  present  in  seventy-six  per  cent.  There 
are  very  often  two  or  three  thin,  diarrheal  movements,  and  then  only 
blood  and  mucus  are  passed  with  no  trace  of  feces  and  with  no  fecal 
odor.  The  amount  of  blood  varies  from  a  quantity  sufficient  to  stain 
the  mucus,  to  an  ounce  of  semi-fluid  blood.  It  rarely  occurs  without 
some  mucus.  Such  discharges  frequently  follow  attacks  of  severe  colicky 
pain,  and  may  occur  several  times  in  an  hour.  They  may  continue,  or 
after  a  day  or  two  they  may  be  succeeded  by  absolute  stoppage.  Diar- 
rhea throughout  the  attack  is  rare  in  children,  particularly  so  in  in- 
fants. It  belongs  generally  to  chronic  cases.  Constipation  is  complete 
in  most  of  the  acute  cases,  neither  gas  nor  feces  being  passed — a  fact 
which  the  discharge  of  blood  and  mucus  may  lead  one  to  overlook. 

Tenesmus  is  very  common  if  the  tumor  is  rectal.  Eelaxation  of  the 
sphincter  is  met  with  in  a  considerable  proportion  of  the  cases  when  the 
tumor  is  in  the  sigmoid  flexure,  or  rectum. 

During  the  first  twenty-four  or  forty-eight  hours  the  abdominal  walls 
are  soft  and  relaxed,  and  may  even  be  retracted.  Usually  there  is  then 
little  resistance  to  abdominal  palpation.  After  the  second  or  third  day 
there  is  usually  tympanites;  but  this  does  not  necessarily  mean  that 
peritonitis  exists.  Localized  tenderness  is  a  symptom  of  some  impor- 
tance when  a  tumor  is  absent.  Scanty  urine  has  been  noted  in  a  few 
cases,  but  is  of  no  special  value  in  showing  the  seat  of  obstruction. 

In  the  acute  cases  the  general  symptoms  are  very  striking.  They  are 
the  ordinary .  ones  of  severe  shock — marked  prostration,  pallor  with  an 
anxious  expression  of  the  face,  general  muscular  relaxation,  cold  extrem- 
ities, cold  perspiration,  and  often  a  subnormal  temperature.  Early  there 
is  marked  restlessness,  and  even  convulsions  may  occur.  Later  there  is 
apathy,  dulness,  even  semi-stupor.  The  temperature  during  the  first 
twenty-four  hours  is  usually  not  elevated,  and  is  frequently  subnormal. 
Toward  the  close  of  the  disease  it  rises  rapidly  to  103°,  104°  F.,  or  even 
higher,  quite  independently  of  peritonitis.  A  rapidly  rising  temperature 
is  always  a  bad  symptom,  and  usually  betokens  death  within  twenty- 
four  hours.  Wasting  is  seen  in  the  chronic  cases,  and  may  be  quite 
rapid. 

Course,  Duration,  and  Termination. — Of  198  cases  under  ten  years, 
155  were  classed  as  acute,  lasting  less  than  seven  da3's;  33  as  subacute, 
lasting  from  one  to  four  weeks;  10  were  chronic,  lasting  over  four  weeks. 
Nearly  all  the  cases  occurring  in  infancy  are  acute. 

Spontaneous  reduction  is,  without  doubt,  possible  in  intussusception. 


INTUSSUSCEPTION  417 

Treves  and  others  are  of  the  opinion  that  this  happens  much  more  fre- 
quently than  is  generally  supposed,  and  that  many  cases  of  severe  colic 
are  really  cases  of  slight  intussusception.  There  are  seen  in  both  con- 
ditions the  tendency  to  vomit,  the  paroxysmal  pain,  the  constitutional 
depression,  and  often  the  sudden  cessation  of  the  symptoms,  especially 
under  the  influence  of  opium ;  but  to  make  a  positive  diagnosis  of  invagi- 
nation in  such  cases  is  impossible.  Intussusception  may  be  cured  spon- 
taneously by  sloughing  of  the  invaginated  part,  the  continuity  of  the 
intestine  being  preserved  by  adhesions.  Such  a  result  is  rare  at  all  ages, 
and  is  almost  never  seen  in  infancy. 

The  most  frequent  cause  of  death  in  acute  cases  is  shock.  Peritonitis 
is  not  found  at  autopsy  or  operation  so  often  as  might  be  expected.  In 
fifty-eight  autopsies,  it  was  seen  but  tv^enty  times,  and  in  seven  of  these 
it  was  limited  to  the  intussusception.  In  but  seven  cases  was  there 
perforation. 

Diagnosis. — This  usually  presents  no  difficulty  in  acute  cases  provided 
the  physician  has  the  condition  in  mind.  The  great  majority  of  such 
cases  present  nearly  all  the  classical  symptoms,  viz.,  sudden  onset,  recur- 
ring colicky  pains,  frequent  vomiting,  bloody  and  mucous  stools  without 
fecal  matter,  general  prostration  or  collapse,  and  low  temperature.  The 
records  show  that  the  most  common  error  is  to  regard  the  case  for  the 
first  few  days  as  one  of  gastro-enteritis  or  ileocolitis,  the  physician's 
attention  being  engrossed  by  the  vomiting  and  bloody  stools.  Given 
the  other  usual  symptoms,  the  presence  of  the  characteristic  tumor  is 
conclusive  evidence  of  intussusception.  Unless  the  patient  is  very  much 
relaxed,  a  satisfactory  examination  is  possible  only  under  full  anesthesia. 
In  any  case  of  acute  intestinal  obstruction  in  infants,  intussusception 
should  first  be  considered.  We  once  saw  in  a  young  infant  with  strangu- 
lated hernia  nearly  every  symptom  of  intussusception  except  the  ab- 
dominal tumor;  in  another  infant  with  an  inflamed  Meckel's  diver- 
ticulum there  was  vomiting,  bloody  and  mucous  stools  and  an  elon- 
gated tumor  in  the  hypogastric  region.  Cases  of  chronic  intussuscep- 
tion present  no  diagnostic  symptoms  except  the  tumor.  In  both  acute 
and  chronic  cases  the  rectal  examination  is  most  important  for  diag- 
nosis, and  often  settles  the  question  at  once. 

Prognosis. — The  prognosis  of  intussusception  depends  upon  the  age 
of  the  patient,  upon  the  variety  of  the  disease — whether  acute,  sub- 
acute, or  chronic — and  upon  the  time  when  proper  treatment  is  begun. 

There  were  collected  by  Pilz  in  1870,  94  cases  under  one  year,  the 
mortality  being  84  per  cent.  Of  135  cases  of  the  same  age  reported 
between  1870  and  1891  the  mortality  was  59  per  cent.  Results  in  older 
children  were  somewhat  more  favorable.  Formerly  recovery  was  rare, 
except  in  cases  with  sloughing;  but  with  earlier  diagnosis  and  a  better 


418  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

understanding  of  the  proper  methods  of  treatment,  the  mortality  has 
been  very  much  reduced.  Combining  the  figures  of  Pilz  with  our  own, 
there  are  362  cases  with  231  deaths,  or  63.5  per  cent. 

Gibson  (New  York)  has  collected  reports  of  187  operations  for  intus- 
susception, with  a  general  mortality  of  51  per  cent;  in  126  cases,  in 
which  the  tumor  was  reducible,  it  was  but  36  per  cent;  in  61,  in  which 
it  was  irreducible  or  gangrenous,  it  was  80  per  cent.  The  table  following 
gives  the  mortality  in  relation  to  time  of  operation : 


Time  of  Operation. 


Mortality, 
Per  cent. 


First    day . 

Second 

Third 

Fourth 

Fifth 

Sixth 


37 
39 
61 
67 
73 
75 


After  the  second  day  the  chances  of  success  are  greatly  reduced. 

Treatment. — The  diagnosis  of  acute  intussusception  once  made,  lapa- 
rotomy should  immediately  be  performed  without  an  hour's  unnecessary 
delay.  The  results  following  inflation  of  the  intestine  with  air  and' 
injection  with  water  are  too  uncertain  to  be  depended  upon. 

Operation  should  be  looked  upon  as  a  measure  which,  if  employed 
reasonably  early,  offers  a  good  prospect  of  success.  All  statistics  show 
that  the  result  depends  more  upon  the  time  when  the  operation  is  done 
than  upon  any  other  single  factor.  With  earlier  diagnosis  and  more 
prompt  resort  to  operation,  the  mortality  from  acute  intussusception  has, 
during  the  past  fifteen  years,  been  steadily  falling.  In  chronic  cases, 
also,  laparotomy  offers  altogether  the  best  chance  of  success. 


CHAPTER  IX 

DISEASES  OF   THE  INTESTINES.— (Continued) 

APPENDICITIS 

Appendicitis  is  met  with  at  all  ages,  and  is  not  especially  a  disease 
of  children.  When  it  attacks  those  over  ten  or  twelve  years  of  age  it 
does  not  differ  greatly  from  the  types  observed  in  adults.  All  that  will 
be  attempted  in  this  chapter  will  be  a  consideration  of  the  peculiarities 


APPENDICITIS  419 

of  the  disease  as  it  is  seen  in  children,  particularly  young  children.  For 
a  fuller  discussion  of  the  disease  as  a  whole  the  reader  is  referred  to 
works  on  general  medicine  and  surgery. 

Etiology. — Of  1,000  cases  of  appendicitis  personally  observed  by 
McCosh,  85  occurred  in  children  between  the  ages  of  ten  and  fifteen 
years;  51  between  the  ages  of  five  and  ten  years,  and  only  17  under  five 
years;  of  these  but  4  were  under  two  years.  Churchman's  figures  from 
the  Johns  Hopkins'  Hospital,  in  a  total  of  1,223  cases,  give  only  9  cases 
under  five  years,  and  50  between  five  and  ten  years.  In  infancy  and 
early  childhood  appendicitis  is,  therefore,  a  relatively  rare  disease.  The 
youngest  case  that  has  come  under  our  observation  was  in  an  infant  of 
ten  weeks.  Operation  was  done  and  recovery  followed.  Appendicitis 
in  young  infants  has  been  reported  by  Goyen  (six  weeks),  Shaw  (seven 
weeks),  Demme  (seven  weeks)  and  Savage  (nine  weeks).  The  pre- 
dominance of  the  male  sex  holds  true  even  in  childhood.  Of  101  cases 
under  fifteen  years,  72  were  males  and  29  were  females. 

Eegarding  the  exciting  cause  of  an  attack  but  little  is  yet  definitely 
known.  In  only  a  very  small  proportion  of  the  cases  is  a  foreign 
body  discovered  in  the  appendix.  In  one  of  ours  a  pin  was  found, 
and  a  number  of  similar  cases  are  on  record.  There  is,  however,  often 
a  fecal  concretion  which  is  moulded  into  the  shape  of  a  foreign  body, 
and  formerly  was  often  regarded  as  such.  This  probably  has  some 
relation  to  the  attack  by  causing  disturbances  of  circulation  and  in- 
creasing the  chances  of  infection.  Still  and  others  have  called  attention 
to  the  frequent  occurrence  of  pin  worms  in  the  appendices  of  young  chil- 
dren. There  is  abundant  reason  for  believing  that  these  may  at  times 
be  the  exciting  cause  of  an  attack.  The  bacteria  most  frequently  found 
in  abscesses  from  appendicitis  are  streptococci,  usually  associated  with 
colon  bacilli. 

Lesions. — All  the  common  varieties  of  acute  appendicitis, — the  catar- 
rhal, suppurative,  and  gangrenous, — are  met  with  in  children ;  and,  much 
less  frequently,  the  chronic  form.  The  lesions  present  few  peculiarities 
in  early  life  except  that,  owing,  possibly,  to  the  relation  of  the  appendix 
to  the  omentum,  perforative  inflammations  are  less  likely  to  be  circum- 
scribed by  inflammatory  products  and  much  more  likely  to  result  in  a 
general  peritonitis  than  in  adults.  Whether  or  not  this  be  the  correct 
explanation,  it  is  certainly  true  that  general  peritonitis  is  a  much  more 
common  sequel  than  in  adults.  Another  point  of  some  importance  is 
the  fact  that  in  early  life  the  appendix  is  rather  more  frequently  found 
out  of  the  usual  position.  The  inflammation  excited  by  pin  worms  is 
usually  a  superficial  one;  perforation  and  abscess  formation  are  almost 
unknown  when  they  are  the  cause. 

Symptoms. — In  many  of  the  cases  the  familiar  symptoms  of  appen- 


420  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

dicitis — vomiting,  localized  pain  and  tenderness,  muscular  rigidity,  ab- 
dominal distention,  and  fever — are  all  present,  and  the  diagnosis  is  easy. 
But  in  perhaps  the  larger  number  the  disease  is  irregular  in  its  onset, 
insidious  in  its  course,  and  presents  at  times  great  difficulties  in  diagnosis. 
This  is  particularly  true  of  appendicitis  in  children  under  five  years. 
Vomiting  is  probably  the  most  constant  symptom;  it  is  seldom  absent, 
and  usually  persistent.  If  accompanied  by  pain  and  constipation,  ap- 
pendicitis should  at  once  be  thought  of.  Pain,  though  usually  present,  is 
often  indefinite ;  it  is  generally  hard  to  localize  and  difficult  to  interpret. 
It  may  be  referred  now  to  one  and  now  to  another  part  of  the  abdomen. 
Often  the  only  evidence  of  pain  is  restlessness,  irritability,  and,  in  in- 
fants, frequent  crying.  Tenderness  is  even  more  difficult  to  elicit  than 
pain.  Young  children,  especially  if  nervous  and  sensitive,  shrink  from 
any  touch,  and  the  results  of  abdominal  jDalpation  may  be  most  unreli- 
able. In  others  of  a  different  temperament  positive  information  may  be 
obtained.  In  any  child  under  three  years,  it  is  almost  impossible  to 
make  out  localized  tenderness.  The  same  is  true  of  muscular  rigidity. 
Only  with  the  greatest  amount  of  tact  and  by  diverting  the  patient, 
can  any  information  be  derived  from  this  part  of  the  examination. 
Tenderness  and  muscular  rigidity  are  sometimes  shown  by  the  child's 
disinclination  to  move  either  the  trunk  or  lower  extremities  and  by  evi- 
dences of  pain  when  he  is  moved  by  mother  or  nurse.  When  associated 
with  vomiting,  fever,  and  constipation,  such  symptoms  are  always 
suggestive. 

Constipation  is  usually  present,  but  by  no  means  so  regularly  as  in 
adults.  Diarrhea  is  not  at  all  imcommon,  and,  when  associated  with 
vomiting,  tends  to  divert  attention  from  the  appendix  to  an  ordinary 
gastro-intestinal  attack.  Abdominal  distention,  when  present,  is  of  much 
importance,  taken  with  other  symptoms.  Fever  is  rather  more  apt  to 
be  high  than  in  adults.  But  there  are  many  exceptions,  and,  on  the 
whole,  the  temperature  is  a  very  untrustworthy  guide  either  to  diag- 
nosis or  prognosis.  The  leucocyte  count  is  of  much  assistance  in  diagno- 
sis, at  least  in  suppurative  forms  of  appendicitis.  A  leucocytosis  of  at 
least  10,000  to  20,000  is  usually  present,  with  a  polymorphonuclear  per- 
centage over  75.  Some  special  symptoms  may  be  seen  in  appendicitis 
which  are  quite  misleading.  We  have  on  several  occasions  seen  frequent 
micturition  and  other  marked  manifestations  of  vesical  irritation,  ow- 
ing to  the  position  of  the  appendix  behind  the  bladder.  Pain  just  before 
and  during  defecation  is  occasionally  a  striking  symptom  especially  with 
infants.  The  rigidity  of  the  thigh  flexors  seen  in  cases  of  appendicitis, 
which  comes  on  with  subacute  symptoms,  may  give  rise  to  lameness 
strongly  suggestive  of  disease  at  the  hip. 

Course  of  the  Disease. — A  certain  number  of  cases  begin  with  definite 


APPENDICITIS  421 

symptoms- — pain^  vomiting,  fever,  and  constipation — and  continue  with 
slowly  or  rapidly  advancing  symptoms  to  increasing  prostration,  con- 
tinued vomiting,  constipation,  rapid  pulse,  abdominal  distention,  rigid- 
ity, higher  temperature,  and  death  by  general  peritonitis  at  the  end 
of  five  or  seven  days'  illness.  Others,  with  a  similar  onset,  show  a 
gradual  abatement  of  all  acute  symptoms  after  a  few  days,  and  recovery 
at  the  end  of  ten  days  or  two  weeks,  followed,  perhaps,  by  another  at- 
tack after  a  few  months.  These  types  are  seen  in  children  as  in  adults. 
But  others  are  quite  common.  A  child  may  be  taken  ill,  sometimes 
abruptly,  sometimes  more  gradually,  with  vomiting,  which  is  repeated 
several  times  in  a  single  day,  afterward  only  occasionally.  There  is 
some  pain;  it  is  not  very  definite  and  not  localized.  The  prostration  is 
only  moderate,  the  temperature  not  over  100°  or  100.5°  F.  The  exami- 
nation shows  little.  Tenderness  can  not  be  definitely  made  out;  the 
child  is  irritable,  fretful,  wishes  to  be  left  alone,  and  resists  all  efforts  at 
abdominal  palpation.  The  bowels  are  constipated,  or  they  may  be  at  first 
loose  and  afterward  constipated.  The  child  does  not  seem  very  sick. 
The  attack  is  probably  regarded  as  an  ordinary  one  of  acute  indigestion. 
But  things  do  not  improve  as  they  ought.  The  pulse  becomes  more 
rapid,  the  prostration  greater,  and  the  child  begins  to  look  seriously  ill, 
though  the  temperature  has  not  risen.  The  abdominal  distention  is  now 
considerable  and  tenderness  undoubted.  An  operation  is  decided  on,  and 
there  is  found  a  gangrenous  appendix  and  a  diffuse  general  peritonitis. 
Sometimes  the  grave  symptoms  develop  with  great  rapidity  in  the  course 
of  a  few  hours,  when  previous  symptoms  had  all  been  mild;  sometimes 
so  insidiously  that  the  transition  is  almost  imperceptible. 

Prognosis, — The  prognosis  in  young  children  is  not  good;  of  132 
collected  cases  in  infants  and  very  young  children  the  mortality  was  38 
per  cent.  But  in  those  over  seven  years  old  the  outlook  is  rather  better 
than  in  adults.  The  results  depend  much  upon  early  diagnosis  and 
proper  treatment.  General  peritonitis,  it  is  generally  agreed,  occurs 
much  oftener  in  children  than  in  adults;  it  is  the  cause  of  death  in  about 
80  per  cent  of  the  cases.  Of  43  fatal  cases,  nearly  all  of  them  from 
general  peritonitis,  only  6  died  during  the  first  three  days,  19  from  the 
fourth  to  the  seventh  day,  13  in  the  second  week,  and  5  in  the  third 
week.  If  general  peritonitis  occurs,  the  chances  of  recovery  after  opera- 
tion are,  hoAvever,  usually  better  with  children  than  with  adults. 

Diagnosis. — The  diagnostic  symptoms  of  appendicitis  are  a  sudden 
onset  with  vomiting,  sharp  pain  in  the  abdomen,  and  persistent  acute 
localized  tenderness  in  the  right  iliac  fossa.  Rigidity  of  any  or  all  of 
the  abdominal  muscles  is  also  significant.  Constipation  is  more  fre- 
quent than  diarrhea,  though  the  latter  is  not  rare.  There  is  almost 
invariably  some  elevation  of  temperature,  but  not  often  high  fever. 


42:2  DISEASES  OF  THE  DTOESTTVE  SYSTEM 

Appendicitis  may  be  confounded  with  colic,  indigestion,  and  in 
infants  with  intussusception;  in  older  children  with  abscesses  due  to 
psoitis.  Colic  is  distinguished  by  the  absence  of  localized  tenderness  and 
fever,  by  its  short  duration,  and  by  the  fact  that  the  pain  is  generally 
less  intense.  Severe  colic  with  fever  in  children  over  three  years  old 
should,  however,  always  be  regarded  with  suspicion.  From  acute  indi- 
gestion the  diagnosis  of  appendicitis  is  difficult  at  the  onset,  and  it  may 
be  impossible  for  twenty-four  hours.  However,  the  pain  of  indigestion 
is  rarely  so  severe,  while  the  fever  is  usually  higher.  It  should  be  re- 
membered that  the  pain  in  appendicitis  is  not  always  localized,  nor  is 
the  tumor  always  in  the  right  iliac  fossa.  The  presence  of  pain,  vomit- 
ing, and  localized  tenderness,  and  the  greater  severity  of  the  constitu- 
tional symptoms,  indicate  appendicitis.  We  have  several  times  known 
the  pleurisy  accompanying  pneumonia  at  the  right  base  to  be  mistaken 
for  appendicitis.  With  this  there  may  be  vomiting,  severe  localized  pain, 
and  sometimes  also  localized  tenderness.  Cyclic  vomiting  is  distin- 
guished by  the  history  of  previous  attacks,  the  greater  frequency  with 
which  the  vomiting  occurs,  its  abrupt  cessation  after  twenty-four  to 
seventy-two  hours,  the  sunken  abdomen,  and  the  absence  of  pain,  tender- 
ness, and  rigidity.  The  presence  of  early  acetonuria  is  also  charac- 
teristic. Intussusception,  with  its  pain,  colic,  and  vomiting,  may  sug- 
gest appendicitis,  but  is  rare,  except  in  infants;  fever  is  absent  early 
in  the  disease,  and  a  tumor  is  usually  present.  Acute  or  subacute 
suppuration  in  the  right  iliac  fossa  is  almost  invariably  due  to 
appendicitis. 

The  leucocyte  count  may  be  of  considerable  assistance  in  differentiat- 
ing appendicitis  from  colic,  cyclic  vomiting,  ileocolitis,  and  intussus- 
ception. It  should,  however,  be  remembered  that  in  some  of  the  gravest 
cases  the  leucocytosis  may  be  slight  or  there  may  be  none  at  all.  On 
the  whole,  while  the  presence  of  marked  leucocytosis — i.  e.,  above  30,000 
— ^may  be  of  considerable  assistance  in  the  diagnosis,  no  inference  can 
be  drawn  from  a  normal  count  or  a  slight  leucocytosis  if  the  child  is 
greatly  prostrated.  Whenever,  in  children  over  two  years  old,  there  are 
symptoms  pointing  to  acute  peritonitis,  no  matter  what  their  combina- 
tion or  variety,  appendicitis  should  always  be  suspected. 

Treatment. — Absolute  rest  in  bed  can  n>ot  be  too  strongly  insisted 
upon  whenever  appendicitis  is  suspected,  no  matter  how  mild  the  attacli 
may  ajDpear.  As  a  local  application,  the  ice-bag  is  to  be  preferred. 
Opium  should  not  be  given.  It  does  harm  by  obscuring  important 
symptoms  and  increasing  constipation.  The  colon  should  be  kept  empty 
by  the  daily  use  of  enemata.  After  a  thorough  clearing  of  the  bowels 
in  the  beginning,  preferably  by  a  saline,  cathartics  are  to  be  avoided. 

Appendicitis  is   a   surgical   disease,   and  surgical   advice  should   be 


INTESTINAL  WORMS  423 

sought  early.  In  deciding  as  to  the  time  of  operative  interference,  it 
should  be  remembered  that  localization  of  the  inflammation  is  less  likely 
to  occur  Avith  children  than  with  older  patients  and  that  therefore  the 
dangers  of  general  peritonitis  are  much  greater ;  that  the  progress  of  the 
disease  is  much  less  regular;  that  grave  conditions  are  not  revealed  at 
once  by  grave  symptoms;  that  the  disease  is  an  insidious  one,  and  that 
to  foretell  the  outcome  even  in  tlie  mildest  cases  is  impossible.  Taking- 
all  these  things  into  account,  we  believe  that  immediate  operation,  once 
the  diagnosis  is  made,  is  the  course  to  be  recommended  in  all  cases  of 
acute  appendicitis  in  children.  The  younger  the  child  the  greater  the 
urgency  for  operation. 

INTESTINAL   WORMS 

Judging  by  published  reports,  intestinal  worms  are  much  more  com- 
mon in  Europe  than  in  the  northern  part  of  this  country.  In  18,000 
patients  treated  for  medical  diseases  in  our  dispensary  services  in  New 
York  and  Baltimore  there  was  positive  evidence  of  worms  in  but  135 
cases.  Of  these,  20  had  tapeworms,  55  round  worms,  56  thread  worms 
and  4  both  round  and  thread  worms.  In  private  practice  among  the 
better  classes,  worms  are  certainly  rare. 

Cestodes — Tapeworms. — Cestodes  are  usually  introduced  into  the 
body  by  the  ingestion  of  some  form  of  food  containing  larvae  (cysticerci) . 
The  larva  of  the  tenia  solium  is  most  frequently  found  in  pork;  that  of 
the  tenia  mediocanellata  in  beef;  that  of  the  hothriocephal'us  latus  in 
fish;  that  of  the  tenia  cucumei'ina  inhabits  dog  or  cat  lice,  being  intro- 
duced into  the  intestinal  tract  accidentally  by  the  hands.  Several  varie- 
ties of  tenia  are  found  in  the  human  intestine. 

Tenia  Saginata  or  Mediocanellata — Beep  Tapem^oem. — Infec- 
tion results  from  eating  raw  or  partially  cooked  beef  containing  cys- 
ticerci. The  worm  is  from  twelve  to  twenty  feet  in  length,  and  has  a. 
square  pigmented  head  without  hooks  but  provided  with  four  suckers. 
The  full-sized  segments  are  from  one-half  to  three-fourths  of  an  inch 
long  and  about  half  as  wide. 

Tenia  Solium — Pork  Tapeworm. — This  is  a  rare  form  in  chil- 
dren, and  comes  from  eating  raw  or  partially  cooked  pork  or  sausage. 
It  is  from  six  to  ten  feet  in  length,  the  segments  being  nearly  square. 
The  head  is  about  the  size  of  a  mustard  seed  and  is  pigmented.  It  also 
is  provided  with  four  suckers  and  a  proboscis,  surrounding  which  is  a 
circle  of  about  twenty-six  booklets. 

Tenia  Cucumeeina  or  Elliptica. — The  larvae  of  this  form  develop 
in  a  louse  found  on  the  skin  of  dogs  and  cats.  Children  who  play  with 
infected  animals  are  the  ones  affected,  the  parasite  being  conveyed  to 


424  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  mouth  usually  by  means  of  the  hands;  it  may  thus  be  found  even 
in  young  infants.  This  form  of  tenia  is  much  smaller  than  either  of 
the  preceding  varieties^  the  full  length  being  only  from  six  to  twelve 
inches. 

BoTHRiocEPHALUs  Latus. — This  is  a  rare  form  except  in  the  sea 
countries  of  northern  Europe  and  Switzerland,  where  it  is  said  to  be 
very  common.  The  larvae  are  harbored  by  certain  fish,  by  eating  which 
when  insufficiently  cooked  they  are  introduced  into  the  body.  The  full- 
grown  worm  is  from  twenty-five  to  thirty  feet  in  length. 

Tenia  Nana. — The  tenia  nana,  or  dwarf  tapeworm,  is  the  smallest 
of  all  the  cestodes.  It  is  a  narrow  worm  of  one-half  to  three-fourths  of 
an  inch  in  length,  and  is  composed  of  one  hundred  to  two  hundred 
segments.  It  has  a  slender  neck  and  globular  head  which  contains  four 
suckers  and  twenty  or  thirty  booklets.  The  habitat  of  the  nana  is  the 
upper  part  of  the  ileum  where  it  is  often  found  in  immense  numbers. 
A  single  stool  may  contain  several  hundred  worms.  The  ova  have  two 
definite  membranes  within  the  inner  one  of  which  three  pairs  of  hook- 
lets  are  found.  The  cysticercus  stage  of  this  parasite  is  not  known. 
It  is  probable  that  infection  occurs  from  swallowing  the  ova  them- 
selves. As  a  similar  parasite  inhabits  the  intestinal  tract  of  rats  and 
mice  it  is  possible  that  these  animals  play  a  part  in  transmission. 
From  the  observations  of  Schloss  it  seems  probable  that  in  the  vicin- 
ity of  New  York  this  is  the  most  frequent  intestinal  parasite  of 
childhood. 

Sym.ptoms. — The  only  positive  evidence  of  tapeworm  is  the  discharge 
of  the  worms  or  separated  segments,  either  singly  or  in  groups.  Occa- 
sionally worms  pass  into  the  stomach  and  are  vomited.  Various  abdomi- 
nal symptoms  may  be  associated  with  worms,  but  most  of  these  are  very 
indefinite  in  character  and  are  more  often  due  to  other  causes.  The 
most  frequent  symptoms  are  bad  breath,  various  annoying  sensations, 
colicky  attacks,  inordinate  or  capricious  appetite,  and  diarrhea.  Usu-. 
ally,  if  the  patient  is  in  good  health,  no  constitutional  symptoms  are 
seen.  Sometimes,  particularly  with  the  bothriocephalus  latus,  there  is  a 
very  grave  degree  of  anemia.  The  increase  in  the  number  of  eosinophile 
cells  in  the  blood  is  of  considerable  diagnostic  value.  They  frequently 
form  from  four  to  ten  per  cent  of  the  leucocytes,  while  in  normal  blood 
the  usual  number  is  less  than  two  per  cent.  Many  cases  are  on  rec- 
ord, some  of  them  in  children,  in  which  the  symptoms  of  pernicious 
anemia  have  been  present  and  have  disappeared  after  the  expulsion  of 
the  tapeworm.  Nervous  symptoms  are  not  so  often  seen  as  with  round- 
worms, and  will  be  discussed  in  connection  with  them. 

Trea/menl— Prophylaxis  requires  the  cooking  of  meat  to  a  suffi- 
cient degree  to   destroy  the   cysticerci,     There   is   especial   danger   in 


INTESTINAL  WOEMS  425 

eating  raw  pork  or  sausage;  that  from  rare  beef  is  much  less.  The  list 
of  drugs  used  for  the  expulsion  of  the  worm  is  a  long  one;  probably  . 
the  most  efficient  is  the  oleoresin  of  male  fern ;  it  is,  however,  difficult  to 
administer  and  it  is  very  likely  to  provoke  vomiting.  It  may  be  given 
in  capsules  containing  TTL  x  to  TT],  xx,  or  in  an  emulsion  made  up  with 
simple  elixir  and  acacia,  in  which  TU  v  to  TTL  x  are  contained  ir  one 
dram.  For  a  child  of  four  years  at  least  one  dram 'of  the  male  iern 
should  be  given  in  the  course  of  six  to  eight  hours.  The  vermifuge 
should  be  preceded  by  several  hours'  fasting,  and  the  bowels  previously 
opened  by  a  laxative.  The  following  plan  of  administration  has  been 
found  satisfactory :  a  light  supper  of  milk,  and  in  the  morning  a  saline 
laxative  on  rising,  but  no  breakfast;  after  the  saline  has  acted  freely 
the  remedy  is  to  be  given,  and  following  the  last  dose,  half  an  ounce  of 
castor  oil  or  some  other  active  purge.  The  effect  of  the  cathartic  is 
aided  by  a  large  injection  of  warm  soap  and  water.  Only  milk  should 
be  given  that  day.  The  fragments  passed  should  be  carefully  examined 
to  see  if  the  head  has  been  expelled,  as  the  worm  is  very  likely  to  be 
broken  at  the  neck.  If  this  occurs  it  will  grow  again,  and  in  about 
three  months  segments  will  appear  in  the  stool.  Other  drugs  useful 
for  tenia  are  pumpkin  seeds  which  are  given  in  powdered  form,  infusion 
of  pomegranate  root,  turpentine,  and  chloroform. 

Nematodes. — Three  varieties  are  found  in  the  intestinal  canal,  the 
ascaris  lumbricoides,  the  oxyuris  vermicularis,  and  the  uncinaria 
Americana. 

Ascaris  Lumbricoides — Eoundworm.- — This  worm  is  usually  found 
in  the  small  intestine.  It  is  much  more  frequently  met  with  in  children 
than  is  the  tapeworm.  It  is  exceedingly  rare  in  infancy,  but  is  usually 
seen  between  the  third  and  tenth  years.  In  over  two  thousand  autopsies 
upon  infants  we  have  only  twice  found  a  roundworm  in  the  intestine. 

The  roundworm  resembles  the  ordinary  earthworm;  it  is  from  five 
to  ten  inches  long,  the  female  being  longer  than  the  male.  It  is  of  a 
light  gray  color  with  a  slightly  pinkish  tint,  cylindrical,  and  tapering 
toward  the  extremities.  The  eggs  are  oval  in  form,  about  -^^q  inch  in 
diameter,  and  numbered  by  millions.  These  worms  rarely  exist  singly; 
usually  from  two  to  ten  are  present,  but  there  may  be  hundreds.  When 
very  numerous  they  coil  up  and  form  large  masses,  which  may  cause 
intestinal  obstruction. 

The  migration  of  these  worms  is  curious,  and  in  some  instances  truly 
remarkable.  They  frequently  enter  the  stomach  and  are  vomited.  Occa- 
sionally one  may  appear  in  the  nose.  They  have  been  known  to  pass 
through  the  Eustachian  tube  into  the  middle  ear  and  to  appear  in  the 
external  meatus.  Entering  the  larynx  they  have  produced  fatal  as- 
phyxia.    It  is  not  very  rare  for  them  to  enter  the  common  bile  duct 


426  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

and  produce  jaundice.  They  may  even  enter  in  great  numbers  the 
smaller  bile  ducts  and  produce  hepatic  abscesses.  They  have  been 
found  in  the  pancreatic  duct,  in  the  vermiform  appendix,  and  in  the 
splenic  vein.  It  has  long  been  known  that  they  would  perforate  an 
intestine  which  was  the  seat  of  ulceration,  but  well-authenticated  cases 
have  been  reported  in  which  they  have  perforated  an  intestine  previ- 
ously healthy,  setting  up  a  fatal  peritonitis.  In  Archambault's  case 
they  perforated  the  stomach.  In  cases  of  a  persistent  Meckel's  diverticu- 
lum, worms  have  been  discharged  from  an  umbilical  fistula.  They  have 
been  found  in  umbilical  abscesses.  Considering,  however,  the  frequency 
of  roundworms,  migrations  are  rare. 

Symptoms. — The  symptoms  of  roundworms  are  of  the  most  in- 
definite kind;  often  there  are  none  until  the  worm  is  discovered  in  the 
stools.  It  is  then  fair  to  assume  that  other  worms  are  also  present.  The 
most  frequent  abdominal  symptoms  are  colic,  tympanites,  and  other 
symptoms  of  indigestion,  loss  of  appetite,  disturbed  sleep  and  grinding 
of  the  teeth  at  night.  These  symptoms  are  much  more  frequently  due 
to  other  causes  than  to  worms,  but  when  all  are  present  the  existence  of 
worms  should  be  suspected. 

A  great  variety  of  nervous  symptoms  may  be  associated  with  intes- 
tinal worms.  They  are  more  often  seen  with  lumbricoids  than  with 
either  of  the  other  varieties.  The  symptoms  may  be  of  the  most  puzzling 
character,  and  may  simulate  very  closely  those  of  serious  organic  dis- 
ease. There  may  be  jDrolonged  low  fever,  chills,  headache,  vertigo,  hal- 
lucinations, hysterical  seizures,  epileptiform  attacks,  convulsions,  tetany, 
transient  paralyses  such  as  strabismus,  and  even  hemiplegia  and  aphasia. 
All  these  have  been  observed  in  connection  with  intestinal  worms,  and 
from  the  fact  that  the  symptoms  disappeared  completely  after  the  worms 
were  expelled,  there  seems  to  be  but  little  doubt  that  they  were  the  cause 
of  the  symptoms.  As  in  the  case  of  the  abdominal  symptoms,  however, 
intestinal  worms  are  only  one  of  the  causes  of  such  nervous  disturliances, 
and  certainly  not  a  frequent  one;  but  the  possibility  that  nervous  dis- 
turbances may  depend  upon  worms  should  not  be  overlooked.  The  blood 
generally  shows  eosinojjhilia,  as  in  patients  with  tapeworm. 

The  only  positive  evidence  of  the  existence  of  roundworms  is  the  dis- 
charge of  a  worm  from  the  body,  or  the  discovery  of  the  ova  in  the  stools. 
A  microscopic  examination  of  the  stools  is  a  valuable  means  of  diagnosis, 
and  one  that  is  too  infrequently  employed.  When  worms  are  present  the 
ova  may  be  found  in  great  numbers.  Their  continued  presence,  after  the 
discharge  of  one  worm,  indicates  that  other  worms  remain. 

Treatment. — An  efficient  agent  for  the  removal  of  the  worms  is 
santonin.  The  same  plan  of  administration  may  be  followed  as  in  the 
case  of  the  tapeworm,  viz.,  to  give  the  drug  on  an  empty  stomach. 


INTESTINAL  WORMS  427 

preceded  by  a  laxative.  Santonin  is  best  given  in  powdered  form  mixed 
with  sugar.  For  a  child  of  five  years  as  much  as  three  grains  are  usually 
required.  This  amount  should  be  given  in  three  doses  at  intervals  of 
four  hours,  soon  followed  by  a  purge  of  calomel  or  castor  oil.  Oil  of 
chenopodium  is  somewhat  easier  of  administration  and  is  quite  as  effi- 
cient. It  may  be  given  as  described  under  the  treatment  for  Hookworm. 
The  great  difficulty  with  santonin  is  its  tendency  to  provoke  vomiting. 
Occasionally  in  susceptible  children,  even  with  ordinary  doses,  toxic 
symptoms  may  develop,  such  as  yellow  vision,  dark-red  or  yellow  urine, 
and  nervous  excitement  or  delirium. 

OxYUEis  Vermiculaeis — PiNWORM — THREADWORM. — The  oxyuris 
resembles  a  short  piece  of  white  thread.  The  female  is  about  one-third 
of  an  inch  long,  the  male  about  one-half  that  length,  but  is  less  fre- 
quently seen.  The  worm  tapers  toward  the  tail.  The  ova  are  of  slightly 
irregular  size,  and  are  considerably  smaller  than  those  of  the  round- 
worm. 

The  oxyuris  inhabits  the  rectum,  the  cecum,  and,  according  to  Still, 
very  frequently  the  appendix.  These  worms  may  be  found  also  in  the 
lower  small  intestine,  in  the  stomach,  and  even  in  the  mouth.  If  present 
in  the  rectum  they  are  usually  discovered  by  separating  the  folds  of  the 
anus.  The  number  of  worms  is  usually  large.  The  irritation  to  which 
they  give  rise  causes  a  great  production  of  mucus,  and  frequently  leads 
to  a  chronic  catarrh  of  the  colon  of  considerable  severity.  The  worms 
are  imbedded  in  the  mucus;  often  they  form  with  it  small  balls.  Ac- 
cording to  Leuckart,  they  are  incapable  of  multiplying  in  situ.  Doubt 
has  recently  been  thrown  upon  this  view  by  the  observations  of  Still. 
From  the  immature  character  and  the  large  numbers  of  the  worms 
found  in  the  appendix  (111  in  one  case),  this  writer  believes  that  the 
appendix  may  be  a  breeding  place.  The  ova  as  well  as  the  worms  are 
passed  in  enormous  numbers  with  the  stools.  They  attach  themselves 
to  the  folds  of  the  skin,  the  hairs  about  the  anus,  and  even  to  the  genitals. 
The  patient  may,  through  lack  of  cleanliness  of  the  parts,  continually 
re-infect  himself.  After  discharge  from  the  body,  the  ova  may  be 
carried  by  flies  and  deposited  upon  fruits,  vegetables,  or  in  drinking 
water. 

Symptoms. — The  principal  local  symptom  caused  by  the  oxyuris  is 
itching  of  the  anus  or  the  genitals.  This  is  caused  by  the  migration  of 
the  worms  from  the  bowel,  and  usually  comes  on  at  about  the  same  hour 
at,  night,  generally  soon  after  the  patient  has  retired.  It  is  sometimes  so 
intense  as  to  be  almost  intolerable.  It  leads  to  frequent  micturition,  to 
incontinence  of  urine,  in  the  male  to  balanitis,  and  in  the  female  to 
vaginitis  or  vulvitis,  and  in  both,  but  especially  in  the  latter,  it  may  be 
the  cause  of  masturbation.     Owing  to  the  catarrhal  colitis  which  is  ex- 


428  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

cited,  there  is  discharged  from  time  to  time  a  large  quantity  of  mucus. 
Severe  colicky  pains  are  often  associated.  The  irritation  may  lead  to 
prolapsus  ani.  Nervous  symptoms  are  not  so  frequently  associated 
as  with  the  other  varieties  of  worms,  although  we  have  seen  at  least 
one  case  of  chorea  in  which  they  were  almost  certainly  the  cause.  They 
have  been  known  to  excite  convulsions.  The  general  health  is  some- 
times undermined  and  there  may  be  marked  and  progressive  loss  in 
weight. 

Treatment. — This  is  usually  spoken  of  as  a  very  simple  matter,  and 
no  doubt  in  recent  cases,  or  where  the  number  of  worms  is  small,  this  is 
true;  but  where  the  number  is  large,  and  considerable  catarrhal  inflam- 
mation of  the  colon  is  present,  it  is  often  a  matter  of  the  greatest  diffi- 
culty to  rid  the  bowel  of  these  parasites.  Cases  frequently  resist  treat- 
ment by  injection  for  months,  even  though  thoroughly  used.  The  reason 
for  this  is,  that  only  the  lower  colon  is  reached  by  injections  while  the 
worms  may  be  chiefly  in  the  cecum  or  even  in  the  appendix  and  small 
intestine.  While,  therefore,  injections  are  important  and  indeed  invalu- 
able, they  can  not  be  relied  upon  exclusively.  The  most  scrupulous  atten- 
tion to  cleanliness  is  an  absolute  necessity  as  the  first  step  in  the  treat- 
ment of  all  cases.  It  is  well  to  bathe  the  parts  about  the  anus  after  each 
stool,  and  even  two  or  three  times  a  day,  with  a  bichlorid  solution,  1  to 
10,000.  Itching  is  best  controlled  by  the  application  of  mercurial  oint- 
ment to  the  folds  of  the  anus  at  bedtime,  this  efl:ectually  preventing  the 
escape  of  the  worms  from  the  bowel.  The  local  application  of  cold  will 
sometimes  have  the  same  effect.  The  most  efficient  of  the  injections  is 
probably  the  bichlorid.  The  colon  should  first  be  thoroughly  cleansed  by 
an  injection  of  lukewarm  water  containing  one  teaspoonful  of  borax  to 
the  pint,  in  order  to  remove  the  mucus.  Wlien  this  has  been  discharged, 
half  a  pint  of  the  bichlorid  solution  of  the  strength  mentioned  should  be 
injected  high  into  the  bowel  through  a  catheter,  and  retained  as  long 
as  possible.  This  should  be  repeated  every  second  or  third  night.  On 
other  nights  a  simple  saline  injection  may  be  employed.  The  infusion  of 
quassia,  asafetida,  aloes,  and  garlic  are  also  useful.  Solutions  of  car- 
bolic acid  should  never  be  employed. 

When  the  worms  are  high  in  the  colon,  drugs  by  the  mouth  must 
be  combined  with  injections.  The  most  efficient  remedies  are  santonin 
and  the  oil  of  chenopodium,,  which  may  be  used  as  for  roundworms. 
The  expulsion  of  the  worms  is  aided  by  saline  cathartics ;  simple  bitters, 
such  as  gentian  and  quassia,  are  also  of  some  value.  We  have  known 
one  case,  which  resisted  for  over  two  years  everything  which  had  been 
tried,  to  be  cured  in  two  or  three  weeks  by  injections  of  a  decoction  of 
garlic,  in  connection  with  which  garlic  was  given  in  liberal  quantities 
by  the  mouth. 


INTESTINAL  WORMS  429 

Uncinaria  Americana  or  Hookworm. — This  belongs  to  the  class 
of  nematodes.  The  males  are  one-fourth  to  one-half  inch  in  length  and 
the  females  slightly  longer.  The  parasite  resembles  the  anhylostomum 
duodenale  of  Euroj^e.  Infection  usually  takes  place  through  the  skin 
of  the  bare  feet,  more  rarely  that  of  the  hands.  It  is  possible,  however, 
to  contract  the  disease  by  eating  dirty  fruit  or  vegetables  contaminated 
by  the  developing  larvae;  but  infection  does  not  occur  from  swallowing 
the  ova  or  young  larvae.  After  entering  the  skin  the  larvae  find  their 
way  into  the  circulation  and  thus  reach  the  lungs.  From  the  lungs  they 
may  migrate  or  be  coughed  up  into  the  mouth  and  then  swallowed. 
They  are  not  acted  upon  by  the  gastro-intestinal  secretions,  and  in  the 
upper  part  of  the  small  intestine  they  develop  into  mature  worms. 
These  may  exist  in  the  small  intestine  for  years. 

The  symptoms  in  the  milder  cases  are  minor  digestive  disturbances, 
general  malnutrition  with  moderate  anemia  and  arrested  growth.  In 
the  more  severe  cases  the  anemia  is  very  marked,  the  hemoglobin  often 
falling  to  thirty  per  cent  or  below.  The  leucocytes  are  normal  in  num- 
ber or  slightly  increased ;  but  the  percentage  of  eosinophiles  is  above  the 
normal.  In  most  patients  the  proportion  reaches  five  or  ten  per  cent;  it 
may  however  be  twenty-five  per  cent  or  even  higher.  Edema  of  the  face 
is  common  and  there  may  be  general  dropsy  without  albuminuria.  Af- 
fected children  besides  being  very  backward  in. physical  development,  are 
dull,  inattentive  and  entirely  wanting  in  physical  or  mental  energy. 
The  appetite  is  sometimes  absent;  but  more  characteristic  is  the  crav- 
ing, not  only  for  every  kind  of  food,  but  for  such  articles  as  clay,  dirt, 
chalk,  etc.  Death  may  be  due  to  the  progressive  failure  of  nutrition 
or  to  intercurrent  disease. 

Prophylaxis  in  the  individual  consists  chiefly  in  the  protection  of  the 
feet  of  persons  living  in  an  infected  district,  by  wearing  shoes.  The 
chief  remedy  for  the  hookworm  is  thymol.  Its  administration  should  be 
preceded  by  one  or  more  full  doses  of  the  sulphate  of  magnesia  or  soda 
given  after  twelve  hours'  fasting.  The  quantity  of  thymol  given  to  a 
child  of  five  years  should  be  six  or  eight  grains  in  divided  doses  in  the 
course  of  three  or  four  hours.  It  may  be  administered  either  in  capsule 
or  in  suspension.  Two  hours  after  the  last  dose,  the  salts  should  be 
repeated ;  but  no  food  should  be  given  until  the  cathartic  has  acted  freely. 
Castor  oil  should  not  be  used.  A  repetition  of  the  treatment  is  often 
necessary  before  a  cure  is  accomplished. 

The  oil  of  chenopodium  is  apparently  quite  as  effective  as  thymol 
and  has  the  advantage  of  being  much  cheaper.  It  may  be  administered 
dropped  upon  sugar.  The  usual  dosage  is  one  drop  per  year  of  age  up 
to  ten  years.  A  dose  of  Epsom  salts  is  given  on  the  preceding  day  and 
three  doses  of  the  oil  at  two-hour  intervals  the  next  morning,  the  last 


430  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

dose  to  be  followed  by  castor  oil.    It  should  be  remembered  that  cheno- 
podium  is  toxic  in  over  doses. 


CHAPTER  X 

DISEASES   OF   THE  RECTUM 
PROLAPSUS  ANI 

Under  this  term  are  included  two  conditions.  In  the  first,  or  partial 
prolapse,  there  is  simply  an  eversion  of  the  mucous  membrane  which 
protrudes  beyond  the  sphincter.  In  the  second,  or  complete  prolapse, 
there  is  invagination  of  the  rectal  wall  for  a  variable  distance,  usually 
two  or  three  inches. 

Etiology; — Prolapse  is  most  common  in  children  during  the  second 
and  third  years.  Its  frequency  in  early  life  is  partly  due  to  the  lack 
of  support  furnished  by  the  levator-ani  muscles.  It  also  occurs  very 
readily  when  the  ischiorectal  fat  is  scanty;  it  is  therefore  often  seen  in 
children  suffering  from  marasmus.  The  exciting  cause  may  be  anything 
which  provokes  severe  and  prolonged  straining.  This  may  be  either  the 
tenesmus  accompanying  inflammation  of  the  rectal  mucous  membrane 
or  chronic  constipation.  It  may  come  from  phimosis  or  stricture  of  the 
urethra,  and  it  is  a  very  frequent  symptom  of  stone  in  the  bladder. 

Symptoms. — Prolapse  usually  occurs  during  the  act  of  defecation.  It 
is  generally  easily  reduced,  but  shows  a  great  disposition  to  return  with 
every  stool.  In  obstinate  cases  the  bowel  comes  down  at  other  times. 
The  appearance  of  the  tumor  varies  with  its  size.  In  the  slighter  form 
there  is  simply  a  ring  composed  of  a  fold  of  mucous  membrane  sur- 
rounding the  anus.  In  the  more  severe  form  there  is  a  flattened,  corru- 
gated tumor,  usually  about  the  size  of  a  small  tomato.  The  mucous 
membrane  covering  the  tumor  is  of  a  deep  purplish-red  color,  and  bleeds 
readily.  It  may  be  the  seat  of  catarrhal  or  membranous  inflammation. 
The  diagnosis  in  most  cases  is  easy,  although  the  tumor  has  been  con- 
founded with  polj'pus  and  intussusception. 

Treatment. — In  most  cases  reduction  is  easily  accomplished  by  laying 
the  child  upon  his  face  across  the  lap,  and  making  gentle  pressure  upon 
the  tumor  with  oiled  flngers.  The  application  of  cold,  either  by  means 
of  ice  or  cold  cloths,  is  of  assistance  in  cases  which  are  not  at  once  re- 
duced by  pressure.  After  reduction,  in  the  milder  cases  the  child  should 
be  kept  upon  his  back  for  at  least  an  hour.  When  the  tumor  tends  to 
come  down  with  every  stool,  special  attention  should  be  given  at  this 


FISSURE  OP  THE  ANUS  431 

time.  If  an  infant,  the  bowels  should  always  move  while  the  child  lies 
upon  his  back,  and  during  defecation  the  buttocks  should  be  pressed  to- 
gether by  a  nurse.  Older  children  should  use  an  inclined  seat  placed  at 
an  angle  of  about  forty-five  degrees,  but  should  never  sit  iipon  a  low 
chair  or  assume  any  position  in  which  straining  is  easy.  After  defecation 
the  patient  should  lie  down  for  at  least  half  an  hour.  When  there  is 
constipation,  the  bowels  should  be  kept  free  by  means  of  laxatives.  If 
there  is  diarrhea,  tenesmus  may  be  overcome  by  frequent  sponging' 
with  ice  water,  or  by  the  use  of  small  injections  of  ice  water  and  tannic 
acid,  in  the  proportion  of  twenty  grains  to  the  ounce.  In  more  severe 
cases  it  may  be  controlled  by  the  use  of  suppositories  of  opium.  When 
the  bowel  tends  to  come  down  frequently,  this  may  be  prevented  by  the 
use  of  an  adhesive  strap  two  or  three  inches  wide,  placed  tightly  across 
the  buttocks.  This  is  better  in  the  milder  cases  than  a  T-bandage.  The 
great  majority  of  the  cases  are  cured  by  these  means  in  the  course  of  a 
few  weeks. 

In  the  most  severe  cases  the  bowel  not  only  protrudes  during  defeca- 
tion, but  also  in  the  interval,  and  it  may  be  down  for  days  at  a  time. 
Such  cases  are  rarely  seen  except  in  infants  who  have  very  flabby  muscles, 
and  but  little  adipose  tissue  at  the  floor  of  the  pelvis.  Eeduction  is 
sometimes  difficult  in  cases  when  the  prolapse  has  lasted  a  long  time.  It 
is  often  facilitated  by  painting  the  protruding  part  with  a  solution  of 
epinephrin,  and  then  dilating  the  sphincter  by  passing  the  finger 
into  the  central  opening  of  the  tumor.  After  reduction,  suppositories 
containing  from  one-fourth  to  one-half  grain  of  cocain  may  be  inserted. 
They  are  more  efficient  than  those  containing  opium  or  belladonna.  A 
firm  pad  should  be  applied  over  the  anus,  held  in  position  by  a  T-bandage. 
For  several  days  at  a  time  a  short  rubber  tube  may  be  kept  in  the  rec- 
tum, held  in  place  by  adhesive  plaster.  The  bowels  should  be  kept  freely 
open.  Where  all  other  measures  fail,  the  protruding  part  may  be 
touched  with  the  Paquelin  cautery,  linear  markings  being  made  at  in- 
tervals of  an  inch.    Amputation  or  excision  is  not  required  in  children. 


FISSURE  OF  THE  ANUS 

This  is  not  a  very  uncommon  condition  in  children.  The  most  fre- 
quent cause  is  the  passage  of  a  large,  hard,  fecal  mass.  Sometimes  it 
results  from  traumatism  inflicted  with  the  nozzle  of  a  syringe  while 
giving  an  enema.  It  may  be  produced  by  the  scratching  excited  by  pin- 
worms.  In  the  beginning  there  is  a  simple  tear  at  the  margin  of  the 
anus.  The  laceration  which  is  produced  usually  heals  promptly;  but  if 
the  cause  is  repeated,  healing  is  prevented,  and  there  is  finally  produced 


432  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

a  linear  ulcery  or  a  true  fissure,  wliicli  may  last  for  some  time  and  be 
a  source  of  great  annoyance. 

A  fresh  fissure  has  the  appearance  of  any  other  tear  at  a  mucocuta- 
neous orifice.  One  of  longer  standing  has  a  gray  base,  slightly  indurated 
edges,  often  discharges  a  small  amount  of  pus,  and  bleeds  a  drop  or  two 
with  nearly  every  movement  of  the  bowels.  The  most  constant  symptom 
is  pain,  which  usually  occurs  with  the  act  of  defecation  and  continues 
for  some  time  afterward.  It  is  most  severe  when  the  fissure  is  just  at  the 
margin  of  the  sphincter,  and  leads  the  child  to  resist  every  inclination  to 
have  the  bowels  move,  so  that  it  becomes  a  cause  of  chronic  constipation, 
which  condition  again  greatly  aggravates  the  fissure.  The  pain  is  often 
referred  to  other  parts  in  the  neighborhood. 

The  treatment  is  simple  and  usually  efficient.  It  consists  in  clean- 
liness, overcoming  the  constipation,  and  touching  the  fissure  with  nitrate 
of  silver,  preferably  with  the  solid  stick.  If  the  case  is  not  speedily 
relieved  by  such  measures,  the  sphincter  should  be  stretched  as  in  adult 
patients. 

PROCTITIS 

Proctitis,  or  inflammation  of  the  rectum,  usually  occurs  with  inflam- 
mation of  the  rest  of  the  large  intestine,  but  it  may  occur  alone.  It  is 
to  the  cases  in  which  only  the  rectum  is  involved  that  the  term  is  gen- 
erally applied. 

The  causes  are  for  the  most  part  local.  A  frequent  one  in  infants 
is  the  use  of  irritating  injections  or  suppositories,  either  for  the  relief  of 
constipation  or  as  a  means  of  administering  certain  drugs.  We  have  seen 
one  obstinate  case  in  an  infant  a  year  old,  following  the  prolonged  use  of 
glycerin  suppositories.  It  is  sometimes  caused  by  traumatism,  especially 
by,  the  careless  giving  of  an  enema.  It  accompanies  pin  worms.  In 
certain  cases  it  may  result  from  direct  infection  through  the  anus.  This 
may  be  from  a.gonococcus  inflammation  extending  from  the  vagina  or 
urethra,  or  from  an  infection  due  to  other  bacteria,  particularly  in  cases 
of  measles,  scarlet  fever,  and  diphtheria;  or,  finally,  it  may  be  due  to 
syphilis.     Proctitis  may  be  catarrhal,  membranous,  or  ulcerative. 

Catarrhal  Proctitisu — The  pathological  conditions  are  the  same  as  in 
ordinary  catarrhal  inflammation  of  the  intestinal  mucous  membrane.  By 
the  introduction  of  a  speculum,  or  by  simply  everting  the  mucous  mem- 
brane, it  is  seen  to  be  reddened,  swollen,  and  bleeds  easily.  There  is  a 
copious  secretion  of  mucus.  In  cases  of  long  standing  there  may  be 
superficial  ulceration  appearing  as  a  white  or  yellowish-white  surface, 
usually  just  inside  the  sphincter. 

The  symptoms  are  chiefly  local,  although  a  condition  of  general  irri- 


PROCTITIS  433 

tability  may  result  from  the  local  condition.  There  is  heightened  reflex 
action,  so  that  the  stool  often  comes  with  a  spurt.  There  is  pain  with 
defecation,  and  mucus  is  discharged,  usually  as  a  clear,  jelly-like  mass, 
and  sometimes  in  the  form  of  a  cast,  but  not  generally  mixed  with  the 
stool.  There  are  usually  traces  of  blood,  sometimes  quite  large  hemor- 
rhages. In  the  most  acute  cases,  tenesmus  is  present  both  during  and 
after  the  stool.  There  may  be  prolapsus  ani.  The  skin  in  the  vicinity  is 
irritated  by  the  discharges,  most  frequently  so  in  infants.  If  the  cause 
is  pinworms,  there  may  be  intense  itching.  The  duration  of  the  disease 
is  indefinite,  depending  upon  the  cause.  It  may  be  a  few  days  or  many 
months.  The  inflammation  may  extend  from  the  rectum  to  neighboring 
parts,  leading  to  ischiorectal  abscess. 

Membranous  Proctitis. — It  has  been  customary  to  describe  this  as  a 
complication  of  diphtheria,  usually  occurring  with  diphtheria  of  the  ex- 
ternal genitals.  As  few  of  these  cases  have  been  studied  bacteriolog- 
ically,  it  is  impossible  to  say  what  proportion  of  them,  if  any,  are  to  be 
regarded  as  true  diphtheria.  When  the  infection  is  from  the  intes- 
tine above,  the  rectum  is  never  affected  alone.  When  it  is  from  below, 
this  may  be  the  case.  The  lesions  are  the  same  as  in  membranous  in- 
flammation occurring  higher  in  the  colon.  The  symptoms  resemble  those 
of  the  catarrhal  variety  with  the  addition  that  the  stools  contain  pieces 
of  pseudo-membrane.  This  can  be  made  out  only  by  repeatedly  washing 
the  discharges  with  water.  If  accompanied  by  prolapse,  the  pseudo- 
membrane  may  be  seen.  Membranous  proctitis  may  be  complicated  by 
a  membranous  inflammation  of  the  genitals  or  the  perineum.  Although 
it  is  usually  acute,  it  may  last  for  weeks. 

Ulcerative  Proctitis. — Ulcers  of  the  rectum  may  be  the  result  of  a 
catarrhal  inflammation;  these,  however,  are  usually  superflcial,  affecting 
the  mucous  membrane  only,  and  in  most  cases  heal  rapidly.  Sometimes 
they  extend  more  deeply  into  the  submucous  or  even  the  muscular  coat. 
They  are  then  chronic,  often  very  obstinate,  and  may  last  indeflnitely. 
Follicular  ulcers  of  the  rectum  are  nearly  always  associated  with  the 
same  condition  in  the  sigmoid  flexure.  These  are  always  multiple  and 
usually  small,  rarely  being  more  than  a  quarter  of  an  inch  in  diameter. 
Sometimes  the  small  ones  coalesce,  producing  much  larger  ulcers.  Single 
ulcers  may  be  of  tuberculous  origin.  Syphilitic  ulcers  are  extremely 
rare  in  children. 

The  symptoms  of  ulcer  of  the  rectum  are  mainly  two — pain  and  hem- 
orrhage. The  pain  is  of  variable  intensity,  and  may  be  referred  to  the 
coccyx,  or  to  any  of  the  neighboring  parts.  The  amount  of  bleeding 
may  be  small,  the  blood  coming  in  clots,  or  it  may  be  fluid  and  in  so 
large  a  quantity  as  to  produce  general  symptoms.  It  usually  accom- 
panies every  stool.    In  addition  the  stool  contains  more  or  less  pus,  par- 


434  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ticularly  in  chronic  cases.  When  the  ulcer  is  low  down,  tenesmus  is 
usually  present  and  may  be  a  prominent  symptom.  The  duration  of 
the  symptoms  is  indefinite;  often  they  last  for  many  months  and  lead 
to  a  marked  deterioration  in  the  general  health.  A  positive  diagnosis 
of  ulcer  can  be  made  only  by  examination  with  a  speculum. 

Treatment. — In  cases  of  acute  catarrhal  proctitis  injections  of  some 
bland  fluids  should  be  employed,  such  as  a  starch-water,  limewater,  a  mix- 
ture of  oil  and  limewater,  or  a  warm  one-per-cent  saline  solution.  The 
local  cause,  if  one  exists,  should  be  removed.  In  the  most  acute  cases 
the  patient  should  be  kept  in  bed.  When  the  tenesmus  is  severe,  sup- 
positories of  opium  may  be  used.  In  the  more  chronic  cases  saline 
injections  should  be  given,  and  followed  by  a  mild  astringent  like  tannic 
acid,  ten  grains  to  the  ounce,  or  a  one-per-cent  solution  of  hamamelis. 
Cases  associated  with  pinworms  are  especially  obstinate.  Here  the  treat- 
ment is  first  to  be  directed  to  the  worms,  and  afterward  to  the  proctitis. 

In  the  membranous  cases  the  same  measures  are  to  be  employed,  and 
in  addition  the  injection  of  a  warm  boric-acid  solution  two  or  three 
times  a  day. 

Cases  of  ulcer  require  the  most  careful  treatment.  In  many  there  is 
but  little  tendency  to  spontaneous  recovery.  An  examination  with  the 
specukim  should  be  insisted  upon  in  all  cases  of  chronic  proctitis,  to 
make  sure  of  the  diagnosis.  Rest  in  bed  is  essential  to  a  rapid  improve- 
ment. The  bowels  should  be  kept  freely  open  by  the  use  of  laxatives  and 
injections  of  a  boric-acid  solution,  or  one  or  two  ounces  of  liquid  albolene 
may  be  injected  every  night  and  retained.  If  this  does  not  relieve  the 
patient,  a  weak  solution  of  nitrate  of  silver  (one  grain  to  the  ounce) 
may  be  injected  daily  after  washing  out  the  bowel  with  tepid  water. 
If  a  stronger  solution  than  this  is  used,  it  should  be  neutralized  after 
half  a  minute  by  the  injection  of  a  saline  solution. 


ISCHIORECTAL  ABSCESS 

This  is  not  a  very  rare  condition  even  in  infancy.  Infection  from  the 
rectum,  usually  through  the  lymph  channels,  seems  to  be  the  most  com- 
mon cause,  although  sometimes  the  abscess  may  be  traced  directly  to  trau- 
matism. 

Essentially  the  same  varieties  of  inflammation  are  seen  in  early  life  as 
in  adults.  Most  of  these  cases  recover  promptly  after  simple  incision 
and  cleanliness,  fistula  being  a  rare  sequel. 


INCONTINENCE  OF  FECES  43,' 


RECTAL  POLYPUS 


Polypi  are  rarely  seen  in  children,  but,  when  present,  may  be  the 
cause  of  rather  obscure  symptoms.  The  most  important  one  is  hemor- 
rhage. This  at  first  occurs  at  intervals  of  days  or  weeks.  The  amount 
of  blood  lost  is  from  a  dram  to  an  ounce  or  more.  Later,  the  hemor- 
rhages become  more  frequent  and  may  be  almost  continuous,  although 
rarely  profuse  enough  to  produce  serious  symptoms.  The  diagnosis  of 
polypus  is  made  only  after  a  local  examination.  Sometimes  the  tumors 
are  within  the  reach  of  the  finger;  in  other  cases  a  proctoscope  must  be 
employed.  Spontaneous  cure  often  takes  place  by  the  sloughing  of  the 
tumor,  after  which  the  bleeding  soon  ceases.  In  other  cases  operation 
is  necessary. 

HEMORRHOIDS 

These,  fortunately,  are  not  often  seen  in  children,  although  they  occur 
in  those  as  young  as  three  or  four  years,  and  in  some  cases  may  even  be 
congenital.  The  principal  cause  is  chronic  constipation,  rarely  diarrhea. 
The  tumors  are  generally  small  and  external,  the  chief  symptom  com- 
plained of  being  pain  on  defecation.  Bleeding  sometimes  accompanies 
the  pain,  but  the  hemorrhages  are  usually  small.  The  treatment  is  to  be 
directed  toward  the  underlying  cause.  In  most  of  the  cases  this  suffices 
to  cure  the  condition.  Operation  is  rarely  required  in  young  children, 
although  neglect  may  make  this  procedure  necessary. 


INCONTINENCE  OF  FECES 

Inability  to  control  the  fecal  evacuations  is  seen  in  certain  cases  of 
paraplegia  due  to  myelitis,  after  injurj  of  the  lumbar  portion  of  the 
spinal  cord,  and  in  spina  bifida.  It  may  occur  with  the  usual  or  with  the 
occult  variety,  associated  with  incontinence  of  urine,  when  there  is  no 
paralysis  of  the  extremities.  It  is  also  seen  in  acute  disease,  as  in  the 
coma  of  meningitis,  and  occasionally  in  the  typhoid  condition  and  in 
extreme  adynamia,  from  any  cause.  It  is  quite  common  in  severe  attacks 
of  chorea.  It  may  sometimes  be  seen  after  operations  for  atresia  of  the 
anus  or  rectum.  In  all  these  conditions  incontinence  of  feces  is  a 
symptom  giving  rise  to  much  annoyance  and  needing  careful  attention. 
Uncleanline'ss  with  reference  to  excreta,  seen  in  idiocy,  can  hardly  be 
classed  as  incontinence. 

Besides  these  familiar  forms,  the  condition  is  sometimes  seen  from 


436 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


causes  somewhat  resembling  those  of  incontinence  of  urine.  The  tone 
of  the  sphincter  becomes  so  feeble  that  it  does  not  resist  even  the  slightr 
est  impulse  to  evacuate  the  rectum.  The  discharge  may  take  place  with 
but  little  warning,  and  may  occur  either  by  day  or  night.  In  some  cases 
a  local  cause  exists,  such  as  stretching  of  the  sphincter  by  an  old  rectal 
prolapse.  It  has  followed  overdistention  of  the  rectum  from  prolonged 
chronic  constipation.  Ostheimer  reports  a  case  in  which  a  vesical  cal- 
culus was  present.  It  is  sometimes  seen  after  severe  acute  illness,  as  a 
result  of  a  loss  of  general  muscular  tone.  In  certain  children  it  has  been 
known  to  persist  from  infancy  until  the  age  of  ten  or  twelve  years.  It 
may  come  on  as  a  somewhat  acute  condition  in  highly  nervous  patients 
with  poor  general  nutrition.  The  causes  are  chiefly  of  local  and  nervous 
origin.  The  treatment  is  rather  unsatisfactory,  except  in  recent  cases 
and  in  those  due  to  local  causes  which  can  be  removed.  If  constipation 
ex;ists  the  rectum  should  be  emptied  daily,  preferably  by  an  enema. 
The  remedies  which  have  proven  most  successful  are  strychnia,  ergot, 
and  belladonna,  but  they  must  be  given  in  full  doses,  sometimes  advan- 
tageously by  suppository  as  well  as  by  mouth.  The  general  health  should 
receive  careful  attention. 


CHAPTER  XI 
DISEASES   OF   THE   LIVER 

Aside  from  the  different  forms  of  degeneration  which  are  seen  in  the 
various  infectious  diseases,  the  liver  is  not  often  the  seat  of  serious  dis- 
ease in  infancy  and  early  childhood.  Jn  later  childhood  nearly  all  the 
forms  seen  in  adult  life  are  occasionally  met  with,  although  even  then 
they  are  quite  rare. 

Size  and  Position. — The  weight  of  the  liver  in  the  newly-born  child, 
from  one  hundred  and  seven  observations  of  Birch-Hirschfeld,  is  4.5 
ounces  (127  grams),  or  about  4.2  per  cent  of  the  body  weight.  The 
accompanying  table  gives  the  results  of  one  hundred  and  seventy-four  ob- 


Age. 

Average. 

Per  cent  of 

Ounces. 

Grams. 

body  weight. 

3  months 

6.3 

7.5 

11.0 

14.0 

16.0 

180 
212 
311 
397 
453 

3.1 

6        "       

3.0 

12        "         

3.40 

2  years         

3.37 

3     «     

3.26 

CATARRHAL  JAUNDICE  437 

servations  upon  the  liver  in  infancy  in  the  autopsy  room  of  the  New 
York  Infant  Asylum. 

In  adults,  according  to  Frerichs,  the  Aveight  of  the  liver  is  about  2.5 
per  cent  of  the  weight  of  the  body. 

The  upper  border  of  the  liver  is  best  made  out  by  percussion.  In  the 
child,  the  upper  limit  of  the  liver  dulness  in  the  mammary  line  is  found 
in  the  fifth  intercostal  space;  in  the  axillarj  line,  in  the  seventh  space; 
posteriorly,  in  the  ninth  space.  The  lower  border  is  best  determined  by 
palpation.  This,  as  a  rule,  in  the  mammary  line  is  found  about  one-half 
an  inch  below  the  free  border  of  the  ribs.  According  to  Steffen,  the  left 
lobe  is  relatively  larger  in  the  child  than  in  the  adult.  The  liver  may  be 
displaced  downward  by  contraction  of  the  chest,  as  in  rickets,  or  by  an 
accumulation  of  fluid  in  the  pleural  cavity.  It  is  frequently  found  lower 
than  normal  in  conditions  of  great  emaciation,  owing  to  relaxation  of  the 
abdominal  walls  and  its  ligamentous  supports.  Upward  displacement 
is  much  less  frequent,  and  depends  usually  upon  ascites  or  abdominal 
tumors. 

Malformations  and  Malpositions. — Congenital  malformations  relate 
chiefly  to  the  bile  ducts.  These  have  been  considered  in  the  chapter  de- 
voted to  Icterus  in  the  Newly  Born. 

The  liver  may  be  found  upon  the  left  side  in  cases  of  general  trans- 
position of  the  viscera.  In  diaphragmatic  hernia  it  has  been  found  in 
the  thoracic  cavity. 

CATARRHAL  JAUNDICE 

This  is  due  to  a  catarrhal  inflammation  of  the  common  bile  duct 
with  which  there  is  usually  associated  a  similar  inflammation  of  the 
duodenum  and  sometimes  of  the  stomach  also.  The  term  gastro- 
duodenitis  is  sometimes  used  synonymously  with  catarrhal  jaundice. 
The  jaundice  in  these  cases  is  due  to  obstruction  which  is  caused  by 
swelling  of  the  mucous  membrane  of  the  bile  duct.  Catarrhal  jaundice 
is  rare  in  infancy.  In  children  from  three  to  six  years  old  it  is  not  un- 
common, and  curiously  occurs  much  more  frequently  in  the  fall  months. 
This  suggests  an  infectious  origin.  For  the  most  part  its  causes  are 
obscure. 

It  occasionally  complicates  malarial  fever  and  may  occur  with  any  of 
the  infectious  diseases.  Eehn  has  described  a  form  which  occurred 
epidemically. 

The  symptoms  of  the  disease  are  quite  uniform.  When  primary,  the 
onset  is  like  an  ordinary  attack  of  indigestion,  with  vomiting,  pain, 
slight  fever,  and  a  moderate  amount  of  prostration.  The  vomiting  in 
some  of  the  cases  is  repeated  for  several  days.     The  pain  may  be  quite 


438  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

severe,  and  localized  in  the  region  of  the  duodenum.  It  may  be  asso- 
ciated with  tenderness  in  this  region.  The  bowels  are  usually  consti- 
pated. After  three  or  four  days,  icterus,  which  is  the  only  diagnostic 
symptom,  appears.  It  is  first  seen  in  the  conjunctivae,  afterward  in  the 
skin,  varying  in  degree  according  to  the  severity  of  the  attack,  but  in 
most  cases  not  being  very  intense.  It  is  accompanied  by  the  regular 
symptoms  of  obstructive  jaundice.  The  stools  are  gray,  sometimes  Avhite : 
there  is  a  marked  amount  of  intestinal  flatulence.  The  urine  is  very 
dark,  of  a  yellowish-green  or  bronze  hue,  and  stains  the  clothing.  There 
is  complete  anorexia;  the  tongue  is  thickly  coated  with  a  white  fur. 
Headache,  dulness,  and  languor  are  present,  and  the  patient  feels 
wretchedly.  The  slow  pulse  and  the  itching  skin  are  uncommon  symp- 
toms in  children.  The  liver  is  usually  found  slightly  enlarged,  and  some- 
times tender  on  pressure.  The  duration  of  the  disease  is  about  two  weeks, 
the  general  symptoms  disappearing  before  the  icterus.  Eecurrences  and 
prolonged'  attacks  are  occasionally  seen.  The  diagnosis  rarely  presents 
any  difficulty,  and  the  prognosis  is  invariably  good. 

The  fats  and  starches  of  the  food  should  be  reduced  to  a  low  point 
or  be  entirely  prohibited.  Patients  usually  do  much  better  upon  a  diet 
of  rare  meat,  fruit,  and  skimmed  milk,  or  buttermilk.  If  there  is  very 
much  vomiting,  food  should  be  temporarily  withheld  and  later  skimmed 
milk  should  be  given  largely  diluted  with  limewater.  The  amount  of 
food  given  should  be  small,  but  water  should  be  allowed  freely,  par- 
ticiilarly  the  alkaline  mineral  waters.  The  bowels  should  be  kept  open, 
if  necessary  by  means  of  cathartics.  In  most  of  the  cases  no  other  treat- 
ment is  necessary.  When  the  pain  is  severe  it  may  be  relieved  by  coun- 
ter-irritation by  mustard,  turpentine,  or  even  cantharides.  The  restricted 
diet  should  in  all  cases  be  continued  for  at  least  a  week  after  the  jaun- 
dice has  disappeared. 

NEW  GROWTHS 

New  growths  of  the  liver  are  rare  in  children  and  are  usually  sec- 
ondary to  deposits  elsewhere,  most  frequently  in  the  kidney.  They  are 
generally  sarcomatous.  Primary  sarcoma  of  the  liver  has,  however,  been 
observed,  and  at  so  early  an  age  as  to  make  it  practically  certain  that 
the  condition  was  a  congenital  one.  In  most  of  the  cases  there  is  simply 
a  slowly  increasing  abdominal  tumor  and  progressive  asthenia. 

ACUTE  YELLOW  ATROPHY^ 

This  form  of  hepatic  disease  is  rare  in  children.  Greves  has  re- 
ported  a  well-marked   case  in   an   infant  of  twenty   months,   and  has 


ABSCESS  OF  THE  LIVER  439 

collected  seventeen  other  cases  under  ten  years  of  age;  the  youngest  was 
in  an  infant  three  months  old.  The  symptoms  and  course  of  the  disease 
are  essentially  the  same  as  in  adults.  A  condition  closely  allied  to  this 
is  occasionally  seen  as  a  result  of  the  administration  of  chloroform. 


CONGESTION  OF  THE  LIVER 

Congestion  of  the  liver  occurs  from  the  same  causes  in  children  as 
in  adults.  Acute  congestion  is  not  often  seen.  Chronic  congestion  is 
more  common,  and  is  usually  secondary  to  general  venous  obstruction  de- 
pendent upon  congenital  or  acquired  heart  disease,  atelectasis,  or  other 
pulmonary  conditions,  particularly  chronic  pleurisy,  chronic  interstitial 
pneumonia  and  emphysema.  Chronic  congestion  of  the  liver  causes  no 
characteristic  symptoms  except  a  moderate  enlargement  of  the  organ 
with  some  pain  and  tenderness.  The  treatment  is  that  of  the  primary 
disease. 

ABSCESS  OF  THE  LIVER— SUPPURATIVE  HEPATITIS 

In  1890  Musser  found  but  thirty-four  recorded  cases  of  abscess  of 
the  liver  in  children  under  thirteen  years.  Since  that  time  a  few  addi- 
tional cases  have  been  reported.  In  the  above  collection,  there  have 
not  been  included  cases  of  suppurative  hepatitis  occurring  in  the  newly 
born. 

As  in  adults,  abscess  of  the  liver  may  result  from  traumatism,  or  it 
may  be  secondary  to  suppurative  pylephlebitis,  which  depends  upon  a 
focus  of  infection  in  the  umbilical  vein,  or  in  some  part  of  the  abdomen 
from  which  the  l)ranches  of  the  portal  vein  arise.  Pylephlebitis  may  fol- 
low appendicitis,  it  may  follow  typhoid  fever  directly,  or  be  due  to  sup- 
piH'ation  of  the  mesenteric  glands  or  peritonitis  following  typhoid.  In 
seven  of  the  cases  collected  by  Musser  the  disease  was  due  to  migration 
of  roundworms  from  the  intestine  into  the  hepatic  ducts.  Menger 
(Texas)  has  reported  one  case  following  dysentery,  the  only  one,  we 
think,  on  record  in  this  country.  Very  rarely  great  numbers  of  minute 
abscesses  are  found  as  a  result  of  suppurative  thrombosis  of  the  jugular 
bulb  following  middle  ear  disease.  In  quite  a  number  of  cases  no  ade- 
quate cause  can  be  found. 

In  the  cases  occurring  in  pyemia  and  in  those  associated  with  pyle- 
phlebitis there  are  usually  several  abscesses;  in  traumatic  cases  generally 
but  one.  If  untreated,  the  majority  of  cases  prove  fatal  either  from  ex- 
haustion or  from  rupture  into  the  pleura  or  peritoneum.  In  Asch's 
case  spontaneous  cure  took  place  by  rupture  into  the  intestine. 


440  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Symptams. — Occasionally  abscess  of  the  liver  is  latent,  but  in  most 
of  the  cases  the  symptoms  are  marked  and  sufficiently  characteristic  to 
make  the  diagnosis  a  matter  of  no  great  difficulty.  The  most  constant 
general  symptoms  are  chills,  which  may  be  single,  but  are  usually  re- 
peated; fever,  which  is  commonly  of  the  hectic  variety  and  followed  by 
sweating;  prostration,  vomiting,  diarrhea,  and  cachexia.  Jaundice  is 
present  in  less  than  half  the  cases,  and  is  rarely  intense.  The  liver  is 
almost  invariably  sufficiently  enlarged  to  be  easily  made  out  by  palpation 
or  by  percussion;  the  enlargement  in  most  cases  is  chiefly  downward. 
Pain  is  quite  constant  and  frequently  intense,  but  not  always  in  the 
region  of  the  liver.  It  may  be  in  the  epigastrium,  at  the  umbilicus,  in 
the  lower  part  of  the  abdomen,  and  occasionally  in  the  right  shoulder. 
Tenderness  over  the  liver  is  usually  present.  A  positive  diagnosis  of 
hepatic  abscess  is  to  be  made  only  by  aspiration  and  the  withdrawal  of 
a  fluid  having  the  characteristics  of  "liver  pus."  Pulmonary  symptoms 
usually  exist  with  an  abscess  occupying  the  convexity  of  the  right  lobe. 
There  may  be  cough  and  dyspnea  from  pressure,  or  pleurisy  from  ex- 
tension of  the  inflammation  through  the  diaphragm,  or  from  rupture 
into  the  pleural  cavity.  The  usual  duration  of  abscess  of  the  liver  after 
the  beginning  of  the  symptoms  is  from  one  to  two  months.  The  prog- 
nosis will  depend  upon  the  cause  of  the  disease.  The  pyemic  cases  are 
usually  fatal.  In  Musser's  collection,  the  proportion  of  recoveries  was 
about  thirty  per  cent.  At  the  present  time,  with  improved  methods  of 
treatment  and  earlier  diagnosis,  the  outlook  is  somewhat  better  than  this. 

Treatment. — This  is  purely  surgical,  unless  the  abscess  is  due  to  an 
amebic  colitis.  In  that  case  emetin  hydrochlorid  should  also  be  given 
hypodermically  as  advised  under  amebic  colitis.  Cases  have  been  re- 
ported where,  after  undoubted  evidences  of  abscess  have  been  present, 
recovery  has  ensued  with  the  use  of  emetin  alone.  Without  operation, 
however,  the  chances  of  recovery  are  slight.  A  small  number  of  cases 
have  been  cured  by  aspiration,  but  in  the  vast  majority  of  abscesses 
due  to  any  cause  only  incision  and  drainage  are  to  be  depended  upon, 
and,  if  the  abscess  is  accessible,  should  be  resorted  to  as  soon  as  the 
diagnosis  is  established. 

CIRRHOSIS 

Cirrhosis  of  the  liver  is  exceedingly  rare  in  early  life,  although  quite 
a  number  of  cases  are  now  on  record  between  the  ages  of  seven  and  four- 
teen years.  Sixty-five  have  been  collected  by  Howard  and  fifty-three  by 
Laure  and  Honor  at.  jSTearly  all  the  cases  in  these  collections  were  be- 
tween nine  and  fifteen  years  old.  Cirrhosis  in  infancy  is  usually  of 
syphilitic  origin.    Two-thirds  of  those  in  Howard's  collection  were  males. 


AMYLOID  DEGENERATION  OF  THE  LIVER  441 

The  etiology  in  most  of  the  cases  is  obscure ;  in  over  half  of  those  re- 
ported no  cause  could  be  discovered.  Fifteen  per  cent  of  Howard's 
cases  were  traced  to  alcoholism,  eleven  per  cent  to  syphilis,  and  eleven 
per  cent  to  tuberculosis.  Laure  and  Honorat  believe  that  the  eruptive 
fevers  sometimes  play  an  important  part  as  an  etiological  factor,  and 
that  at  other  times  the  cause  is  possibly  malaria. 

The  anatomical  features  of  cirrhosis  in  early  life  are  essentially  the 
same  as  in  adults.  The  liver  is  sometimes  enlarged,  but  usually  it  is 
smaller  than  normal.  The  connective  tissue  may  be  distributed  around 
the  lobules,  along  the  bile  ducts,  in  irregular  patches,  or  in  striations 
through  the  organ.  Associated  with  this  there  is  atrophy  and  fatty 
degeneration  of  the  liver  cells.  In  some  of  the  cases  reported  there  has 
been  also  a  similar  increase  in  the  connective  tissue  of  the  spleen  and 
kidneys. 

Symptoms. — These  are  very  much  the  same  as  in  adult  life.  In  the 
beginning  there  are  the  indefinite  disturbances  referable  to  the  digestive 
organs,  and  the  liver  may  be  slightly  enlarged;  later  there  is  ascites, 
enlargement  of  the  spleen,  and  dilatation  of  the  abdominal  veins.  Ascites 
is  a  pretty  constant  symptom,  and  is  generally  marked.  Slight  icterus 
is  often  present,  but  a  marked  amount  is  rare.  There  may  be  hemor- 
rhages from  the  stomach,  from  the  nose,  or  from  other  organs ;  in  a  few 
cases  there  is  slight  fever.  The  late  symptoms  are,  a  small  liver,  marked 
ascites  with  the  consequent  embarrassment  of  respiration,  cachexia,  and 
sometimes  general  dropsy.  Diarrhea  is  a  much  more  constant  symptom 
than  in  adults.  Death  usually  takes  place  from  exhaustion.  The  course 
of  cirrhosis  in  children  is  commonly  more  rapid  than  in  adults,  and  the 
progress  is  steadily  downward. 

Treatment. — Medicinal  treatment  is  of  avail  only  with  patients  who 
are  syphilitic.  These  should  be  put  upon  antisyphilitic  remedies  in  full 
doses.  The  treatment  in  other  respects  is  symptomatic  and  palliative. 
The  ascites  may  require  paracentesis  as  in  adults. 


AMYLOID  DEGENERATION  {Waxy  or  Lardaceous  Liver) 

From  the  experiments  of  Krawkow,  Davidsohn,  and  others  there 
seems  now  little  doubt  that  amyloid  degeneration  can  be  produced  by  the 
prolonged  action  of  the  staphylococcus  aureus,  and  probably  by  other 
organisms.  Amyloid  degeneration  of  the  liver  is  associated  with  similar 
changes  in  the  spleen  and  kidneys,  and  sometimes  in  the  villi  of  the  small 
intestine,  and  is  usually  seen  in  children  after  long-continued  suppura- 
tion in  chronic  bone  or  Joint  disease,  empyema,  tuberculosis,  or  syphilis. 

The  liver  is  generally  very  much  enlarged ;  in  extreme  cases  a  weight 


142  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

of  six  or  seven  pounds  may  be  reached.  It  is  of  a  glistening,  waxy  ap- 
pearance, very  firm  and  hard.  With  a  solution  of  iodin,  a  mahogany- 
brown  reaction  is  obtained.  The  am3doid  substance  is  deposited  l^etween 
the  capillaries  and  the  hepatic  cells,  leading  to  occlusion  of  the  vessels 
and  atro^jhy  of  tlie  cells  from  pressure. 

Amyloid  li\er  per  se  produces  few  symptoms.  Ascites  is  rarely  pres- 
ent except  in  cases  in  which  the  liver  is  very  large,  and  jaimdice  does  not 
occur.  In  addition  to  the  symptoms  of  the  original  disease  in  the 
course  of  which  the  amyloid  degeneration  occurs,  there  is  the  peculiar 
waxy  cachexia  which  is  seen  in  no  other  condition,  but  resembles  some- 
what that  belonging  to  malignant  disease.  The  face  has  the  appearance 
of  alabaster,  and  the  skin  has  a  singular  translucency.  The  liver  may  be 
so  large'  as  to  form  a  tumor,  sometimes  nearly  filling  the  abdominal 
cavity.  Not  infrequently  it  extends  to  the  umbilicus,  and  even  to  the 
crest  of  the  ilium.  The  surface  is  smooth  and  hard,  and  the  edges  usu- 
ally rounded.  There  is  no  localized  pain  or  tenderness.  The  spleen  is 
invariably  enlarged.  As  a  result  of  the  associated  amyloid  degeneration 
of  the  kidney,  there  may  be  anasarca  and  allmminuria.  Dropsy  may 
occur  from  pressure  of  the  large  liver  upon  the  vena  cava,  apart  from 
the  condition  of  the  kidney. 

Amyloid  changes  usually  take  place  slowly,  the  whole  course  of  the 
disease  being  marked  by  years,  the  patient  dying  from  slow  asthenia, 
from  nephritis,  or  from  some  acute  intercurrent  disease.  As  a  rule,  cases 
go  on  steadily  from  bad  to  worse;  but  sometimes,  after  the  disease  has 
reached   a  certain  point,  the   condition  remains  stationary  for  a  long 

time. 

The  prognosis  is  always  bad,  although  in  a  few  cases  improvement, 
and  even  cure,  are'  stated  to  have  occurred  after  the  excision  of  the  dis- 
eased joints  upon  which  the  amyloid  degeneration  depended.  Waen  due 
to  syphilis,  the  usual  antisyphilitic  remedies  should  be  given. 


FATTY  LIVER 

Fatty  infiltration  of  the  liver  is  generally  a  secondary  condition  in 
early  life,  and  causes  no  symptoms  by  which  it  can  be  positively  recog- 
nized. Considerable  discussion  has  of  late  arisen  regarding  its  frequency 
in  infants.  From  our  records  at  the  Babies'  Hospital,  Wollstein  has 
tabulated  345  consecutive  autopsies  in  which  the  condition  of  the  liver 
was  carefully  noted.  The  liver  was  fatty  in  201,  or  58  per  cent.  Of 
these  autopsies,  63  were  cases  of  tuberculosis,  in  43  of  which,  or  68  per 
cent,  the  liver  was  fatty. 

The  general  nutrition  of  the  345  infants  was  as  follows : 


BILIARY  CALCULI  443 

Wasted 188:  liver  fatty,  104,  or  55  per  cent — very  fatty  in  17. 

Fairly  nourished ": . .     80:       "         "       52,   "65    "       "  "       "      "    9. 

Well  nourished 77:      "        "       45,   "  59    "      "  "       "      "20. 

These  figures  coincide  very  closely  with  the  observations  of  Free- 
man at  the  New  York  Foundling  Hospital,  and  indicate  that  fatty  liver 
is  not,  as  has  been  so  often  asserted,  much  more  frequent  in  wasted 
infants  than  in  others.  The  cause  of  this  change  in  the  liver  is  as  yet 
but  little  understood. 

The  liver  is  moderately  enlarged,  smooth,  with  rounded  edges,  of  a 
yellowish-red  or  a  lemon-yellow  color,  and  can  be  indented  with  the 
finger.  A  warm  knife  becomes  coated  with  oil  after  cutting.  'Microscop- 
ically there  is  seen  an  accumulation  of  fat  in  the  liver  cells,  usually 
irregularly  distributed,  but  chiefly  in  the  periphery  of  the  lobule.  Jaun- 
dice, ascites,  and  the  other  peculiar  symptoms  of  hepatic  disease  are 
absent.  The  liver  is  moderately  increased  in  size.  Its  functions  are  not 
interfered  with  in  such  a  way  as  to  be  recognized  by  the  symptoms. 
The  treatment  is  that  of  the  original  disease. 


HYDATIDS 

Echinococcus  disease  of  the  liver,  while  rare  among  adults  in  this 
country,  is  almost  unknown  in  children.  We  have  been  able  to  find  but 
two  recorded  cases  in  America.  From  twenty-two  European  cases  col- 
lected by  Pontou,  it  appears  that  unilocular  cysts  are  especially  frequent 
in  young  subjects.  If  the  upjier  surface  is  affected,  pulmonary  symp- 
.toms,  cough  and  dyspnea,  are  usually  prjBsent;  if  the  imder  surface 
of  the  organ,  there  is  pressure  upon  the  portal  vein,  the  vena  cava,  bile 
ducts,  stomach,  and  intestines.  This  pressure  may  cause  icterus,  dilata- 
tion of  the  superficial  abdominal  veins,  and  sometimes  ascites.  The  local 
signs  are  enlargement  of  the  liver  with  a  tumor,  which  is  easily  recog- 
nized in  children  because  of  the  thin  abdominal  w^alls.  The  hydatid 
fremitus  is  usually  obtained.  By  aspiration  a  clear  fluid  is  withdrawn, 
showing  under  the  microscope  the  presence  of  the  hooklets,  which  estab- 
lishes the  diagnosis.  Occasionally  cure  may  take  place. by  spontaneous 
rupture  or  suppuration  of  the  cyst,  but  in  most  cases,  when  left  to  itself, 
the  disease  proves  fatal.  The  treatment  is  surgical,  and  consists  in 
aspiration  or  in  incision,  and  the  evacuation  of  the  cyst. 

BILIARY  CALCULI 

Up  to  the  age  of  puberty  calculi  are  extremely  rare.  Of  twenty  cases 
collected  by  Still,  eleven  occurred  in  newly-born  infants  or  else  gave 


.444  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

symptoms  during  the  first  month  of  life.     The  prominent  symptom  was 
intense  and  persistent  jaundice.    Nearly  all  died  within  the  first  month, 
the  autopsy  usually  showing  multiple  calculi  in  the  common  duct. 
The  cases  in  older  children  do  not  differ  from  those  in  adults. 


CHAPTEE  XII 

DISEASES   OF    THE   PERITONEUM 

Inflammation  of  the  peritoneum  is  seen  at  all  ages,  even  in  the 
first  weeks  of  life;  but  is  less  frequent  in  children  than  in  adults  since 
most  of  the  causes  which  are  operative  in  later  life  either  do  not  exist 
at  all  in  childhood  or  are  infreqiient. 

We    shall    consider    separately    acute,    chronic,    and    tuberculous 
peritonitis. 
» 

ACUTE  PERITONITIS 

Acute  peritonitis  may  occur  at  any  period  of  infancy  or  childhood. 
It  may  even  exist  in  intra-uterine  life.  In  the  newly  born,  peritonitis  is 
not  infrequent.  After  this  time  it  is  exceedingly  rare  during  infancy, 
only  four  cases,  including  all  varieties,  being  met  with  in  726  consecutive 
autopsies  in  the  ISTew  York  Infant  Asylum.  After  the  fifth  year  the 
disease  is  relatively  much  more  common.  Of  the  187  cases  above  re- 
ferred to,  25  per  cent  occurred  in  the  newly  born,  21  per  cent  between 
one  and  five  years,  and  54  per  cent  between  the  fifth  and  the  sixteenth 
years. 

Etiology. — In  the  newly  born,  peritonitis  is  seen  as  one  of  the  fre- 
quent lesions  of  acute  pyogenic  infection.  It  is  usually  due  to  direct 
infection  through  the  umbilical  vessels.  In  infancy  and  childhood, 
peritonitis  occurs  both  as  a  primary  and  secondary  inflammation.  The 
primary  form  is  rare.  It  may  be  due  to  traumatism,  such  as  falls  or 
blows,  or  to  surgical  operations  upon  the  abdomen ;  it  has  occurred  after 
an  injection  for  the  cure  of  a  congenital  hydrocele.  Very  rarely  the 
inflammation  seems  to  have  been  excited  by  exposure,  and  it  may  follow 
severe  burns.  Cases  of  acute  peritonitis  are  occasionally  seen  which  are 
apparently  primary.  We  have  met  with  four  in  young  children,  two 
being  due  to  the  pneumococcus  and  two  to  the  streptococcus. 

The  secondary  form  is  more  common.  The  most  frequent  of  all 
causes  is  appendicitis,  which  should  always  be  suspected  in  acute  perito- 


ACUTE  PERITONITIS  "  445 

nitis  occurring  without  definite  cause.  Extension  of  inflammation  from 
the  viscera  to  the  peritoneum  is  very  much  less  frequent  in  children  than 
in  adults.  It  is  very  rarely  seen  as  a  complication  of  dysentery.  It 
is  also  rare  in  typhoid  fever.  It  is  occasionally  due  to  abscess  of  the 
liver,  ulcer  of  the  stomach,  acute  intestinal  obstruction  from  internal 
strangulation,  intussusception,  volvulus,  and  congenital  atresia.  It  may 
extend  from  inflammation  of  the  pleura.  This  may  be  in  the  form  of 
an  empyema  which  burrows  through  the  diaphragm,  or,  without  bur- 
rowing, the  infection  may  take  place  through  the  lymph  channels;  or 
it  may  be  secondary  to  a  general  pneumococcus  septicemia.  Peritonitis 
is  infrequently  due  to  infection  through  the  female  genital  tract,  espe- 
cially in  gonococcus  vulvovaginitis  in  older  girls.  Extension  of  inflam- 
mation from  the  male  genital  organs  is  very  rare.  In  one  case  at  the 
'New  York  Infant  Asylum,  fatal  peritonitis  in  an  infant  started  from 
a  suppurative  inflammation  of  the  tunica  vaginalis  of  unknown  origin, 
the  infection  extending  into  the  peritoneum  through  the  inguinal  canal. 
Any  abscess  in  the  neighborhood  may  rupture  into  the  peritoneum 
and  excite  peritonitis.  Those  most  frequent  in  children  are  connected 
with  Pott's  disease,  perinephritis,  and  cellulitis  of  the  abdominal  wall. 
It  is  occasionally  seen  in  pyemia  from^  any  cause,  and  quite  frequently 
occurs  as  one  of  the  complications  of  septic  sore  throat. 

Of  the  acute  infectious  diseases,  peritonitis  is  most  frequently  seen 
with  pneumonia,  and  very  rarely  with  scarlet  fever.  It  is  also  seen  as 
one  of  the  complications  of  septic  sore  throat.  When  secondary  to 
pneumonia,  there  is  usually  intense  pleurisy  and  sometimes  also  peri- 
carditis and  meningitis;  in  other  words  a  general  pneumococcus  infec- 
tion is  present. 

The  bacteria  most  frequently  associated  with  acute  peritonitis  in 
children  are :  the  streptococcus,  especially  in  the  newly  born ;  the  pneu- 
mococcus in  cases  complicating  pneumonia  or  empyema;  and  the  strep- 
tococcus associated  with  the  h.  coli  communis  in  those  following  intes- 
tinal perforation. 

Lesions. — 'In  the  fibrinous  form  there  are  changes  similar  to  those 
occurring  in  inflammation  of  the  pleura  and  the  other  serous  membranes. 
The  peritoneum  is  injected  and  fibrin  is  thrown  out  in  considerable 
quantity,  usually  accompanied  by  a  small  amount  of  serum.  The  process 
is  usually  a  localized  one.  The  peritoneum  lining  the  abdominal  wall, 
as  well  as  that  covering  the  adjacent  coils  of  intestine  and  the  solid 
viscera,  is  covered  by  patches  of  yellowish-gray  fibrin,  causing  adhesions 
between  the  various  viscera  and  often  matting  the  intestines  together. 
In  recent  cases  these  adhesions  are  soft,  and  easily  broken  down;  in  old 
cases  they  are  quite  firm,  and  they  may  result  in  the  formation  of 
connective-tissue  bands  which  are  the  source  of  subsequent  trouble.  In 
16 


446  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

other  cases  the  serum  is  more  abundant,  usually  clear,  but  it  may  be 
turbid  or  even  bloody. 

In  the  purulent  form  the  products  are  serum,  tibrin,  and  pus.  When 
peritonitis  results  from  perforation  it  is,  as  a  rule,  purulent  from  the 
outset,  and  the  pus  is  foul  and  stinking.  The  amount  of  pus  is  pro- 
portionally larger  than  in  adult  cases.  When  the  disease  proves  fatal 
in  a  few  days  there  is  found  an  extensive  exudation  of  fibrin,  with  the 
formation  of  small  pockets  containing  pus  among  the  coils  of  intestine. 
Occasionally  there  may  be  larger  collections  of  pus  in  the  peritoneal 
cavity.  In  cases  which  have  lasted  a  long  time — generally  those  of 
localized  inflammation — the  process  results  in  the  formation  of  a  peri- 
toneal abscess.  This  consists  in  a  collection  of  pus  in  some  part  of  the 
peritoneal  cavity,  the  situation  depending  upon  the  cause,  but  it  is 
usually  in  one  iliac  fossa  or  in  the  pelvis.  The  abscess  is  shut  off  from 
the  rest  of  the  peritoneal  cavity  by  a  thick  Avail  of  fibrin.  If  left  alone, 
such  abscesses  may  open  into  the  rectum,  vagina,  bladder,  pelvis  of  the 
kidney,  or  externally — usually  at  the  umbilicus.  After  the  discharge  of 
pus  the  cavity  may  contract  and  fill  up  by  granulation,  and  the  patient 
recover. 

Inflammations  of  the  other  serous  membranes,  especially  the  pleura, 
are  often  associated  with  peritonitis. 

Symptoms. — The  symptoms  of  acute  peritonitis  in  older  children,  as 
in  adults,  are  usually  well  marked  and  sufficiently  characteristic  to  enable 
one  to  recognize  the  disease  easily;  but  not  so  in  the  case  of  infants.  In 
them  the  symptoms  are  often  obscure,  and  the  disease  may  be  found  at 
autopsy  when  not  suspected  during  life.  The  onset  is  nearly  always 
abrupt,  with  fever  and  vomiting.  As  a  rule,  the  temperature  is  high — 
from  103°  to  105°  F.  Vomiting  may  occur  only  at  the  onset,  but  it 
often  continues;  the  vomited  matters  are  usually  green.  Older  children 
complain  of  pain,  which  may  be  localized  or  general,  and  in  younger 
ones  this  is  indicated  by  crying  and  fretfulness.  The  abdomen  very  soon 
becomes  swollen  and  tympanitic,  this  being  one  of  the  most  constant 
features  of  the  disease.  The  distention  is  generally  uniform,  but  it  may 
be  irregular.  There  is  tenderness  on  pressure,  and  usually  marked  rigid- 
ity of  the  abdominal  walls.  The  pain  causes  the  child  to  assume  a  fixed 
position  and  he  cries  if  moved  or  disturbed.  The  posture  is  generally 
dorsal,  with  the  thighs  flexed.  The  bowels  are  in  most  cases  constipated, 
but  diarrhea  is  by  no  means  rare.  The  abdominal  distention  causes 
dyspnea  and  thoracic  breathing.  There  may  be  retention  of  urine  or 
frequent  micturition. 

The  general  symptoms,  almost  from  the  beginning,  are  those  of  a 
serious  disease.  The  pulse  is  small,  rapid,  and  compressible.  The 
prostration  is  great,  from  the  very  outset.     The  face  is  pinched,  the 


ACUTE  PERITONITIS  447 

mouth  is  drawn,  and  the  features  indicate  pain.  In  severe  cases  there 
may  be  hiccough,  cokl  extremities,  clammy  perspiration,  and  collapse. 
The  mind  is  usually  clear.  In  infants  there  may  be  convulsions.  A 
polymorphonuclear  leucocytosis  is  almost  invariably  present,  but  is 
wanting  in  some  cases  of  the  gravest  type. 

In  the  most  severe  forms  of  general  peritonitis  the  course  is  short 
and  intense,  and  the  disease  goes  on  rapidly  from  bad  to  worse  until 
death  occurs.  In  infants  this  is  often  on  the  third  or  fourth  day.  The 
very  severe  forms  of  general  peritonitis  in  older  children  run  the  same 
rapid  course.  In  other  cases  the  course  is  slower,  lasting  a  week  or  ten 
days.  If  the  patient  lives  longer  than  this  the  case  is  more  hopeful, 
because  the  process  is  more  apt  to  be  localized.  The  development  of 
peritoneal  abscess  is  indicated  by  the  continuance  of  the  temperature, 
which  may  assume  a  hectic  type,  and  be  accompanied  by  chills  and 
sweating.     There  are  the  local  sig-ns  of  an  abdominal  tumor. 

Prognosis. — Acute  general  peritonitis,  whatever  its  cause,  is  a  very 
serious  disease  in  childhood.  Of  eighty  cases  of  all  varieties  under 
sixteen  years  of  age,  sixty-nine  per  cent  were  fatal.  In  the  newly  born 
and  in  infancy  the  disease  is  almost  invariably  fatal.  In  older  children 
the  outlook  is  not  quite  so  hopeless,^  and  depends  upon  the  exciting 
cause. 

Treatment. — The  medical  treatment  of  acute  general  peritonitis  in 
children  is  extremely  unsatisfactory,  as  the  disease  is  almost  always  fatal 
unless  it  can  be  relieved  surgically.  Opium  is  indicated  only  for  the  re- 
lief of  the  single  symptom,  pain.  It  has,  however,  serious  disadvantages 
in  that  it  may  mask  important  symptoms.  Other  medical  treatment  is 
symptomatic  only  and  is  to  be  employed  in  conjunction  with  surgical 
measures. 

As  a  local  application  cold  is  usually  to  be  preferred.  It  may  be 
applied  either  by  an  ice-bag  or  by  a  Leiter's  coil.  If  children  rebel 
against  the  use  of  cold,  heat  may  be  substituted.  Turpentine  stupes  may 
aid  in  relieving  tympanites. 

Feeding  is  always  a  difficult  matter  on  account  of  the  strong  tend- 
enc_y  to  vomit;  this  is  due  to  regurgitation  from  the  intestine  into 
the  stomach,  which  in  some  eases  is  almost  continuous.  In  such  con- 
ditions great  benefit  may  be  obtained  from  washing  the  stomach  shortly 
before  feeding,  repeating  this  several  times  each  day.  In  this  way  vomit- 
ing may  often  be  controlled  and  the  stomach  made  ready  for  food.  The 
diet  should  be  milk,  broth,  or  buttermilk. 

In  every  case  of  acute  peritonitis  an  immediate  exploratory  operation 
should  be  done  if  the  child's  general  condition  will  permit.  Appendicitis 
is  often  found  to  be  the  cause  when  least  expected ;  and  even  when  the 
peritonitis  is  due  to  some  other  cause  operation  gives  the  only  chance 


448  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

for  recovery.     Operation  is  also  indicated  in  localized  inflammations  with 
the  formation  of  peritoneal  abscesses. 


CHRONIC  (NON-TUBERCULOUS)  PERITONITIS 

Peritonitis  may  occur  in  fetal  life  with  the  production  of  extensive 
adhesions,  which  may  interfere  with  the  development  of  the  intestine  and 
result  in  various  malformations.  These  cases  have  been  ascribed  by 
Silbermann  to  syphilis. 

Chronic  peritonitis  may  follow  the  acute  form,  in  which  there  are 
left  adhesions  which  slowly  increase  owing  to  the  production  of  new 
connective  tissue.  Such  cases  are  sometimes  chronic  from  the  be- 
ginning. 

The  peritoneal  abscesses  which  follow  the  suppurative  form  may 
run  a  chronic  course.  Chronic  localized  peritonitis  may  occur  in  con- 
nection with  disease  of  any  of  the  organs  covered  by  the  peritoneum. 

Chronic  Peritonitis  with  Ascites. — In  most  cases  this  is  chronic  from 
the  outset  and  independent  of  the  causes  above  mentioned.  By  far  the 
most  frequent  form  of  inflammation  is  that  due  to  tuberculosis,  and  by 
some  writers  the  opinion  is  still  held  that  chronic  peritonitis  with  ascites 
is  always  tuberculous.  After  the  observations  reported  by  Henoch,  Yier- 
ordt,  Fiedler,  and  others,  there  seems  to  be  little  room  for  doubting 
the  existence  of  a  chronic  non-tuberculous  form  of  peritonitis  witli 
ascites,  although  it  must  be  considered  a  rare  disease. 

Etiology. — Xearly  all  the  cases  thus  far  reported  have  occurred 
in  children  over  six  years  old.  The  causes  are  for  the  most  part  ob- 
scure. Chronic  peritonitis  may  be  associated  with  disease  of  the  intes- 
tines or  the  solid  viscera  of  the  abdomen,  especially  with  new  growths 
of  the  kidney,  liver,  etc. 

Lesions. — The  post-mortem  observations  thus  far  have  been  few.  In 
the  reported  cases  there  has  been  found  a  large  amount  of  greenish 
serum  in  the  general  peritoneal  cavity,  with  a  very  moderate  amount  of 
fibrin  and  with  adhesions,  which  are  sometimes  few  and  sometimes  very 
numerous.     Chronic  pleurisy  may  be  associated. 

Symptoms. — The  early  symptoms  are  of  a  very  indefinite  character, 
but  often  nothing  whatever  is  noticed  until  the  swelling  of  the  abdomen 
begins.  The  enlargement  comes  on  rather  gradually  in  the  course  of  a 
few  weeks.  Pain  is  slight,  or  wanting  altogether.  There  may  be  some 
abdominal  tenderness.  The  abdomen  is  usually  distended  with  fluid. 
The  general  symptoms  are  very  few.  In  some  cases  there  is  a  slight 
evening  rise  of  temperature  of  one  or  two  degrees.  There  may  be  gen- 
eral weakness,  loss  of  appetite,  and  moderate  anemia. 


TUBERCULOUS  PERITONITIS  449 

The  usual  course  of  the  disease  is  for  the  fluid  to  remain  for  a 
time  and  then  undergo  slow  absorption.  In  some  instances  there  is  no 
tendency  to  absorption  of  the  fluid,  the  general  health  is  gradually  un- 
dermined, and  the  patients  die  from  exhaustion  or  from  some  inter- 
current disease.  The  diagnosis  rests  upon  the  presence  of  ascites,  devel- 
oping gradually  without  any  signs  or  symptoms  of  disease  in  the  heart, 
liver,  or  other  organs.  The  points  which  distinguish  it  from  tuberculous 
peritonitis  are  considered  under  that  disease.  The  prognosis  must  be 
guarded  on  account  of  the  difficulty  in  making  a  positive  diagnosis  from 
the  tuberculous  form. 

Treatment. — The  treatment  is  entirely  symptomatic.  The  patient 
should  be  kept  at  rest,  preferably  confined  to  bed.  When  there  is  no 
tendency  to  absorption,  and  especially  when  the  patient's  general 
health  begins  to  suft'er,  the  fluid  should  be  removed  by  paracentesis.  If 
it  continues  to  accumulate  after  repeated  tapping,  laparotomy  may 
be  performed,  for  in  some  cases  this  has  the  same  beneficial  effect  as  in 
tuberculous  peritonitis. 


TUBERCULOUS  PERITONITIS 

The  peritoneum  is  quite  frequently  the  seat  of  tuberculous  inflam- 
mation in  early  life.  It  occurs  especially  between  the  ages  of  one  and 
five  years,  but  is  infrequent  during  the  first  year.  Of  100  cases  observed 
by  Still,  the  largest  number  were  seen  in  the  second  year  of  life.  In 
255  autopsies  upon  tuberculous  patients,  most  of  them  under  three  years 
old,  of  which  we  have  records,  the  peritoneum  was  involved  in  8.6  per 
cent;  but  in  a  majority  of  these  the  peritonitis  was  not  the  most  impor- 
tant lesion  nor  the  cause  of  death.  Tuberculous  peritonitis  is  apparently 
much  more  frequent  in  Europe  than  in  this  country.  Thus,  Still  states 
that  this  was  the  cause  of  death  in  16.8  per  cent  of  his  tuberculous 
patients  under  twelve  years  of  age,  and  in  12  per  cent  of  the  deaths 
from  tuberculosis  under  two  years.  In  105  autopsies,  for  the  most  part 
upon  older  tuberculous  children,  Ashby  found  the  peritoneum  involved 
in  36  per  cent.  In  883  collected  autopsies  upop  tuberculous  children  of 
all  ages,  Biedert  found  the  peritoneum  involved  in  18.3  per  cent.  These 
figures  do  not  represent  the  number  of  cases  of  tuberculous  peritonitis, 
as  in  many  of  them  only  a  few  miliary  tubercles  were  present. 

It  is  possible  for  peritonitis  to  occur  as  the  primary  lesion  of  tuber- 
culosis, the  bacilli  entering  by  way  of  the  intestine,  causing  no  lesion  of 
the  mucous  membrane ;  but  in  the  great  majority  of  cases  it  is  secondary 
to  tuberculosis  of  the  intestine,  the  mesenteric  glands,  the  pleura,  or 
to  that  of  more  distant  parts,  such  as  the  lungs,  the  bronchial  glands, 


450  diseasp:s  of  the  digestive  system 

etc.  In  a  small  number  of  cases  there  is  a  history  of  some  local  excit- 
ing cause,  such  as  a  fall  or  blow  upon  the  abdomen.  The  bovine  type 
of  the  tubercle  bacillus  is  more  frequently  found  in  tuberculous  peri- 
tonitis than  in  any  other  form  of  tuberculosis,  possibly  excepting  cervical 
adenitis,  ■which  fact  is  strongly  suggestive  of  milk  as  the  source  of 
infection. 

Tuberculous  peritonitis  is  usually  associated  with  other  abdominal 
lesions — tuberculosis  of  the  mesenteric  glands,  intestinal  ulceration,  etc. 
It  is  very  rarely  acute,  but  usually  occurs  as  a  subacute  or  chronic 
disease. 

The  peritoneum  may  be  involved  as  one  of  the  lesions  in  acute  or 
subacute  general  miliary  tuberculosis.  The  lesions  consist  in  a  deposit 
of  miliary  tubercles,  wliich  are  generally  rather  sparsely  scattered  over 
the  peritoneum.  The  evidences  of  inflammation  are  very  slight,  or  they 
may  be  absent  altogether.  These  cases  do  not  come  under  observation 
as  cases  of  peritonitis,  as  there  are  no  abdominal  symptoms. 

The  principal  anatomical  and  clinical  varieties  of  tuberculous  peri- 
tonitis are  the  ascitic  and  the  fibrous  forms. 

The  Ascitic  Form. — This  is  much  less  frequent  than  th^  fibrous  form. 
The  peritoneum  is  thickly  sown  with  miliary  tubercles,  both  discrete 
and  in  conglomerate  masses.  They  are  found  in  the  omentum  and  the 
mesenter}',  upon  the  surface  of  the  intestines  and  the  solid  viscera. 
The  peritoneum  shows  in  varying  degrees  the  changes  of  acute  or  sub- 
acute inflammation,  with  the  production  of  a  moderate  amount  of  fibrin 
and  a  large  amount  of  serum.  In  the  most  acute  cases  the  fluid  is 
in  the  general  peritoneal  cavity.  In  those  of  longer  diiration  it  may 
be  sacculated.  The  fluid  is  usually  abundant,  but  not  excessive.  It  is 
most  commonly  a  straw-colored  serum,  but  it  may  be  seropurulent, 
or  even  bloody.  There  are  commonly  other  lesions  of  tuberculosis  in 
the  body,  but  they  are  usually  less  marked  than  those  of  the 
peritoneum. 

Clinically,  ascitic  cases  usually  present  the  symptoms  of  a  low  grade 
of  peritoneal  inflammation.  The  onset  is  gradual,  with  indefinite  gen- 
eral symptoms.  There  is  usually  some  fever — 100°  to  101. .5°  F.  There 
is  general  weakness,  prostration,  and  some  loss  of  flesh,  but  not  rapid 
emaciation.  Vomiting  is  not  prominent,  and  pain  and  tenderness  are 
often  absent.  There  may  be  nothing  distinctive  until  distention  of  the 
abdomen  is  seen.  This  at  first  is  due  to  intestinal  gas.  but  later  to  fluid, 
which  may  accumulate  in  sufficient  quantity  to  fill  the  general  peritoneal 
cavity.  The  bowels  may  be  constipated  or  there  may  be  diarrhea.  In 
other  cases  there  may  be  only  a  slowly  developing  ascites  without  any 
inflammatory  signs,  and  the  abdominal  enlargement  is  practically  the 
only  symptom. 


TUBERCULOUS  PERITONITIS  451 

The  ascitic  form  of  tuberculous  peritonitis  may  result  fatally,  death 
occurring  from  general  tuberculosis  or  by  slow  exhaustion  from  the  local 
disease;  the  duration  under  these  conditions  is  usually  from  two  to  six 
months,  xlt  other  times  the  fluid  may  gradually  undergo  absorption 
and  recovery  take  place,  or  after  absorption  the  fibrous  form  of  inflam- 
mation may  develop. 

The  Fibrous  Form. — This  is  generally  slower  in  its  development  and 
more  chronic  in  its  course  than  the  ascitic  form.  There  is  a  tuberculous 
inflammation,  the  products  of  which  have  undergone  transformation  to  a 
greater  or  less  extent  into  fibrous  tissue.  The  most  important  feature 
of  these  cases  is  the  production  of  extensive  organized  adhesions  be- 
tween the  solid  viscera  and  the  intestines,  between  the  intestinal  coils, 
and  between  the  intestines  and  the  abdominal  walls.  The  intestines  may 
be  compressed  against  the  spine  by  bands. 

These  adhesions  and  their  mechanical  consequences  are  sometimes 
almost  the  only  lesions  present.  In  other  cases  there  may  be  an  ac- 
cumulation of  fluid,  which  may  be  sacculated  or  in  the  general  peritoneal 
cavity.  This  may  be  serous,  seropurulent,  or  purulent.  The  omentum 
may  be  greatly  thickened.  There  are  often  present  in  the  fibrous  exu- 
date covering  the  intestines,  in  the  omentum,  and  in  the  mesentery, 
tuberculous  deposits  consisting  of  caseous  nodules  or  larger  caseous 
masses,  which  are  frequently  softened  at  the  center.  Tuberculous 
deposits  are  found  upon  the  peritoneal  surface  of  the  intestine,  and 
infiltrate  the  intestinal  walls,  often  leading  to  perforation,  and  some- 
times to  fistulous  communications  between  adherent  intestinal  coils. 
There  may  also  be  tuberculous  infiltration  of  the  abdominal  walls, 
accompanied  by  cellulitis,  resulting  in  abscesses,  which  may  open  ex- 
ternally, usually  in  the  neighborhood  of  the  umbilicus. 

Clinically,  these  cases  are  distinguished  by  their  slow,  irregular 
course.  They  are  the  most  chronic  of  all  the  forms.  The  onset  is 
generally  insidious,  and  fever  is  commonly  absent.  There  is  rarely 
vomiting.  The  bowels  may  be  constipated  or  loose.  For  a  long  time 
the  general  health  may  remain  good.  The  only  characteristic  symptom 
is  the  enlargement  of  the  abdomen.  In  the  early  part  of  the  disease  this 
is  chiefly  from  the  tympanites,  but  later  there  may  be  some  accumulation 
of  fluid.  It  is  rare  that  the  inflammation  remains  entirely  fibrinous. 
Ascites  usually  develops  very  slowly,  but  may  be  abundant.  The  adhe- 
sions of  the  intestines  may  give  rise  to  irregularities  in  the  outline  of 
the  abdomen.  Ascites  may  be  present  for  a  time  and  then  disappear 
spontaneously,  and  the  general  health  may  so  improve  that  the  patient 
is  considered  quite  well.  There  may  even  be  a  permanent  cure.  In 
other  cases,  after  symptoms  have  been  absent  for  some  time,  relapses 
occur,  and  more  fluid  is  poured  out.     In  addition  to  these  symptoms, 


452  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

others  are  present  depending  upon  the  mechanical  effects  of  pressure 
from  the  contracting  adhesions.  There  may  be  more  or  less  constric- 
tion of  the  intestine,  pressure  upon  the  vena  cava,  the  renal  or  portal 
veins,  the  thoracic  duct  or  its  branches,  or  upon  the  stomach.  These 
(conditions  may  give  rise  to  dyspeptic  symptoms,  emaciation,  edema  of 
the  lower  extremities,  and  albuminuria.  In  some  cases  tuberculous 
peritonitis  is  entirely  latent,  and  it  is  discovered  at  autopsy  when  there 
have  been  either  no  abdominal  symptoms  during  life,  or  only  colicky 
pains  of  an  indefinite  character.  The  course  of  this  form  of  peritonitis 
is  slow  and  irregular;  it  generally  lasts  for  from  six  to  twelve  months, 
although  with  intermissions  and  exacerbations  it  may  extend  over 
several  years. 

If  softening  and  breaking  down  of  inflammatory  products  take  place, 
well-marked  constitutional  symptoms  are  usually  present.  These  are 
partly  from  the  peritonitis  and  partly  from  general  tuberculosis.  Fever 
is  regularly  present,  the  temperature  usually  ranging  from  99°  to 
102°  F.,  though  it  is  occasionally  much  higher.  There  is  progressive 
emaciation,  anemia,  prostration,  and  sweating.  Diarrhea  is  frequent 
and  the  intestinal  discharges  may  at  times  be  bloody.  The  abdomen  is 
large,  but  not  so  much  distended  as  in  some  of  the  other  forms;  the 
superficial  veins  are  frequently  prominent.  Ascites  often  can  not  be 
made  out  by  percussion,  even  though  fluid  is  present.  Areas  of  dulness 
and  tympanitic  resonance  are  irregularly  distributed.  Kodular  masses 
of  various  sizes  and  irregular  shapes  may  be  felt  anywhere  in  the  abdo- 
men, but  they  are  more  frequently  in  the  region  of  the  umbilicus  and  in 
the  right  iliac  fossa  than  elsewhere.  The  epigastric  region  may  be 
occupied  by  a  smooth,  hard  tumor — the  thickened  omentum — which 
may  resemble  the  liver.  There  may  be  the  signs  of  phlegmonous  inflam- 
mation of  the  abdominal  wall  in  the  neighborhood  of  the  umbilicus, 
and  even  an  abscess,  which, ,  after  opening,  may  leave  a  fistulous  com- 
munication with  the  peritoneum.  There  are  usually  some  signs  of  dis- 
ease in  the  lungs,  and  the  pulmonary  symptoms  may  mask  those  of  the 
abdomen.  The  course  of  the  disease,  when  softening  and  breaking  down 
have  taken  place,  is  steadily  progressive,  the  usual  duration  being  from 
three  to  six  months.  Death  results  from  the  pulmonary  disease,  from 
tuberculous  meningitis,  from  exhaustion,  and  occasionally  it  is  due  to 
accidents  associated  with  perforation. 

Diag^nosis. — The  esserutial  symptoms  of  tuberculous  peritonitis  are  an 
enlarged  abdomen,  often  with  evidence  of  fluid,  wasting,  colicky  pains, 
irregularity  of  the  bowels,  nodular  masses  in  the  abdomen,  and  usually 
slight  but  continuous  fever.  In  young  children  chronic  ascites  with 
fever  usually  means  tuberculous  peritonitis.  Pouting  of  the  navel,  with 
induration  and  redness  about  it,  is  suggestive,  and  any  chronic  abscess 


TUBERCULOUS  PERITONITIS  453 

in  the  neighborhood  of  the  umbilicus  is  suspicious.  If  the  abdominal 
effusion  is  sacculated  instead  of  diffuse,  the  probabilities  of  peritonitis 
are  much  increased.  If  there  are  added  physical  signs  pointing  to  dis- 
ease of  the  lungs  or  the  evidence  of  tuberculosis  elsewhere,  and  a  positive 
cutaneous  tuberculin  reaction,  the  diagnosis  is  almost  certain.  Cirrhosis 
of  the  liver  is  practically  unknown  in  infancy  and  early  childhood. 
When  ascites  is  absent,  tuberculosis  of  the  peritoneum  may  be  suspected 
if  there  are  irregular  nodules  or  masses  in  various  parts  of  the  abdomen, 
with  tenderness,  emaciation,  colicky  pains,  and,  in  the  later  stages, 
fever.  But  fever  may  be  absent  for  a  long  time,  even  though  local 
symptoms  are  marked.  The  epigastric  tumor  due  to  omental  thickening 
may  be  mistaken  for  the  liver;  but  it  generally  extends  quite  across  the 
abdomen,  and  the  upper  as  well  as  lower  border  can  often  be  felt. 
Fecal  masses  may  resemble  tuberculous  deposits,  but  are  removed  by 
cathartics  and  enemata. 

Abdominal  paracentesis  to  establish  the  presence  of  fluid  or  to  allow 
of  its  examination  is  not  Justifiable.  The  danger  of  injury  to  the 
intestines  even  when  a  considerable  accumulation  of  fluid  is  present  is 
too  great. 

Prognosis. — Tuberculous  peritonitis  is  always  a  serious  disease,  but 
by  no  means  a  hopeless  one.  The  younger  the  child  as  a  rule  the  more 
rapid  the  progress  of  the  disease  and  the  worse  the  outlook.  The 
prognosis  is  especially  bad  during  the  first  three  years  of  life;  at  this 
period  most  of  the  cases  terminate  fatally.  Many  cases  occurring  in 
older  children  recover  spontaneously  and  entirely.  The  most  hopeful 
ones  are  those  with  ascites.  But  even  in  the  fibrous  form  some  appar- 
ently complete  recoveries  take  place,  the  adhesions  disappearing  by 
absorption  to  a  degree  truly  remarkable.  The  most  unfavorable  cases 
are  those  in  which  there  is  strong  evidence  of  the  breaking  down  of 
tuberculous  deposits,  with  continuous  fever  and  wasting. 

Treatment. — The  general  treatment  of  tuberculous  peritonitis  is  sim- 
ilar to  that  of  tuberculosis  in  other  parts  of  the  body.  The  essentials 
are,  rest,  which  should  be  invariably  in  the  recumbent  position,  a 
climate  mild  enough  to  permit  the  patient  to  remain  out  of  doors  the 
greater  part  of  the  time,  and  very  careful  attention  to  feeding,  with  the 
purpose  of  improving  the  general  nutrition.  Heliotherapy,  or  the  direct 
exposure  of  the  abdomen  to  the  sun's  rays,  has  been  much  vaunted 
as  a  remedy  and  merits  a  trial  as  it  can  be  employed  in  conjunction 
with  the  measures  just  mentioned.  Beginning  with  a  few  minutes' 
exposure  the  time  may  be  gradually  lengthened  to  two  or  three  hours. 
Under  general  treatment  a  very  considerable  number  of  patients  re- 
cover, especially  those  who  are  over  three  years  old.  Such  a  termina- 
tion is  more  likely  if  the  diagnosis  has  been  made  early  and   if  the 


454  DISEASES  OF  THE  DiaESTIVE  SYSTEM 

disease  is  limited  to  tlie  jjeritoneiim.  Drugs  play  but  a  small  part  in 
the  treatment  of  these  cases.  The  value  of  tuberculin  in  tuberculous 
peritonitis  has  not  yet  been  established. 

In  cases  not  progressing  favorably  under  medical  treatment,  the 
question  of  operation  should  be  considered.  This  was  for  a  number 
of  years  a  very  frequent  procedure  and  was  employed  in  almost  all 
cases.  The  results  were  not,  however,  such  as  to  make  it  advisable 
as  a  routine  measure.  Hygienic  treatment  alone  accomplishes  in  gen- 
eral as  much  if  not  more.  In  certain  circumstances,  operation  is 
advisable.  The  most  favorable  cases  are  those  of  the  ascitic  variety. 
It  may  be  useful  also  with  localized  or  general  suppuration  and  for 
the  relief  of  intestinal  obstruction  occurring  in  the  course  of  the  dis- 
ease. Operation  affords  temporary  relief  in  some  cases  when  the  dis- 
tention is  very  great.  In  the  fibrous  form  not  much  is  to  be  expected 
from  it.  Operation  may  be  done  for  the  relief  of  recurring  colicky 
pains  due  presumably  to  constriction  by  bands.  The  existence  of  other 
foci  of  tuberculosis  does  not  contraindicate  operation  except  when  these 
are  chiefly  intestinal,  or  when  there  is  advanced  general  tuberculosis.  In 
deciding  the  question  of  operation,  its  unfavorable  results  should  also  be 
borne  in  mind.  A  not  uncommon  consequence  is  injury  to  the  intestine 
from  the  breaking  up  of  adhesions,  which  may  result  in  fecal  fistulae. 
For  the  surgical  aspect  of  the  treatment  the  reader  should  consult  works 
upon  surgery. 

ASCITES 

Ascites  consists  in  an  accumulation  of  fluid,  usually  clear  serum,  in 
the  general  peritoneal  cavity.  It  is  a  symptom  of  the  various  forms  of 
peritonitis,  especially  the  chronic  varieties  described  in  the  preceding 
pages.  It  may  be  due  also  to  portal  obstruction  from  cirrhosis  of  the 
liver,  or  pressure  upon  the  portal  vein  by  peritoneal  adhesions  or  large 
lymphatic  glands.  It  is  occasionally  seen,  in  all  forms  of  abdominal 
tumors.  Ascites  may  occur  in  general  dropsy  from  cardiac  disease, 
or  from  any  condition  causing  pressure  upon  the  vena  cava.  It  is  also 
seen  in  the  general  dropsy  of  renal  disease.  A  moderate  amount  of 
ascites  is  often  met  with  in  extreme  anemia  or  leukemia. 

Small  accumulations  of  fluid  in  the  peritoneal  cavity  are  difficult  of 
detection.  Large  amounts  are  generally  easily  made  out.  There  is  a 
uniform  smooth  distention  of  the  abdomen  and  dilatation  of  the  super- 
ficial veins,  especially  about  the  umbilicus.  On  palpation,  the  wave  of 
fluctuation  can  be  obtained  by  placing  one  hand  against  the  abdomen 
upon  one  side  and  giving  the  opposite  side  a  sharp  tap.  A  similar  wave 
may  be  felt  when  there  is  tympanitic  distention.     The  two  are,  however, 


SUBPHRENIC  ABSCESS  455 

distinguished  by  having  an  assistant  make  pressure  with  the  edge  of 
the  hand  along  the  linea  alba  while  the  test  is  being  made;  this  ob- 
structs the  wave  transmitted  through  the  abdominal  wall,  but  does  not 
affect  that  through  the  fluid.  On  percussion  in  the  sitting  posture, 
there  is  dulness  below  and  resonance  above.  When  4he  patient  is  recum- 
bent, there  is  resonance  in  the  median  line  and  dulness  or  flatness  in 
the  lateral  portion  of  the  abdomen. 

The  prognosis  and  treatment  of  ascites  will  depend  upon  its  cause. 

Chylous  Ascites. — This  term  is  applied  to  certain  cases  in  which  the 
abdominal  fluid  contains  fat.  The  color  may  be  milky-white  or  light 
brown,  and  the  fluid,  after  standing,  may  have  at  its  surface  a  thick, 
creamy  layer.  The  amount  of  fat  present  has  been  as  high  as  five  per 
cent.  This  condition  is  rare  in  childhood.  The  exact  pathology  is  as 
yet  not  well  understood.  In  the  cases  which  have  thus  far  come  to 
autopsy  there  has  usually  been  found  chronic  peritonitis,  sometimes 
simple,  sometimes  tuberculous.  The  lymph  vessels  in  some  of  the  cases 
have  been  empty,  and  often  no  obstruction  of  the  lymph  circulation 
could  be  discovered.  The  fat  is  believed  by  some  to  be  derived  from 
fatty  degeneration  of  the  products  of  chronic  inflammation,  but  this 
seems  hardly  sufficient  to  explain  the  large  amount  of  fat  sometimes 
found.  In  some  of  the  cases  it  has  been  due  to  a  wound  of  the  thoracic 
duct.  The  amount  of  fluid  is  frequently  very  large.  The  prognosis  is 
usually  bad,  although  Pounds  has  reported  a  case  in  a  girl  of  ten  years, 
where  recovery  followed  laparotomy.  Tuberculous  peritonitis  was 
present. 

SUBPHRENIC  ABSCESS 

In  the  group  of  cases  of  localized  peritonitis  or  peritoneal  abscess, 
must  be  included  subphrenic  abscess.  This  is  a  rare  condition  in  child- 
hood, and  consists  in  an  accumulation  of  pus  just  beneath  the  diaphragm 
and  above  the  liver.  Its  cause  may  be  either  in  the  thorax  or  in  the  ab- 
domen. It  may  complicate  acute  pneumonia,  usually  of  the  right  lower 
lobe,  by  a  direct  extension  of  infection  through  the  lymph  channels. 
Sometimes  it  has  been  associated  with  phthisical  cavities.  In  the  abdo- 
men it  results  from  the  extension  of  some  focus  of  suppuration,  such 
as  an  abscess  around  the  appendix  or  abscess  of  the  liver.  The  accumu- 
lation of  pus  is  sometimes  very  great,  so  that  the  diaphragm  is  crowded 
high  into  the  thorax. 

The  symptoms  and  physical  signs  closely  resemble  those  of  empyema, 
and  most  of  the  cases  have  been  operated  upon  with  the  belief  that  the 
Surgeon  was  dealing  with  empyema.  Meltzer  has  reported  a  case  in  a 
child  of  two  years  which  followed  pneumonia  of  the  right  base.     At  the 


456  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

operation  only  a  few  drops  of  pus  were  found  in  the  pleural  cavity;  but 
there  was  discovered  a  pinhole  opening  in  the  diaphragm,  from  which 
the  pus  had  escaped,  and  a  large  subphrenic  abscess.  This  was  evacu- 
ated, and  the  patient  recovered  perfectly.  Subphrenic  abscesses  may 
contain  air;  they  are  then  likely  to  be  mistaken  for  pneumothorax. 
These  abscesses  require  incision  and  drainage  like  other  forms  of  peri- 
toneal abscess. 


SECTION  lY 
DISEASES  OF  THE  KESPIEATOEY  SYSTEM 

CHAPTEE  I 

NASAL   CAVITIES 

ACUTE  RHINOPHARYNGITIS 

(Acute  Nasal  Catarrh — Coryza) 

Although  the  symptoms  of  acute  nasal  catarrh  are  chiefly  nasal, 
the  principal  seat  of  the  pathological  process  is  the  rhinopharynx. 

Etiology. — Certain  children  are  predisposed  to  attacks  of  acute  nasal 
catarrh.  This  predisposition,  as  it  sometimes  extends  to  entire  fam- 
ilies, may  be  inherited;  but  more  frequently  it  is  acquired,  and  usually 
by  the  following  mode  of  life :  It  is  seen  in  children  who  get  very  little 
fresh  air,  because  they  are  kept  indoors  unless  the  weather  is  perfect; 
who  live  in  houses  always  overheated;  whose  sleeping  rooms  are  kept 
carefully  closed  at  night  for  fear  they  may  take  cold;  who  are  for  the 
same  reason  so  overloaded  with  clothing  that  they  can  not  engage  in 
any  active  play  without  being  thrown  into  a  profuse  perspiration.  These 
conditions  after  a  time  result  in  a  great  sensitiveness  of  all  the  mucous 
membranes,  but  especially  those  of  the  nose  and  pharynx,  which  is  much 
increased  by  residence  in  a  damp,  changeable  climate.  Young  infants 
and  those  who  are  rachitic,  are  frequent  sufferers  from  acute  nasal 
catarrh.  Attacks  are  often  brought  on  by  insufficient  covering  for  the 
head,  by  wetting  the  feet,  by  cold  and  exposure,  especially  to  street  dust 
and  the  raw  winds  of  winter  and  spring,  accompanied  by  the  damp- 
ness which  occurs  with  melting  snow.  In  susceptible  children  the  ex- 
citing cause  is  often  a  very  trivial  one.  A  draught  of  cold  air  for  a 
few  minutes  may  be  sufficient  to  excite  sneezing  and  a  nasal  discharge. 
Atmospheric  conditions  are  probably  not  the  only  cause  of  acute  nasal 
catarrh.  Microorganisms  certainly  play  an  important  part.  The 
staphylococcus,  streptococcus  and  pneumococcus  are  commonly  found 
associated  with  this  condition,  much  less  frequently  the  influenza  bacillus. 

457 


458  DISEASES  OF  THE  RESPTKATOEY  SYSTEM 

Eecent  observations  of  Timnicliff  showed  the  presence  of  a  new  organism 
called  the  "bacillus  rhinitis"  in  98  per  cent  of  the  cases  of  acute  rhinitis 
studied  and  in  66  per  cent  it  was  the  only  organism  present.  It  is  a 
Gram-negative  anaerobic  bacillus.  Acute  catarrh  may  be  sporadic  or 
epidemic ;  certain  forms  are  contagious,  being  communicated  by  children 
using  the  same  handkerchief,  occupying  the  same  bed  or  simply  by 
close  contact. 

Acute  nasal  catarrh  may  be  a  symptom  of  measles,  nasal  diphtheria, 
or  influenza,  and  it  may  accompany  erysipelas  of  the  face. 

Symptoms. — In  the  mild  form  the  changes  in  the  mucous  membrane 
of  the  nose  are- not  great,  and  are  usually  secondary  to  those  of  the 
rhinopharynx,  being  in  a  large  measure  due  to  the  discharge.  There  is 
redness  and  slight  swelling.  The  nasal  passages  may  be  for  the  time 
quite  occluded  by  the  discharge,  which  is  usually  profuse,  at  first  sero- 
mucous,  and  later  mucopurulent.  The  symptoms  may  be  very  transient, 
sometimes  passing  away  in  a  few  hours,  in  which  case  there  is  only  a 
vasomotor  disturbance;  or  they  may  continue  and  develop  into  a  true 
inflammation.  The  discharge  may  excoriate  the  nostrils  and  the  upper 
lip.  At  the  onset  there  is  usually  sneezing,  and  in  infants  often  a  slight 
fever. 

In  older  children  there  is  no  rise  of  temperature  except  in  the 
most  severe  cases.  The  obstruction  to  nasal  respiration  causes  mouth- 
breathing,  and  the  dryness  and  discomfort  which  result  from  it  produce 
disturbed  sleep,  snuffling  and  difficulty  in  nursing,  this  being  in  severe 
cases  almost  impossible.  The  inflammation  may  extend  to  the  lachrymal 
duct,  involving  the  eyes  in  a  mild  conjunctivitis.  The  process  often 
extends  to  the  larynx  and  bronchi,  with  hoarseness  and  cough.  There 
may  be  closure  of  the  Eustachian  tubes,  causing  deafness  and  otalgia. 
The  chief  complication  for  which  the  physician  should  watch  is  otitis. 

The  severe  form  in  infants  is  often  attended  by  marked  constitutional 
symptoms;  the  temperature  may  be  as  high  as  104°  or  105°  F.  and  some- 
times fluctuates  widely.  The  discharge  soon  becomes  mucopurulent  and 
is  very  profuse,  pouring  from  the  anterior  nares  and  filling  the  pharynx. 
The  cultures  in  this  form  frequently  show  the  pneumococcus.  Severe 
symptoms  often  continue  for  a  week  or  more,  the  child  being  seriously 
ill.  Complications  are  almost  always  present.  In  most  cases  there  is 
cervical  adenitis  and  otitis.  If  the  child  is  a  delicate  one  bronchopneu- 
monia is  apt  to  develop.  Eetropharyngeal  abscess  is  not  infrequently 
seen. 

Dia^osis. — ^It  is  important  to  distinguish  between  a  simple  acute 
catarrh  and  one  due  to  measles,  influenza,  nasal  diphtheria,  or  hereditary 
syphilis.  Measles  and  influenza  usually  cause  more  fever  and  general 
constitutional  disturbance  than  does  simple  catarrh.     Nasal  diphtheria 


ACUTE  RHINOPHARYNGITIS  459 

may  be  ptesent  when  there  is  only  a  profuse  discharge  tinged  with  blood. 
When  such  a  discharge  persists  for  two  or  three  weeks  this  is  always  to 
be  suspected,  even  though  the  constitutional  symptoms  may  be  very 
slight.  The  only  positive  means  of  excluding  diphtheria  is  by  cultures. 
A  persistent  acute  nasal  catarrh  in  a  young  infant  should  always  sug- 
gest syphilis,  and  the  patient  should  be  carefully  watched  for  the  de- 
velopment of  other  symptoms. 

Treatment.— A  young  child  suffering  from  acute  coryza  should  be 
kept  indoors  in  a  room  with  an  even  temperature  of  about  70°  F.,  the 
bowels  freely  opened,  and  the  amount  of  food  somewhat  reduced.  The 
only  drug  which  seems  to  have  much  influence  upon  the  secretion  is 
belladonna. 

Useful  local  applications  are  liquid  albolene,  oleostearate  of  zinc,  or 
alkaline  sprays,  such  as  Seller's  solution,  to  clear  away  the  secretions. 
If  the  nasal  obstruction  causes  great  interference  with  respiration  or 
nursing,  epinephrin  diluted  with  a  saline  solution  may  be  used  with  a 
medicine  dropper. 

The  upper  lip  and  nostrils  should  be  protected  by  vaseline  or  some 
simple  ointment.  Under  no  circumstances  should  irritating  or  astrin- 
gent injections  be  given.  In  older  ^children  inhalations  of  spirits  of 
camphor  may  be  used  with  some  advantage. 

The  severe  cases  require  more  active  treatment.  For  most  of  them 
nasal  irrigation  with  a  warm  saline  solution  is  to  be  advised.  This 
should  be  done  as  in  diphtheria.  After  cleansing  the  rhinopharynx  a 
few  drops  of  a  five-per-cent  solution  of  argyrol  may  be  dropped  into  the 
nostrils  two  or  three  times  daily. 

Prophylaxis  consists  in  solving  the  perplexing  question,  so  often 
put  to  the  physician,  of  how  to  i^revent  children  from  "taking  cold." 
This  is  a  matter  of  the  utmost  importance,  and  follows  what  has  been 
previously  said  under  the  head  of  Etiology.  No  amount  of  cod-liver  oil 
and  iron  will  remove  this  tendency  to  catarrh  so  long  as  bad  hygienic 
conditions  continue.  Sleeping  rooms  should  be  large  and  well  ventilated, 
and  a  window  should  be  kept  open  at  night,  except  in  very  severe  weather 
or  during  acute  attacks.  The  temperature  of  the  house  during  the  day 
should  be  kept  from  65°  to  68°  F.,  but  not  above  this.  Children  should 
be  accustomed  to  go  out  of  doors  unless  the  weather  is  especially  bad. 
So  firmly  rooted  in  the  minds  of  the  laity  is  the  idea  that  acute  catarrhs 
come  from  cold,  that  the  habit  of  coddling  delicate  children  is  always 
likely  to  be  carried  to  an  extreme. 

With  every  delicate  and  "catarrhal"  child  one  should  begin  in  the 
summer  by  having  him  live  in  the  open  air  as  much  as  possible,  sleep- 
ing in  a  room  with  free  ventilation,  with  moderate  covering,  and  con- 
tinuing the   same  practice  into  the  fall  and  early  winter.     If  begun 


460  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

gradually  in  this  way  there  is  little  difficulty  in  continuing  throughout 
the  winter; 

The  next  point  to  be  iijsisted  on  is  cold  sponging  immediately  upon 
rising  in  the  morning,  especially  about  the  chest,  throat,  and  spine.  The 
use  of  chest  protectors,  cotton  pads,  and  extremely  thick  clothing  should 
be  prohibited.  Woolen  underclothing  should  be  worn  upon  the  chest 
throughout  the  year,  and  upon  the  legs  also  in  winter ;  the  very  lightest 
in  summer,  and  only  a  medium  weight  in  winter. 

Frequently  repeated  attacks  point  to  the  presence  of  adenoid  vegeta- 
tions in  tiie  pharynx,  and  no  measures  are  of  much  avail  until  these 
are  removed. 

CHRONIC  NASAL  CATARRH 

This  term  is  rather  loosely  used  to  designate  a  chronic  nasal  dis- 
charge. Such  a  discharge  is  common  both  in  infancy  and  childhood. 
It  is  a  condition  frequently  neglected  by  jDhysicians.  Patients  are  too 
often  subjected  to  routine  constitutional  treatment  by  cod-liver  oil  and 
preparations  of  iodin,  with  the  idea  that  such  cases  are  "scrofulous," 
while  local  treatment  is  either  neglected  altogether,  or  consists  only  of 
the  use  of  the  nasal  douche  or  syringing  Avith  a  saline  solution.  Perma- 
nent damage  to  the  organs  of  hearing,  smell,  speech,  and  respiration  may 
result  from  neglecting  or  ignoring  chronic  nasal  catarrh  in  childhood. 

Chronic  nasal  catarrh  is  not  to  be  regarded  as  a  disease,  but  only  as 
a  symptom  which  may  be  due  to  any  one  of  a  variety  of  pathological 
conditions,  each  of  which  requires  very  different  treatment,  viz.,  adenoid 
growths  of  the  pharynx,  foreign  bodies  in  the  nose,  polypi,  deviation 
of  the  septum  or  any  other  congenital  deformity  of  the  nasal  passages, 
the  various  forms  of  chronic  rhinitis,  and  syphilis,  which  causes  a  form 
of  rhinitis  peculiar  to  itself. 

Adenoid  Growths  of  the  Pharynx. — These  are  more  fully  discussed 
elsewhere.  They  are  by  far  the  most  frequent  cause  of  chronic  nasal 
discharge  in  infants  and  young  children,  and  should  be  first  sus- 
pected. The  nasal  discharge  accompanying  adenoid  growths  is  due  to 
a  chronic  rhinopharyngitis.  Treatment  is  without  avail  unless  the 
growths  are  removed.  After  this  is  done  the  nasal  discharge  usually 
disappears  quite  promptly. 

Foreign  Bodies  in  the  Nose. — This  condition  should  be  suspected 
whenever  there  is  an  abundant  mucopurulent  discharge  limited  to  one 
nostril.  Foreign  bodies  in  the  nose  are  quite  frequent  in  young  children. 
Peas,  beans,  beads,  or  shoe  buttons  are  most  frequently  lodged  there. 
The  efforts  at  removal  on  the  part  of  the  child,  or  the  parents,  gen- 
erally result  in  pushing  the  body  farther  into  the  nose.     It  first  sets' 


CHRONIC  RHINITIS  461 

up  a  mechanical  irritation,  accompanied  by  pain,  swelling,  sneezing,  and 
sometimes  hemorrhage.  This  is  followed  by  a  catarrhal  inflammation 
which  in  the  course  of  a  few  days  becomes  purulent  and  may  last  in- 
definitely. The  discharge  is  generally  quite  abundant.  The  symptoms 
point  to  an  obstruction  of  one  nostril,  and  an  examination  with  a  probe 
readily  detects  the  presence  of  the  foreign  body. 

In  recent  cases  the  removal  of  the  foreign  body  may  sometimes  be 
accomplished  by  compressing  the  empty  nostril  and  having  the  child 
blow  his  nose  strongly.  Often  the  sneezing  which  the  foreign  body  ex- 
cites is  sufficient  to  remove  it.  Before  any  attempt  is  made  to  seize  the 
body  with  forceps,  cocain  should  be  used,  not  only  for  the  purpose  of 
preventing  pain,  but  in  order  to  contract  the  mucous  membrane  so  as  to 
allow  better  manipulation.  In  many  cases  general  anesthesia  is  neces- 
sary. In  most  circumstances  ordinary  foreign  bodies  can  with  proper 
forceps  be  extracted  without  difficulty.  No  subsequent  treatment  is  re- 
quired, except  the  use  of  some  mild  antiseptic  to  keep  the  nose  clean  for 
a  few  days,  as  the  inflammation  quickly  subsides  after  the  removal  of 
the  cause. 

Nasal  Polypi. — These  are  among  the  infrequent  causes  of  chronic 
nasal  discharge  in  childhood.  They  are  especially  rare  before  the  seventh 
year,  but  both  mucous  and  fibrous  polypi  are  seen.  The  symptoms  are 
those  of  a  chronic  nasal  catarrh  with  partial  or  complete  obstruction  of 
one  or  both  sides.  Polypi  increase  in  size  with  the  occurrence  of  every 
acute  coryza,  and  are  always  especially  troublesome  in  damp  weather. 
They  may  be  accompanied  by  reflex  symptoms,  such  as  cough,  sneezing, 
and  even  by  attacks  of  asthma.  There  may  be  headache,  and  sometimes 
disturbances  of  smell,  taste,  and  hearing.  The  symptoms  are  of  much 
longer  duration  than  in  the  case  of  obstruction  from  a  foreign  body,  the 
discharge  is  not  so  abundant,  and  is  not  purulent.  The  diagnosis  is 
made  only  by  local  examination. 

Polypi  may  be  removed  with  the  forceps,  but  this  is  best  accomplished 
by  the  use  of  the  wire  snare.  When  they  have  been  present  for  a  long 
time  the  accompanying  chronic  rhinitis  may  require  subsequent 
treatment. 

Deviation  of  the  nasal  septum,  and  other  congenital  deformities 
which  may  cause  narrowing  of  the  nasal  respiratory  tract,  are  conditions 
which  belong  to  the  specialist. 


CHRONIC  RHINITIS 

Simple  Chronic  Rhinitis. — ^Simple  chronic  rhinitis  existing  alone  is 
of  rare  occurrence  in  young  children.    In  the  cases  so  classed  the  symp- 


462  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

toms  are  usually  due  to  rhinopharyngitis,  which  almost  invariably  de- 
pends upon  adenoid  growths.  The  growth  may  be  a  small  one,  so  that 
the  sym]3toms  of  obstruction  are  slight  or  absent.  A  frequent  com- 
plication is  chronic  enlargement  of  the  cervical  lymph  nodes. 

The  only  constant  symptom  is  an  excessive  nasal  discharge  which  is 
usually  mucous  but  which  may  be  mucopurulent.  It  is  easily  removed 
by  blowing  the  nose  if  the  child  is  old  enough  to  be  taught  to  do  this. 
Children  too  young  to  clear  the  nose  in  this  way  suffer  from  almost  con- 
stant discomfort.  The  amount  of  discharge  depends  upon  the  severity  of 
the  case.  It  frequently  causes  irritation  of  the  upper  lip,  which  may  be 
the  seat  of  eczema  or  impetigo,  especially  in  infants.  The  lip  may  be 
swollen  and  prominent.  The  condition  of  the  external  parts  is  aggra- 
vated by  the  constant  disposition  to  pick  the  nose,  which  may  be  over- 
come by  the  application  of  a  short  anterior  splint  to  each  elbow. 

Epistaxis  sometimes  occurs.  The  duration  of  the  disease  is  indefi- 
nite ;  it  may  last  for  months  or  even  for  years,  the  symptoms  in  summer 
being  insignificant,  but  returning  every  cold  season.  It  may  terminate, 
in  recovery,  or,  in  children  with  flabby  tissues  and  delicate  constitution, 
it  may  be  followed  in  later  childhood  by  hypertrophic  rhinitis. 

Treatment. — Prophylaxis  is  important.  The  main  purpose  should 
be  to  prevent  attacks  of  acute  nasal  catarrh  by  the  measures  mentioned 
in  the  discussion  of  that  disease.  The  general  treatment  should  not  be 
routine,  but  based  upon  the  indications  of  each  case.  General  tonic 
treatment  is  required  in  most  cases. 

Local  treatment  consists  first  in  cleanliness,  and,  secondly,  in  the  use 
of  astringents.  In  infants,  if  the  discharge  is  abundant,  an  efficient 
method  of  getting  rid  of  it  is  by  nasal  syringing.  This  is  attended 
by  some  risk  of  forcing  materials  into  the  middle  ear ;  but  if  very  care- 
fully done,  the  danger  seems  to  be  less  than  that  of  allowing  the  dis- 
charge to  remain.  All  solutions  are  to  be  made  with  sterile  water  and 
used  warm,  either  with  a  nasal  douche  or  syringe.  ISTo  force  should 
be  employed.  Either  Dobell's  or  Seller's  solution  may  be  employed, 
diluted  with  an  equal  amount  of  water.  Eecently  there  have  been  intro- 
duced several  devices  for  removing  abundant  secretion  by  means  of 
suction,  which  obviate  the  risks  attendant  upon  the  syringe  and  are 
even  more  efficient.  Ordinarily,  the  nose  should  be  cleansed  thoroughly 
twice  a  day,  more  frequently  in  very  severe  cases.  Harm  is  often  done 
by  the  overzealous  use  of  local  treatment  in  these  conditions. 

Syphilitic  Rhinitis. — Ehinitis  is  seen  both  in  early  and  late  hered- 
itary syphilis.  Coryza,  or  snuffles,  is  one  of  its  earliest  and  most  con- 
stant symptoms.  It  usually  begins  between  the  third  and  sixth  weeks 
of  life,  rarely  after  the  third  month.  The  pathological  condition  is  a 
subacute  catarrhal  rhinitis,  sometimes  with  the  formation  of  superficial 


EPTSTAXIS  463 

ulcers  or  mucous  patches.  The  disease  is  usually  attended  by  a  profuse 
nasal  discharge  of  seromucus  or  mucopus,  occasionally  tinged  with  blood. 
It  may  continue  from  a  few  weeks  to  two  or  three  months.  It  usually 
requires  only  constitutional  treatment  and  protection  of  the  nostrils 
and  lips  by  the  use  of  the  ointment  of  the  yellow  oxid  of  mercury 
diluted  with  four  parts  of  vaseline.  When  the  discharge  is  very  abun- 
dant any  one  of  the  cleansing  solutions  previously  mentioned  may  be 
used  as  a  spray. 

The  rhinitis  of  late  hereditary  syphilis  is  a  very  different  patholog- 
ical condition.  There  are  here  gummatous  deposits  which  break  down, 
and  form  ulcers  of  the  mucous  membrane  and  deeper  tissues.  There  is 
also  periostitis,  with  extension  of  the  disease  to  the  cartilages  and  bones 
of  the  nasal  fossae,  particularly  of  the  septum.  There  may  be  perfora- 
tion of  the  triangular  cartilage,  necrosis  of  the  vomer  or  nasal  bones, 
perforation  of  the  hard  or  soft  palate,  and  at  times  extensive  ulceration 
of  the  alae  nasi  and  the  face.  Cicatrization  may  follow,  causing  stenosis 
of  the  nostril.  These  lesions  in  the  nose  are  generally  accompanied  by 
deep  ulceration  of  the  pharynx  and  soft  palate.  They  usually  occur  in 
children  who  have  presented  the  early  symptoms  of  hereditary  syphilis, 
but  are  occasionally  seen  when  no  such  history  can  be  obtained.  Such 
was  the  case  in  a  patient  recently  under  observation  in  the  Babies'  Hos- 
pital, who  had  perforation  of  the  nasal  septum  and  of  the  floor  of  the 
nasal  fossae,  causing  a  free  communication  with  the  mouth.  These  are 
cases  of  true  ozena.  The  odor  from  the  discharge  is  at  times  almost 
intolerable.  When  neglected  these  cases  go  on  from  bad  to  worse 
and  may  continue  for  years,  producing  unsightly  deformities. 

The  constitutional  treatment  is  that  of  hereditary  syphilis  in  gen- 
eral and  is  discussed  in  the  chapter  upon  that  disease. 

Locally  there  may  be  used  a  spray  of  one  of  the  cleansing  solutions 
already  mentioned,  or  black  wash,  or  a  solution  of  bichlorid  of  mercury, 
1  to  10,000.  Although  improvement  may  take  place  quite  promptly,  the 
results  of  treatment  in  the  late  cases  are  often  unsatisfactory,  as  the 
disease  has  usually  progressed  so  far  before  treatment  is  begim  that 
some  deformity  of  the  nose  results,  usually  a  sinking  in  of  the  bridge 
and  flattening  of  the  alae.  giving  rise  to  the  so-called  "saddle-back" 
deformity. 

EPISTAXIS 

The  hemorrhage  may  come  from  any  part  of  the  nasal  fossae,  but  it 
is  generally  from  the  anterior  nares,  and  most  frequently  from  the  ves- 
sels of  the  septum.  Epistaxis  is  a  rare  symptom  in  the  hemorrhages  of 
the  newly  born,  and  when  present  suggests  syphilis.     It  is  infrequent 


464  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

throughout  infancy,  but  in  childhood  it  is  quite  common,  occurring  in 
boys  more  frequently  than  in  girls.  In  the  latter  it  is  especially  common 
about  the  time  of  puberty.  Children  who  are  kept  much  indoors  in 
overheated  apartments,  and  who  have  susceptible  mucous  membranes  and 
flabby  tissues,  are  particularly  prone  to  it.  The  exciting  cause  may  be  a 
local  one,  like  a  fall  or  blow;  epistaxis  may  be  due  to  picking  the  nose, 
or  to  any  kind  of  mechanical  irritation;  it  may  be  associated  with  nasal 
catarrh;  and  it  is  often  caused  by  a  small  ulcer  upon  the  septum.  An 
attack  may  be  brought  on  by  mental  or  physical  excitement.  It  occurs 
as  an  occasional,  often  an  early  symptom,  in  typhoid  or  malarial  fever, 
in  measles,  or  during  severe  paroxysms  of  pertussis.  It  is  seen  in  the 
hemorrhagic  form  of  all  the  eruptive  fevers,  in  certain  cases  of  diph- 
theria, in  hemophilia  and  scorbutus,  in  grave  anemia,  leukemia,  and  in 
diseases  of  the  heart  and  blood  vessels. 

Symptoms. — Epistaxis  is  frequently  preceded  by  a  sense  of  fulness  or 
pain  in  the  head,  which  is  relieved  by  the  bleeding.  The  blood  is  usually 
from  one  nostril,  and  comes  slowly  by  drops.  The  amount  lost  is  gen- 
erally small,  but  it  may  be  large  enough,  when  repeated,  to  produce  a 
serious  grade  of  anemia  even  in  strong  children;  the  hemorrhage  may 
even  prove  fatal.  Epistaxis  may  be  overlooked  if  the  blood  finds  its 
way  into  the  pharynx  and  is  swallowed.  In  most  of  the  cases  the  hemor- 
rhage ceases  spontaneously  in  from  ten  to  twenty  minutes,  recurring  at 
longer  or  shorter  intervals,  according  to  the  nature  of  the  cause.  Hem- 
orrhage from  adenoid  growths  of  the  pharynx  may  closely  resemble  that 
from  the  nose,  but  otherwise  there  can  rarely  be  any  difficulty  in  recog- 
nizing epistaxis. 

Prognosis. — This  depends  upon  the  cause.  In  the  great  majority  of 
the  so-called  idiopathic  cases  epistaxis  is  not  serious.  Occurring  early  in 
the  course  of  one  of  the  infectious  diseases,  it  does  not  ordinarily  affect 
the  prognosis  unless  it  is  very  severe.  When  it  occurs  late,  however,  it 
is  always  a  bad  sign,  and  particularly  so  in  diphtheria.  It  may  be 
serious  in  any  of  the  hemorrhagic  diseases  or  in  diseases  of  the  blood, 
when  it  is  not  infrequently  a  cause  of  death. 

Treatment. — To  remove  the  predisposition,  a  child  should  receive 
general  tonic  treatment,  especially  plenty  of  outdoor  exercise,  and  every 
means  should  be  taken,  by  the  use  of  cold  baths,  friction,  and  proper 
food,  to  tone  up  the  vascular  system. 

An  efficient  means  of  arresting  the  hemorrhage  is  compression  of  the 
nose  between  the  thumb  and  finger.  This  may  be  combined  with  the 
application  of  ice  over  the  nose,  and  sometimes  small  pieces  of  ice  may 
be  introduced  into  the  nostrils.  The  application  of  cold  to  the  back  of 
the  neck  or  its  use  in  the  mouth  may  be  of  service  by  exciting  reflex 
contraction  of  the  capillary  vessels.     All  tight  clothing  or  bands  about 


CATARRHAL  SPASM  OF  THE  LARYNX  465 

the  neck  should  be  loosened,  and  the  patient  kept  quiet  in  the  sitting 
jposture.  After  the  hemorrhage  has  ceased  the  child  should  not  blow 
his  nose  for  some  time.  Epinephrin  is  one  of  the  most  efficient  local 
means  of  checking  the  bleeding.  Another  valuable  remedy  is  the  peroxid 
of  hydrogen,  used  full  strength.  If  bleeding  continues  in  spite  of  all 
the  above  measures,  the  anterior  nares  should  be  plugged,  and  if  this 
does  not  control  it,  the  posterior  nares  should  be  plugged.  Usually  very 
little  effect  is  seen  from  drugs  given  internally,  although  in  frequently 
recurring  hemorrhages  where  no  local  cause  can  be  discovered,  calcium 
lactate  should  be  tried ;  from  thirty  to  sixty  grains  a  day  should  be  given 
to  a  child  of  five  years. 

The  subcutaneous  use  of  horse  serum  often  has  a  very  decided  effect 
in  controlling  these  hemorrhages  which  do  not  yield  readily  to  the  usual 
treatment.  From  20  to  30  c.c.  may  be  given  to  a  child  of  five  years  and 
repeated  every  few  hours  if  bleeding  continues.  Human  serum  is  even 
more  efficacious.  In  very  severe  hemorrhages  transfusion  may  be  neces- 
sary. In  severe  cases  of  nasal  hemorrhage  recurring  at  short  intervals 
without  any  apparent  cause,  ulcer  of  the  septum  should  be  suspected, 
and,  if  present,  should  be  touched  with  chromic  acid. 


CHAPTER  II 

DISEASES  OF   THE  LARYNX 

The  characteristic  feature  of  laryngeal  disease  in  infants  and  young 
children  is  the  association  of  muscular  spasm  with  every  form  of  inflam- 
mation. Often  it  is  the  laryngeal  spasm,  rather  than  the  inflamma- 
tion, which  gives  rise  to  the  principal  symptoms.  This  spasm  is  only  one 
expression  of  the  great  reflex  irritability  of  young  children. 

CATARRHAL  SPASM  OF  THE  LARYNX 

(Spasmodic  Laryngitis;  Spasmodic  Croup;  Catarrhal  Croup) 

The  term  catarrhal  spasm  is  fairly  descriptive  of  this  disease,  which 
is  characterized  by  a  very  mild  degree  of  catarrhal  inflammation  asso- 
ciated with  marked  laryngeal  spasm. 

Etiology. — It  is  not  often  seen  during  the  first  six  months,  but  is 
frequent  from  this  time  up  to  the  third  year.  After  five  years  it  is  rare. 
It  occurs  rather  oftener  in  children  who  are  well  nourished.    Certain  chil- 


466  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

clren  have  a  predisposition  to  such  attacks,  those  who  have  had  one  attack 
are  likely  to  have  others.  The  condition  has  many  jioints  of  resemblance 
to  spasmodic  asthma  which  may  replace  it  in  later  childhood.  Heredity 
seems  to  have  some  influence  in  producing  this  extreme  susceptibility  of 
the  air  passages.  Catarrhal  spasm  of  the  larynx  is  very^  frequently  asso- 
ciated with  enlarged  tonsils  and  adenoid  growths  of  the  pharynx,  some- 
times with  an  elongated  uvula.  The  exciting  cause  may  be  exposure  to 
cold,  especially  to  high  winds,  or  an  attack  of  indigestion.  There  is  no 
doubt  that  catarrhal  spasm  of  the  larynx  is  seen  at  the  present  time 
much  less  frequently  than  formerly;  the  reason  for  this  is  not  clear. 

Lesions. — The  catarrhal  inflammation  of  the  larynx  affects  chiefly 
the  parts  above  the  cords;  there  is  congestion  and  dryness,  and  later 
increased  secretion  of  mucus.  To  this  there  is  added  a  spasm  of  the 
muscles  of  the  larynx.  There  is  no  submucous  infiltration,  and  no 
tendency  to  edema  of  the  glottis. 

Symptoms. — The  attack  may  be  preceded  for  several  hours  by  slight 
hoarseness,  or  by  a  nasal  discharge.  During  the  day  the  child  may 
appear  perfectly  well.  Usually  there  is  heard  during  the  evening  a 
hollow,  barking  cough,  at  first  infrequent  and  not  severe.  About  mid- 
night this  is  apt  to  increase  in  severity,  and  there  is  now  difficulty  in 
breathing.  As  soon  as  this  becomes  marked  the  child  wakes,  and  presents 
the  characteristic  symptoms  of  an  attack.  In  the  mild  cases  the  dyspnea 
is  not  sufficient  to  waken  the  child.  In  severe  cases  there  is  marked 
dyspnea,  especially  on  inspiration,  and  a  loud  stridor  as  the  air  is  drawn 
through  the  narrowed  opening  of  the  glottis.  This  may  often 
be  heard  in  an  adjoining  room.  There  is  seen  on  inspiration  deep 
recession  of  the  suprasternal  fossa,  the  supraclavicular  spaces,  and  the 
epigastrium;  also  depression  of  the  intercostal  spaces,  and  even  of  the 
walls  of  the  chest.  Any  excitement  increases  the  spasm  and  aggravates 
the  dyspnea.  The  distress  may  be  great;  the  breathing  usually  slow 
and  labored;  the  voice  hoarse,  but  rarely  lost;  the  cough  stridulous, 
hoarse,  and  metallic ;  the  pulse  rapid ;  the  temperature  normal  or  slightly 
elevated,  rarely  over  101°  F.  There  may  be  slight  lividity  of  the  finger- 
tips and  of  the  lips,  and  sometimes  considerable  prostration.  In  the 
course  of  three  or  four  hours  the  attack  slowly  wears  away  and  the  child 
falls  asleep.  During  the  following  day,  aside  from  slight  hoarseness 
and  occasional  cough,  he  is  apparently  well.  Most  of  the  cases  are 
not  so  severe  as  this ;  there  are  the  croupy  cough ,  the  hoarseness  and  gen- 
eral discomfort,  but  not  marked  dyspnea.  On  the  second  night  there 
is  a  repetition  of  the  experience  of  the  first,  usually  quite  as  severe 
unless  affected  by  treatment;  and  on  the  third  day  a  remission  similar 
to  that  of  the  day  previous.  On  the  third  night  the  attack,  if  it  occurs 
at  all,  is  generally  a  mild  one.     Slight  hoarseness  persists  for  several 


CATARRHAL  SPASM  OF  THE  LARYNX  467 

days,  but  otherwise  the  child  is  apparently  well.  Many  children  have 
such  attacks  every  few  weeks  in  the  course  of  the  cold  season,  the  slight- 
est exposure  or  an  indiscretion  in  diet  being  sufficient  to  induce  one. 

Prognosis. — This  is  good,  the  disease  never  proving  fatal,  although 
nothing  is  more  alarming,  at  least  to  parents,  than  to  witness  for  the 
first  time  one  of  these  severe  attacks  of  catarrhal  croup. 

Diagnosis. — Catarrhal  spasm  may  be  confounded  with  laryngismus 
stridulus,  acute  catarrhal  laryngitis  or  with  membranous  croup.  Laryn- 
gismus stridulus  occurs  only  in  infancy.  In  it  there  is  not  simply  stridu- 
lous  breathing,  but  periods  of  complete  arrest  of  respiration.  These 
may  be  repeated  many  times  during  the  day.  and  may  continue  for 
weeks,  being  often  complicated  by  carpopedal  spasm,  sometimes  by  gen- 
eral convulsions. 

From  acute  catarrhal  laryngitis  and  membranous  laryngitis,  catar- 
rhal spasm  is  distinguished  by  its  sudden  onset,  the  mildness  of  the 
symptoms  of  inflammation,  the  spasmodic  character  of  the  dyspnea,  and 
the  daily  remissions.  The  history  of  previous  attacks  will  often  aid 
in  diagnosis.  In  case  of  doubt,  a  positive  diagnosis  can  often  be  made 
by  allowing  the  child  to  inhale  a  little  chloroform.  This  at  once  relieves 
dyspnea  due  to  spasm,  while  it  has  scarcely  any  effect  upon  that  due  to 
inflammation  or  membrane. 

Treatment. — The  purpose  of  treatment  during  the  attack  is  to  pro- 
duce relaxation  of  the  laryngeal  spasm.  This  is  accomplished  by  the  use 
of  emetics,  steam,  and  hot  fomentations  over  the  larynx.  To  produce 
vomiting,  ipecac  is  the  safest  drug.  This  may  be  given  in  the  form 
of  the  syrup,  one-half  teaspoonful  every  ten  or  fifteen  minutes  to  a 
child  of  two  years  until  vomiting  occurs,  or  it  may  be  combined  with 
ten  or  fifteen  drops  of  the  wine  of  antimony.  The  latter  should  not 
be  repeated  more  than  once  or  twice  as  it  may  produce  serious  depres- 
sion. When  given  at  longer  intervals  these  remedies  are  useful  in  relax- 
ing spasm  without  causing  emesis. 

Emetics  have  a  double  value  if  the  attack  is  due  to  indigestion.  If 
there  is  constipation,  an  enema  should  be  given.  Following  the  free 
vomiting  there  is  generally  some  improvement  in  .the  symptoms,  but 
there  may  be  a  recurrence  of  the  spasm  unless  other  means  are  em- 
ployed. To  prevent  this,  antipyrin  is  one  of  the  most  useful  drugs. 
One  grain  may  be  given  to  a  child  one  year  old.  This  may  be  repeated 
every  two  hours  if  necessary.  Quite  as  much  relief  as  that  obtained  from 
the  drugs  mentioned  is  seen  from  the  use  of  steam  inhalations.  For 
this  purpose  the  child  should  be  placed  in  a  closed  tent,  and  steam  intro- 
duced from  a  croup  kettle.  This  may  be  used  in  conjunction  with  other 
measures,  and  continued  as  long  as  necessary.  Poultices  or  hot  fomen- 
tations over  the  larynx  are  also  useful.     In  one  case  in  which  severe 


468  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

spasm  had  recurred  for  eight  successive  nights  in  spite  of  everything 
that  was  tried^  the  child  being  in  great  distress  from  the  dyspnea, 
intubation  was  performed  with  instant  relief.  Tracheotomy,  however, 
would  scarcely  be  advisable. 

During  the  day  following  the  first  night  attack,  the  child  should 
be  kept  in  a  warm  room,  and  it  is  well  to  continue  the  ipecac  in  doses 
too  small  to  produce  vomiting.  After  6  p.m.  the  doses  should  be  doubled, 
and  at  bedtime  two  grains  of  antipyrin  given.  If  so  treated,  the  symp- 
toms may  not  recur  upon  the  second  night,  or  there  may  be  only  the 
cough  without  the  severe  dyspnea.  The  child  should  be  confined  to 
the  house  for  two  or  three  days  after  one  of  these  attacks,  the  drugs  be- 
ing gradually  reduced;  but  the  antipyrin  should  be  given  at  bedtime 
for  three  or  four  successive  nights. 

To  prevent  a  repetition  of  the  attacks  and  remove  the  tendency  to 
them,  it  is  most  important  that  the  child  should  have  plenty  of  fresh  air 
and  cold  bathing,  especially  cold  sponging  about  the  neck  and  chest. 
Everything  which  experience  has  shown  to  bring  on  the  attack  should  be 
carefully  avoided.  Local  causes,  such  as  adenoid  growths  and  hyper- 
trophied  tonsils,  should  receive  appropriate  treatment.  Generally  it  is 
not  necessary  to  exclude  fresh  air  from  the  sleeping  room.  Although  an 
open  window  on  a  cold,  damp  night  may  sometimes  excite  an  attack, 
plenty  of  fresh-  air  regularly  given  tends  rather  to  diminish  the  suscep- 
tibility. If  the  child's  condition  is  poor,  general  tonic  treatment  is  to 
be  employed. 

ACUTE  CATARRHAL  LARYNGITIS 

Acute  laryngitis  is  not  so  frequent  as  the  disease  just  described, 
although  it  is  much  more  severe,  and  may  even  be  fatal.  It  occurs  espe- 
cially in  children  from  one  to  five  years  of  age,  usually  in  the  cold 
season.  Predisposition  to  attacks  is  induced  by  the  same  conditions  as 
in  the  case  of  acute  rhinitis.  Catarrhal  laryngitis  may  be  primary,  when 
it  is  usually  excited  by  cold  or  exposure,^  or  it  may  be  secondary  to 
measles,  influenza,  scarlet  fever,  or  other  infectious  diseases.  It  may 
also  be  of  traumatic  origin,  from  the  inhalation  of  steam  or  irritating 
gases. 


'  The  following  case  is  a  good  illustration  of  a  severe  attack  excited  by  cold : 
A  rather  delicate  infant,  eight  months  old,  was  taken  out,  with  very  scanty 
covering,  on  a  raw  December  day.  In  a  few  hours  hoarseness  and  stridor  were 
noticed,  and  the  temperature  was  101°  F.;  three  hours  later  it  was  103°  F., 
and  in  spite  of  the  usual  remedies  which  were  employed  the  dyspnea  had  reached 
such  a  degree  as  to  require  intubation.  The  tube  was  worn  only  three  days 
and  the   child  made  a  prompt  recovery. 


ACUTE  CATARRHAL  LARYNGITIS  469 

Lesions. — There  is  a  moderately  intense  congestion  of  the  laryngeal 
mucous  membrane,  sometimes  general  and  sometimes  localized.  This 
may  be  seen  with  the  laryngoscope,  but  is  not  always  visible  after  death. 
With  the  congestion  there  are  swelling  and  dryness,  followed  by  increased 
secretion.  In  the  milder  cases  the  process  is  limited  to  the  mucosa.  In 
the  more  severe  cases  it  involves  the  submucosa  also,  which  is  congested, 
edematous,  and  may  be  infiltrated  with  cells.  The  changes  are  especially 
marked  in  the  lymphoid  tissue  of  the  subglottic  region.  The  swelling 
may  be  sufficient  to  produce  a  very  marked  degree  of  laryngeal  stenosis. 
In  many  mild  and  in  all  the  severe  cases  there  is  associated  catarrhal 
inflammation  of  the  trachea,  and  often  of  the  larger  bronchi.  In  young 
children  there  is  very  little  tendency  to  edema  of  the  glottis. 

Symptoms. — In  the  mild  form,  such  as  that  which  is  usually  seen  in 
older  children,  there  is  hoarseness,  or  even  loss  of  voice,  and  a  laryngeal 
cough  which  is  sometimes  hard  and  teasing  and  always  worse  at  night. 
There  may  be  pain  and  soreness  over  the  larynx.  Constitutional  symp- 
toms are  mild  or  absent,  the  patient  not  usually  being  sick  enough  to  go 
to  bed,  and  often  rebelling  even  at  being  kept  indoors.  The  duration 
of  the  disease  is  from  four  to  ten  days,  with  a  strong  tendency  to  relapses 
from  slight  causes. 

The  severe  form  of  catarrhal  laryngitis  is  sometimes  preceded  by 
acute  coryza,  or  there  may  be  mild  laryngeal  symptoms  for  a  few  days 
before  the  development  of  the  more  severe  ones.  In  other  cases  the 
disease  develops  rapidly  and  severe  symptoms  are  present  within  a  few 
hours  from  the  onset. 

When  the  case  is  fully  developed  the  voice  is  metallic  and  hoarse, 
and  occasionally  but  not  usually  lost.  There  is  a  hoarse,  dry,  barking 
cough,  which  is  very  distressing,  and  sometimes  almost  constant.  The 
cough,  like  the  voice,  is  stridulous,  and  more  or  less  stridor  is  present  on 
inspiration.  There  is  a  slight  amount  of  constant  dyspnea,  but  this  is 
scarcely  noticeable  unless  the  chest  is  bared.  Severe  dyspnea  occurs  in 
paroxysms,  usually  at  night.  Then,  we  may  get  the  signs  of  obstructive 
dyspnea  similar  to  those  mentioned  in  severe  attacks  of  catarrhal  spasm. 
This  dyspnea  is  chiefly  inspiratory,  but  in  some  cases  it  increases  stead- 
ily from  the  beginning  of  the  attack,  and  may  be  indistinguishable  from 
that  due  to  membrane.  Constitutional  symptoms  are  usually  present  and 
may  be  severe.  The  temperature  ranges  in  most  cases  from  101°  to 
103°  F.,  but  may  go  to  104°  or  105°  F.  The  pulse  is  rapid  and  full  and 
respiration  is  accelerated.  Children  sometimes  complain  of  pain  in  the 
larynx  and  trachea  which  is  increased  by  coughing.  The  symptoms  are 
severe  for  two  or  even  three  days,  the  fever  continuing  with  moderate 
prostration  and  paroxysms  of  dyspnea,  sometimes  even  attacks  of  suf- 
focation and  cyanosis.    Usually  after  two  or  three  days  there  is  a  grad- 


470  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

ual  subsidence  of  the  dyspnea  and  the  inflammatory  symptoms,  and  the 
ease  goes  on  to  recovery.  At  other  times  the  inflammation  extends  down- 
ward to  the  large  and  then  to  the  small  bronchi,  and  finally  results  in 
bronchopneumonia.  The  attack  may  prore  fatal  from  lar}aigeal  obstruc- 
tion due  to  swelling  and  spasm. 

Diagpiosis. — This  disease  is  chiefly  to  be  distinguished  from  mem- 
branous laryngitis.  The  onset  of  the  two  diseases  may  be  very  similar, 
and  for  the  first  twelve  hours  we  have  no  absolute  means  of  distinguish- 
ing between  them,  except  possibly  by  the  use  of  the  laryngoscope,  which 
.is  often  conclusive  in  older  children  but  not  usually  so  in  infants.  All 
cases,  therefore,  should  be  looked  upon  with  a  degree  of  apprehension. 
The  temperature  in  the  catarrhal  is  usually  higher  than  in  the  mem- 
branous form.  The  dyspnea  is  mainly  paroxysmal,  with  daily  remis- 
sions and  nightly  exacerbations,  and  is  chiefly  inspiratory,  while  that  of 
membranous  laryngitis  is  constant,  steadily  and  often  rapidly  increas- 
ing, and  is  present  both  on  inspiration  and  expiration.  In  catarrhal 
lar}Tigitis  the  voice  is  not  usually  lost,  but  in  the  membranous  form  this 
is  the  rule.  There  can  be  little  room  for  doubt  when  there  are  enlarged 
glands,  membranous  patches  on  the  tonsils,  and  nasal  discharge.  Very 
often,  however,  all  these  evidences  of  diphtheria  are  wanting,  the  really 
difficult  cases  being  those  in  which  the  process  begins  in  the  larynx.  The 
prevalence  of  dij^htheria  and  a  known  exposure  count  for  something  in 
favor  of  membranous  lar^Tigitis.  If  cultures  from  the  pharynx  show 
the  presence  of  Klebs-Loeffier  bacilli,  diphtheria  of  the  larynx  is  certain ; 
but  no  conclusions  can  be  drawn  from  negative  cultures.  In  catarrhal 
as  well  as  in  membranous  laryngitis  there  may  be  extreme  dyspnea, 
cyanosis,  pallor,  prostration,  and  even  death. 

Prognosis. — This  depends  somewhat  upon  the  cause  of  the  disease 
and  also  upon  the  age  of  the  patient.  It  is  much  worse  when  it  is  sec- 
ondary to  measles  or  scarlet  fever.  It  is  better  in  children  over  three 
years  of  age  than  in  infants,  also  when  the  general  condition  of  the 
child  is  good.  The  prognosis  in  severe  catarrhal  laryngitis  should  ahvays 
be  guarded,  not  only  on  its  own  account,  but  also  because  it  is  impos- 
sible at  first  to  be  certain  that  the  case  is  not  one  of  membranous 
laryngitis. 

Treatment. — In  all  cases  children  affected  are  to  be  kept  in  bed,  and 
the  temperature  of  the  room  should  be  between  '70°  and  72°  F.  The  diet 
should  be  light  and  fluid,  and  the  bowels  should  be  freely  opened.  A 
hot  mustard  foot  bath  should  be  given  at  the  outset.  Antipyrin  (one 
grain  every  two  hours  to  a  child  two  years  old)  is  useful  if  there  is 
much  spasmodic  dyspnea.  For  this  symptom  emetics  are  beneficial, 
given  as  in  catarrhal  spasm.  The  use  of  ipecac  and  squills  in  smaller 
doses  than  is  required  for  emesis  (five  drops  each  of  the  syrups  of  ipecac 


SUBMUCOXTS  LARYXCTTTS— EDEMA  OF  THE  GLOTTIS  471 

and  squills  every  two  hours)  may  give  relief,  especially  in  the  early  stage, 
when  the  cough  is  dry,  hard,  and  severe. 

All  the  remedies  mentioned  are  to  be  regarded  as  accessories  to  the 
essential  treatment,  which  consists  in  the  use  of  inhalations.  The  child 
should  be  placed  in  a  tent  into  which  steam  is  introduced  from  a  croup 
kettle.  Simple  steam  may  be  used,  or  pine  needle  oil,  compound  tincture 
of  benzoin,  lime-water,  or  creosote  may  be  added.  In  moderately  severe 
cases  inhalations  should  be  used  for  fifteen  minutes  every  two  hours; 
in  very  severe  ones  they  should  be  continued  the  greater  part  of  the 
time.  Poultices  or  liot  fomentations  may  be  applied  over  the  larynx. 
Relief  is  sometimes  obtained  by  using  counter-irritation  by  mustard. 
In  our  experience  the  local  use  of  cold  is  very  unsatisfactory,  on  account 
of  the  difficulty  of  applying  it  properly,  and  the  objection  to  it  on  the 
part  of  young  children.  Stimulants  may  be  required  late  in  the  disease, 
the  amount  of  prostration  being  the  guide  to  their  use. 

In  cases  of  extreme  dyspnea  operative  interference  may  be  needed. 
It  is  required  more  often  in  infants  and  young  children  than  in  those 
who  are  older.  Opinions  will  of  course  differ  as  to  when  the  dyspnea 
has  reached  the  danger  point.  One  should  not  wait  for  general  cyanosis. 
If  pallor,  marked  prostration,  and  steadily  increasing  dyspnea  are  pres- 
ent the  case  should  not  be  allowed  to  go  on  without  interference,  even 
though  one  may  be  perfectly  sure  that  it  is  one  of  catarrhal  inflam- 
mation only.  The  severity  of  the  dyspnea  is  the  only  guide;  cases  at 
autopsy  may  turn  out  to  be  catarrhal,  which  were  regarded  during 
life  as  undoubtedly  membranous.  If  intubation  is  done,  the  tube  can 
generally  be  dispensed  with  in  two  or  three  days.  Convalescence  is 
usually  rapid,  but  there  is  danger  of  recurring  attacks  during  the 
remainder  of  the  cold  season. 


SUBMUCOUS  LARYNGITIS— EDEMA  OF  THE  GLOTTIS 

These  two  conditions  are  not  quite  identical,  although  they  are  closely 
associated  and  may  be  conveniently  considered  together.  They  are  both 
rare  in  early  life.  In  true  edema  of  the  glottis  there  is  simply  a  drop- 
sical effusion  into  the  submucous  cellular  tissue  of  the  aryteno-epiglottic 
folds,  causing  them  to  project  as  large  rounded  swellings  on  either  side 
of  the  superior  isthmus  of  the  larynx.  They  may  be  of  sufficient  size 
to  cause  serious  or  even  fatal  obstruction  to  respiration.  With  the  laryn- 
goscope they  appear  as  pale-red  tumors,  lying  usually  in  contact  near 
the  base  of  the  tongue.  By  the  finger  their  presence  can  be  quite  readily 
distinguished.  Edema  of  the  glottis  occurs  principally  in  the  late  stages 
of  nephritis. 


472  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

In  the  inflammatory  form  of  edema,  or  true  submucous  laryngitis, 
there  is  the  same  sort  of  swelling  of  these  structures,  but  in  this  case 
it  is  due  to  some  active  inflammation  in  the  neighborhood.  The  swell- 
ing is  partly  from  the  edema  and  partly  from  cell  infiltration.  Usually 
all  the  parts  surrounding  the  upper  opening  of  the  larynx  are  in  a  state 
of  acute  inflammation.  The  epiglottis  may  be  swollen  to  the  thickness 
of  a  finger  and  easily  seen  by  depressing  the  tongue. 

The  exciting  causes  may  be  the  mechanical  irritation  of  a  foreign 
body,  the  inhalation  of  steam  or  irritating  gases,  erysipelas  of  the  neck, 
primary  catarrhal  laryngitis,  or  retropharyngeal  abscess. 

The  symptoms  consist  of  great  inspiratory  dyspnea  with  attacks  of 
suffocation,  while  expiration  may  be  quite  easy.  In  true  edema  there 
are  in  addition  the  symptoms  of  the  primary  disease.  In  the  inflamma- 
tory form  there  are  the  evidences  of  local  inflammation — hoarseness, 
cough,  pain,  and  difficulty  in  swallowing.  A  positive  diagnosis  may  be 
made  by  a  digital  examination.  The  symptoms  may  develop  with 
great  rapidity  in  either  variety,  and  frequently  prove  fatal  in  a  few 
hours. 

The  treatment  of  true  edema  consists  in  scarification  or  multiple 
puncture,  the  application  of  ice  externally,  and  even  the  swallowing  of 
ice;  in  the  inflammatory  form,  in  addition,  local  blood-letting  by  leeches 
and,  as  a  last  resort,  tracheotomy.    Intubation  is  useless  in  either  form. 


CHRONIC  LARYNGITIS 

The  following  varieties  are  seen:  (1)  A  simple  form  usually  asso- 
ciated with  adenoid  vegetations  of  the  pharynx;  (2)  tuberculous;  (3) 
syphilitic;   (4)   that  associated  with  new  growths. 

1.  With  Adenoid  Growths  of  the  Pharynx. — This  is  not  uncom- 
mon. A  slight  superficial  catarrhal  inflammation  develops,  the  symptoms 
of  which  may  continue  for  many  months.  These  cases  are  often  treated 
for  a  long  time  unsuccessfully  by  the  use  of  sprays,  inhalations,  etc., 
but  the  symptoms  disappear  rapidly  after  the  removal  of  the  adenoid 
growths.  Similar  symptoms  may  be  associated  with  hypertrophic 
rhinitis.  In  this  also  the  treatment  should  be  directed  to  the  primary 
condition. 

2.  Tuberculons  Laryngitis. — This  belongs  to  later  childhood,  and  is 
rare  even  then.  In  infancy  it  is  almost  unknown.  Eheindorf  has  re- 
ported a  case  in  a  child  of  thirteen  months,  which  was  regarded  during 
life  as  syphilitic,  but  was  shown  by  autopsy  to  be  tuberculous.  Of  six- 
teen cases  in  children,  reported  by  Eilliet  and  Barthez,  none  occurred 
during  the  first  three  years,  and  only  four  before  the  seventh  year.     The 


CHRONIC  LARYNGITIS  473 

larynx  alone  may  be  affected,  or  the  larynx  and  trachea,  or  the  larynx, 
trachea,  and  lungs.  Pulmonary  tuberculosis  is  usually  found  to  be 
present  at  autopsy,  even  though  there  may  have  been  no  pulmonary 
symptoms.  Demme  has  reported  a  case  of  tuberculous  laryngitis  in  a 
boy  of  four  years  whose  lungs  were  healthy,  death  resulting  from  tuber- 
culous meningitis. 

The  symptoms  are  hoarseness,  aphonia,  laryngeal  cough,  and  muco- 
purulent, sometimes  bloody,  expectoration.  The  sputum  may  contain 
tubercle  bacilli.  With  the  laryngoscope  tuberculous  deposits  may  be 
seen,  but  more  frequently  there  is  tuberculous  ulceration  of  the  mucous 
membrane.  In  children  this  is  usually  superficial,  the  deep  destructive 
ulceration  seen  in  adults  being  very  rare. 

It  is  to  be  differentiated  from  syphilis  chiefly  by  the  general  symp- 
toms, as  the  laryngoscopic  appearances  may  be  very  similar.  Local 
treatment  is  seldom  necessary  and  only  with  older  children.  It  should 
be  in  the  hands  of  a  specialist. 

3.  Syphilitic  Laryn^tis. — In  the  early  stage  of  syphilis  the  larynx  is 
often  the  seat  of  a  catarrhal  inflammation,  which  presents  nothing  espe- 
cially characteristic  except  its  protracted  course.  The  laryngitis  of  late 
hereditary  syphilis  is  quite  rare,  and'  is  likely  to  be  overlooked  because 
of  the  difficulties  in  the  way  of  a  thorough  examination,  and  because  the 
disease  is  usually  painless. 

Strauss  has  collected  fourteen  cases  between  the  ages  of  three  and 
fifteen  years,  and  added  three  of  his  own.  He  states  that  deep  seated 
processes  are  much  more  rare  than  among  adults.  The  parts  most  fre- 
quently affected  are,  first,  the  epiglottis;  secondly,  the  aryteno-epiglottic 
folds ;  thirdly,  the  posterior  laryngeal  wall.  The  epiglottis  was  involved 
in  twelve  of  fourteen  cases.  Usually  there  was  only  perichondritis;  in 
the  more  severe  cases  there  was  partial  or  complete  destruction  of  the 
cartilage.  In  four  cases  papillomatous  masses  were  seen.  In  five  cases 
the  process  extended  from  the  epiglottis  to  the  epiglottic  folds  of  one 
or  both  sides.  In  several  instances  the  superior  vocal  cords  were  thick- 
ened from  hyperplasia,  and  occasionally  small  tumors  were  formed. 
In  only  one  case  was  there  ulceration  of  these  folds.  Changes  in  the 
vocal  cords  and  the  arytenoid  cartilages  were  rare,  occurring  only  with 
extensive  inflammation.  The  symptoms  are  those  of  chronic  laryngitis : 
hoarseness,  sometimes  aphonia,  and  in  a  few  cases  chronic  laryngeal 
stenosis.  The  diagnosis  can  be  made  only  by  means  of  the  laryngoscope. 
In  most  of  the  cases  there  are  present  ulcerations  of  the  palate  or  uvula, 
or  scars  from  previous  ulcers;  sometimes  the  disease  extends  into  the 
nose.  Serious  symptoms  often  result  when  to  old  syphilitic  lesions  there 
is  added  acute  laryngitis  or  edema. 

In  addition  to  the  usual  constitutional  remedies  for  syphilis,  and 


474  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

to  the  means  ordinarily  employed  for  the  relief  of  chronic  laryngitis, 
intubation  may  be  required  in  these  cases  for  the  relief  of  laryngeal 
stenosis.     The  tube  must  usually  be  worn  for  many  months. 


NEW  GROWTHS 

Few  growths  of  the  larynx  are  not  very  rare  in  children.  Excluding 
the  granulations  which  follow  the  use  of  the  tracheal  canula,  the  only 
one  that  is  likely  to  be  met  with  is  papilloma.  This  may  occur  even  in 
infancy.  According  to  Bauchfuss,  the  majority  of  the  cases  begin  dur- 
ing the  first  year.    Boys  are  more  frequently  affected  than  girls. 

The  symptoms  depend  upon  the  size  and  location  of  the  tumor.  The 
earlier  manifestations  are  usually  ascribed  to  chronic  laryngitis.  There 
is  hoarseness,  sometimes  loss  of  voice,  and  a  paroxysmal  cough;  later, 
dyspnea  develops  which  often  increases  by  paroxysms.  The  symptoms 
are  slowly  progressive,  and  it  may  be  several  months  before  they  are  suf- 
ficiently severe  to  attract  special  attention.  A  positive  diagnosis  is  made 
only  by  the  laryngoscope.  There  is  seen  a  whitish  granular  tumor  or 
tumors,  sometimes  pedunculated,  sometimes  with  a  broad  base,  which 
may  be  attached  to  any  part  of  the  larynx.  The  prognosis  is  usually  seri- 
ous on  account  of  the  danger  of  bronchopneumonia  after  operation. 

The  treatment  of  these  cases  belongs  to  the  specialist.  Operative 
removal  of  these  papillomata  usually  results  in  their  recurrence  in 
increased  numbers.  For  this  reason  operations  through  the  mouth  have 
been  largely  given  up.  Papillomatous  tumors  will  often  disappear  en- 
tirely if  complete  rest  for  the  larynx  is  secured  by  means  of  tracheotomy ; 
but  the  tube  must  be  worn  for  from  six  months  to  a  year.  Eadium  has 
been  used  in  a  few  instances  with  brilliant  results,  the  tumor  disappear- 
ing after  a  single  application  and  not  recurring ;  but  extensive  cicatriza- 
tion has  also  been  reported. 


FOREIGN  BODIES  IN  THE  LARYNX  AND  BRONCHI 

The  aspiration  of  foreign  substances  into  the  larynx  is  not  an  un- 
common accident  in  children.  It  usually  happens  from  an  attempt  to 
cough,  laugh,  or  cry  while  the  child  has  something  in  his  mouth.  If 
the  body  is  sharp  and  irregular,  like  a  pin,  the  shell  of  a  nut,  or  a  frag- 
ment of  bone,  it  is  liable  to  become  impacted  in  the  larynx.  If  smooth, 
like  a  pea  or  a  bead,  it  is  usually  drawn  into  one  of  the  bronchi,  generally 
the  right. 

When  the  body  enters  the  larynx  there  is  immediately  excited  a 


FOREIGN  BODIES  IK  THE  LAEYNX  AND  BRONCHI  475 

violent  ^^aroxysmal  cough,  with  dyspnea  amounting  almost  to  suffoca- 
tion. Often  the  body  is  dislodged  by  this  initial  attack  of  coughing. 
If  it  becomes  impacted  in  the  larynx,  it  may  cause  sudden  death  by 
occluding  the  glottis;  elsewhere  it  may  excite  acute  laryngitis,  usually 
of  considerable  severity. 

The  impaction  of  a  foreign  body  in  one  of  the  primary  bronchi,  or 
one  of  the  lobar  divisions,  is  indicated  by  cough  and  a  severe  localized 
pain  in  the  chest.  There  may  be  expectoration  of  blood.  On  auscultat- 
ing the  chest,  there  is  found  an  absence  of  respirator}^  murmur  over  one 
lung  or  one  lobe,  according  to  the  situation  of  the  foreign  body.  Percus- 
sion usually  gives  marked  dulness,  the  signs  thus  suggesting  pleural 
effusion;  or  there  may  be  increased  resonance,  which  may  even  be 
tympanitic,  owing  to  diminished  tension  in  the  part  of  the  lung  involved 
and  to  the  emphysema  which  rapidly  develops  in  the  surrounding  lung. 
If  the  foreign  body  remains  impacted  in  one  of  the  bronchi,  it  usually 
excites  a  localized  inflammation,  which  may  terminate  in  the  formation 
of  an  abscess.  This  may  result  fatally,  or  there  may  follow  a  prolonged 
illness,  with  hectic  symptoms  resembling  pulmonary  tuberculosis;  and 
finally,  after  weeks  or  months,  the  foreign  body  may  be  expelled  by 
an  attack  of  coughing,  and  the  patient  recover  completely.  In  other 
cases  no  abscess  develops  but  there  are  repeated  attacks  of  acute 
pneumonia  which  never  entirely  resolve  so  that  chronic  pneumonia 
of  an  intense  degree  develops.  The  general  health  is  greatly  inter- 
fered with  and  the  child  usually  succumbs  to  one  of  the  recurrent  acute 
attacks. 

The  diagnosis  of  a  foreign  body  in  the  larynx  is  made  by  the  sudden- 
ness of  attack  and  the  violence  of  the  early  symptoms.  In  older  chil- 
dren the  body  may  be  seen  with  the  laryngoscope,  but  in  young  children 
this  is  very  difficult.  The  position  of  a  metallic  or  solid  body  may  be 
revealed  by  the  X-ray.  The  prognosis  is  always  doubtful,  and  depends 
upon  the  nature  of  the  foreign  body  and  the  point  at  which  it  has  been 
arrested.  The  usual  cause  of  death  either  with  or  without  operation  is 
bronchopneumonia. 

The  first  thing  to  be  tried  is  inversion  of  the  patient.  By  this 
means,  assisted  by  the  cough,  the  foreign  body  is  not  infrequently  ex- 
pelled even  though  it  has  passed  below  the  larynx.  The  symptoms  of 
laryngeal  obstruction  may  call  for  immediate  tracheotomy  or  laryn- 
gotomy,  intubation  not  being  applicable  to  these  cases.  If,  after  trache- 
otomy, the  foreign  body  can  be  located  in  the  larynx,  but  can  not 
be  extracted  through  the  tracheal  wound,  the  thyroid  cartilage  should 
be  divided  in  the  median  line.  The  removal  of  a  foreign  body  from  the 
bronchi  or  the  tracheal  bifurcation  should  be  attempted  only  by  one 
skilled  in  bronchoscopy. 


476  DISEASES  OF  THE  RESPIRA'IORY   SYSTEM 

CHAPTER  III 
DISEASES   OF    THE  LUNGS 


THE  PECULIARITIES  OF  THE  LUNGS  IN  INFANCY  AND  EARLY 

CHILDHOOD 

Thorax. — The  general  shape  of  the  thorax  is  somewhat'  cylindrical, 
the  conical  or  dome-shape  of  the  adult  thorax  not  being  attained  until 
puberty.  The  antero-posterior  and  the  transverse  diameters  are  nearly 
equal  in  the  newly  born,  but  after  the  third  year  the  transverse  diameter 
is  always  greater,  the  difference  increasing  steadily  up  to  adult  life.  On 
account  of  the  shape  of  the  chest,  the  lungs  are  situated  rather  more 
posteriorly  in  the  infant  than  in  the  adult. 

The  thoracic  walls  are  very  elastic  and  yielding,  owing  to  the  carti- 
laginous condition  of  a  large  part  of  the  framework.  They  are  relatively 
thinner  than  in  the  adult,  chiefly  from  the  imperfect  development  of  the 
thoracic  muscles.  The  greater  part  of  the  thickness  of  the  thoracic  walls 
is  due  to  the  deposit  of  fat,  generally  abundant  in  well-nourished  in- 
fants; but  where  the  fat  is  scanty  the  walls  are  extremely  thin.  The 
capacity  of  the  thorax  is  considerably  encroached  upon  by  the  high  posi- 
tion of  the  diaphragm,  the  large  size  of  the  thymus  gland,  and  the  fre- 
quent distention  of  the  stomach  and  intestines. 

Respiration. — According  to  Uffelmann,  the  rapidity  of  respiration 
during  sleep  at  the  different  ages  is  as  follows : 

At  birth 35  per  minute. 

At  the  end  of  the  first  year 27     "         " 

At  two  years 25    "         " 

At  six  years .  .  ; 22    "         " 

At  twelve  years 20    "         « 

During  waking  hours  this  rate  is  very  materially  increased,  and 
from  comparatively  slight  disturbance  it  may  be  nearly  twice  as 
rapid. 

The  type  of  respiration  in  infants  is  diaphragmatic,  and  it  continues 
to  be  chiefly  so  until  after  the  seventh  year,  when  the  costal  element 
gradually  becomes  more  and  more  prominent.  The  rhythm  of  respira- 
tion is  easily  disturbed.  In  very  young  infants  the  regular  rhythm  is 
seen  only  in  sleep.  The  lungs  do  not  always  expand  equally;  at  certain 
times  and  in  certain  positions  respiration  may  be  carried  on  for  a  few 
moments  almost  entirel}^  with  one  lung.  For  some  moments  it  may  be 
very  superficial,  and  then  quite  deep.    The  length  of  the  interval  between 


THE  PECULIARITIES  OF  THE  LUNGS  IN  INFANCY  477 

inspiration  and  expiration  varies  much  at  different  times.  Eegular 
rhythmical  respiration  is  not  fully  established  before  the  end  of  the 
second  year.  After  this  time  disturbances  of  rhythm  are  due  chiefly 
to  pulmonary  or  cerebral  disease;  but  in  infancy  quite  marked  irregu- 
larity may  have  little  or  no  significance.  It  is  very  common  in  all 
asthenic  conditions. 

Structure. — As  compared  with  the  adult,  the  trachea  of  the  young 
child  is  larger;  the  bronchi  are  larger  and  occupy  a  greater  space;  the 
air  cells  are  much  smaller  and  occupy  less  space;  and  the  interstitial 
tissue  is  much  more  abundant. 

Physical  Examination. — This  requires  tact  and  time,  but  yields  re- 
sults which  are  quite  as  satisfactory  as  in  adults.  It  should  be  under- 
taken only  in  a  room  having  a  temperature  of  about  70°  F.,  or  before 
an  open  fire. 

Inspection. — This  should  be  made  with  the  chest  bare.  There  should 
be  noted,  the  shape  of  the  chest,  the  presence  of  deformities  from  rickets, 
the  want  of  symmetry  in  the  two  sides,  bulging  of  the  intercostal  spaces, 
whether  the  two  lungs  expand  equally  or  not,  also  variations  in  rhythm, 
and  the  presence  and  extent  of  any  recession  of  the  soft  parts  or  bony 
walls  as  an  indication  of  obstructive  dyspnea. 

Palpation. — This  also  should  be  made  upon  the  bare  skin,  always 
with  the  hand  well  warmed.  Although  we  can  not  get  the  fremitus  of 
the  ordinary  voice,  we  can  get  that  of  the  cry.  This  is  usually  more 
intense  than  in  adults,  on  account  of  the  thinness  of  the  chest  walls.  We 
frequently  get  a  bronchial  fremitus — a  vibration  produced  by  mucus  in 
the  tubes.  The  position  of  the  apex  beat  of  the  heart  should  be  deter- 
mined, it  being  remembered  that  in  infancy  this  is  normally  in  the 
mammary  line,  or  just  inside  of  it,  and  usually  in  the  fourth  intercostal 
space. 

PerciLssion. — For  the  examination  of  the  back,  the  child  may  be  laid 
face  downward  upon  the  nurse's  lap,  or  be  seated  upon  her  arm.  For 
the  front  and  the  lateral  regions  of  the.  chest,  the  child  is  most  con- 
veniently placed  upon  his  side  across  a  hard  pillow.  The  percussion  blow 
must  be  light,  either  with  a  single  finger  or  a  small  percussion  hammer. 
Percussion  should  be  made  both  during  inspiration  and  expiration.  The 
normal  percussion  note  is  somewhat  tympanitic,  this  being  due  to  the 
relatively  large  bronchi  and  the  thin  chest  walls.  This  note  is  exag- 
gerated in  the  interscapular  region  and  beneath  the  clavicle,  especially 
upon  the  right  side.  Here  cracked-pot  resonance  may  be  obtained  even 
in  health. 

Auscultation. — This  may  be  practiced  with  the  naked  ear  or  with  the 
stethoscope.  A  stethoscope  is  absolutely  necessary  for  a  thorough  exam- 
ination of  the  apices  of  the  lungs  in  front  and  the  axillary  regions. 
17 


478  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Most  children  are  less  frightened  by  the  instrument  than  by  the  head  of 
the  physician  during  anterior  auscultation. 

The  normal  respiratory  murmur  of  the  infant  is  generally  described 
as  "puerile."  In  quality  this  has  been  likened  to  the  bronchial  breath- 
ing of  the  adult,  but  the  resemblance  is  not  a  very  close  one.  It  is  rude, 
rather  loud,  and  seems  very  near  the  ear.  Its  peculiar  character  is  due 
to  the  fact  that  the  tracheal  and  bronchial  sounds  are  more  distinct, 
because  not  transmitted  through  so  thick  a  layer  of  lung  and  chest  wall. 
It  is  especially  loud  in  the  regions  where  the  bronchi  are  superficial,  as 
between  the  shoulder-blades  and  beneath  the  clavicles,  particularly  of 
the  right  side.  A  careful  comparison  of  the  two  sides  of  the  chest  will 
generally  enable  an  observer  to  avoid  errors.  The  irregularity  of  rhythm 
which  occurs  from  slight  causes  should  be  remembered,  and  the  infant's 
position  changed  several  times  during  auscultation,  to  avoid  the  mis- 
take of  attaching  too  much  importance  to  a  feeble  respiratory  murmur 
of  one  side. 

On  account  of  the  thinness  of  the  chest  walls,  there  is  difficulty  in 
distinguishing  between  rales  produced  in  the  bronchi  and  pleuritic  fric- 
tion sounds.  Before  drawing  any  inference  from  the  auscultatory  signs, 
both  lungs  must  be  examined  for  several  minutes,  changing  the  child's 
position,  and  often  inducing  a  cry  or  compelling  a  deep  inspiration  by 
other  means,  in  order  to  bring  out  signs  which  otherwise  may  be  over- 
looked. As  auscultation  is  extremely  difficult  or  impossible  in  a  crying 
infant,  this  part  of  the  physical  examination  should  be  made  first  if  the 
child  is  quiet,  since  upon  it  we  must  chiefly  depend  for  diagnosis.  In- 
spection and  percussion  can  be  deferred  until  later. 

Peculiaxities  in  Disease. — There  are  several  peculiarities  connected 
with  the  respiratory  organs  in  infancy  and  early  childhood  which  must 
be  constantly  borne  in  mind  in  studying  their  diseases.  The  muscular 
development  of  the  thoracic  wall  is  feeble.  The  soft,  yielding  character 
of  the  thoracic  framework  causes  the  chest  to  sink  in  readily  from  at- 
mospheric pressure  whenever  there  is  obstructive  dyspnea.  On  account 
of  the  small  size  of  the  air  vesicles,  acute  congestion  may  interfere 
with  their  function  almost  as  completely  as  does  consolidation.  Because 
of  the  delicate  walls  of  the  air  vesicles,  emphysema  is  readily  produced 
in  obstructive  dyspnea,  but  it  is  rarely  permanent.  There  is  a  tendency 
to  collapse,  either  on  the  part  of  lobules  or  groups  of  lobules,  but  very 
rarely  of  an  entire  lobe.  This  is  a  much  less  important  factor  in  the 
production  of  symptoms  in  acute  pulmonary  disease  than  many  writers 
would  lead  us  to  suppose.  The  tendency  of  inflammation  to  spread  from 
the  large  to  the  small  bronchi  is  much  greater  than  in  adults.  In  all 
forms  of  pulmonary  disease  the  rapidity  of  respiration  is  much  greater 
than  in  adults.     Areas  of  consolidation  often  exist  without  appreciable 


ACUTE  CATARRHAL  BRONCHITIS  479 

changes  in  the  percussion  note,  because  they  are  superficial  and  are  sur- 
rounded by  healthy  or  emphysematous  lung.  Flatness  should  always 
suggest  the  presence  of  fluid. 

Probably  the  most  common  mistakes  are  to  confound  bronchial  rales 
with  friction  sounds,  exaggerated  puerile  breathing  with  bronchial  breath- 
ing, and  to  overlook  the  existence  of  fluid  because  of  the  presence  of 
bronchial  breathing. 


ACUTE  CATARRHAL  BRONCHITIS 

Acute  catarrhal  bronchitis  is  one  of  the  most  frequent  conditions  for 
which  the  physician  is  called  upon  to  prescribe  in  children.  It  occurs  at 
all  ages,  from  early  infancy  up  to  puberty.  Its  frequency,  however, 
diminishes  steadily  after  the  second  year.  The  predisposition  to  acute 
bronchitis  exists  with  the  same  constitutional  conditions,  and  is  acquired 
in  the  same  manner  as  the  predisposition  to  the  acute  catarrhal  inflam- 
mations of  the  upper  respiratory  tract.  (See  Acute  Ehinopharyngitis.) 
Bronchitis  is  very  common  in  children  who  are  sufi^ering  from  rickets  and 
malnutrition.  It  is  much  more  frequent  in  the  cold  months,  especially 
in  the  late  winter  and  early  spring,  when  there  are  sudden  atmospheric 
changes  and  high  winds.  The  presence  of  large  tonsils  and  adenoid 
vegetations  of  the  pharynx  are  important  predisposing  causes. 

Bronchitis  may  be  a  primary  or  a  secondary  disease.  The  primary 
form  is  excited  by  cold,  exposure  with  insufficient  clothing  in  severe 
weather,  wetting  of  the  feet,  or  chilling  of  the  surface  in  any  manner. 
Under  these  conditions  it  may  occur  alone,  or  be  associated  with  or 
preceded  by  acute  catarrh  of  the  nose,  pharynx,  or  larynx.  In  rare  cases 
it  is  caused  by  the  inhalation  of  irritants.  Bronchitis  is  an  almost  in- 
variable accompaniment  of  measles  and  influenza.  It  is  very  common 
in  pertussis,  in  scarlet  and  typhoid  fevers,  and  diphtheria,  and  may 
occur  in  any  acute  infectious  disease ;  it  also  complicates  pneumonia  and 
pleurisy.  The  microorganisms  associated  with  bronchitis  are  chiefly 
the  staphylococcus  aureus  and  the  pneumococcus,  often  in  combination; 
next  in  importance  are  the  streptococcus  and,  especially  in  protracted 
cases,  the  influenza  bacillus. 

Lesions. — Acute  catarrhal  bronchitis  is  an  inflammation  of  the 
mucous  membrane  of  the  bronchi.  As  a  rule  it  is  bilateral,  both  sides 
being  involved  to  the  same  degree.  Localized  bronchitis  is  secondary  to 
some  other  pathological  process  in  the  lungs,  usually  tuberculosis,  old 
pleuritic  adhesions,  or  pneumonia.  In  acute  bronchitis  only  the  larger 
tubes  may  be  affected,  this  usually  being  complicated  with  inflammation 
of  the  trachea  (ordinary  tracheobronchitis)  ;  or,  in  addition,  the  process 


480  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

may  extend  to  the  medium-sized  tubes  (severe  bronchitis)  ;  or,  in  infants 
especially,  it  may  extend  to  the  smallest  tubes  (capillary  bronchitis). 
In  the  last-mentioned  form  there  are  invariably  changes  in  the  zones 
of  air  vesicles  surrounding  the  bronchi,  and  these  cases  are  therefore 
more  properly  classed  as  bronchopneumonia.  In  the  first  form  the  in- 
flammation is  superficial,  and  affects  only  the  mucous  membrane  of  the 
bronchi.  In  the  second  form  it  may  involve  the  entire  thickness  of  the, 
bronchial  wall,  and  in  the  third  form  it  does  so  regularly, 

The  pathological  changes  consist  in  congestion  and  swelling  of  the 
mucous  membrane,  desquamation  of  the  epithelium,  and  an  exudation  of 
mucus  and  pus  cells.  At  autopsy  the  injection  of  the  mucous  membrane 
is  usually  distinct ;  pus  and  mucus  cover  the  surface  of  the  larger  bronchi, 
and  by  pressure  ooze  from  the  cut  extremities  of  the  smaller  tubes.  The 
chief  lesion  of  the  walls  of  the  bronchi  consists  in  an  infiltration  with 
leuco.cytes.  In  infants  dying  from  broncliitis,  the  lungs  are  mucli  more 
frequently  emphysematous  than  collapsed.  In  fact  the  readiness  with 
which  emphysema  occurs  in  bronchitis  is  one  of  its  distinguishing  feat- 
ures in  infancy.  However,  this  is  rarely  permanent  but  usually  sub- 
sides rapidly  after  the  acute  attack  is  over.  There  is  swelling  of  the 
lymph  nodes  at  the  root  of  the  lungs,  which  in  most  of  the  acute  cases 
is  slight,  but  in  protracted  cases,  and  after  recurring  attacks,  may  be 
quite  marked.  , 

Symptoms. — It  is  convenient  to  consider  separately  the  symptoms  in 
infants  and  in  older  children. 

The  Bronchitis  of  Infants. — 1.  The  Mild  Form  (Bronchitis  of 
the  Larger  Tubes.)-- — The  onset  is  generally  gradual,  and  the  symptoms 
of  bronchitis  may  be  preceded  by  those  of  catarrh  of  the  nose,  pharynx, 
or  larynx.  The  change  in  the  character  of  the  cough,  the  slightly  .ac- 
celerated iDreathiug,  and  a  further  rise  in  temperature,  indicate  an  ex- 
tension to  the  bronchi.  The  cough  may  be  constant  and  severe,  or  very 
slight.  There  is  no  expectoration.  The  secretions  are  usually  coughed 
up  into  the  mouth  or  pharynx,  and  swallowed.  This  sometimes  excites 
vomiting.  At  other  times  the  mucus  is  coughed  only  into  the  trachea 
or  larynx,  and  aspirated  again  into  the  lungs.  The  respirations  are  from 
forty  to  fifty  a  minute,  and  often  accompanied  by  a  rattling  sound,  due 
to  mucus  in  the  large  bronchi  or  trachea.  The  general  symptoms  are 
not  severe,  and  unless  the  infant  is  very  young  or  very  delicate  no  ap- 
prehension need  be  felt  as  to  the  outcome.  The  temperature  is  generally 
from  100°,  to  102°  F.  for  two  or  three  days,  then  below  100°  F.  A  mod- 
erate amount  of  restlessness  dependent  upon  the  severity  of  the  cough, 
anorexia,  and   sometimes   vomiting  and  diarrhea,   are  usually  present. 

The  physical  signs  in  the  first  stage  are  dry,  sonorous  rales  over  the 
whole  chest.    A  little  later  these  give  place  to  coarse  mucous  rales  heard 


ACUTE  CATARRHAL  BRONCHITIS  481 

everywhere,  but  especially  distinct  between  the  scapulae  and  in  the  infra- 
clavicular regions.  On  palpation  there  is  usually  a  marked  bronchial 
fremitus.  Often  there  is  not  enough  dyspnea  to  cause  recession  of  the 
soft  parts  of  the  chest.  Unless  the  disease  extends  to  the  smaller  bronchi 
and  the  air  vesicles,  the  illness  usually  lasts  about  a  week.  Coarse  rales 
in  the  chest  may  remain  for  some  time  after  the  symptoms  have  subsided. 
Eelapses  are  exceedingly  common.  In  a  delicate  or  rachitic  child,  or  in 
one  whose  surroundings  are  bad,  one  attack  is  likely  to  be  followed  by  a 
succession  of  others,  so  that  the  child  may  not  be  really  well  until  warm 
weather  comes.  The  general  health  may  suifer  from  the  prolonged  con- 
finement to  the  house,  although  the  patient  may  never  have  been  seri- 
ously ill. 

2.  The  Severe  Form  (Bronchitis  of  the  Smaller  Tubes). — This  dif- 
fers from  the  preceding  variety  mainly  in  the  greater  severity  of  all  its 
symptoms.  The  onset  may  be  like  that  just  described,  the  severe  symp- 
toms not  appearing  until  the  patient  has  been  sick  two  or  three  days, 
or  they  may  be  severe  from  the  outset.  If  the  latter,  it  is  indistinguish- 
able from  bronchopneumonia.  There  is  cough,  dyspnea,  accelerated 
breathing,"  fever,  and  moderate,  sometimes  severe,  prostration.  The 
cough  is  tighter,  and  more  frequently  of  a  short,  teasing  character  than 
severe  and  paroxysmal.  There  is  difficulty  in  nursing.  Dyspnea  may 
be  quite  marked  and  is  shown  by  the  active  dilatation  of  the  alae  nasi  and 
the  recession  of  all  the  soft  parts  of  the  chest  on  inspiration.  The 
respirations,  as  a  rule,  are  from  50  to  80  a  minute.  The  temperature 
for  the  first  day  or  two  is  usually  100°  or  102°  F.,  but  it  may  be  103° 
or  104°  F.  So  high  a  temperature  does  not  continue  unless  pneumonia 
develops.  The  prostration  is  in  most  cases  more  closely  related  to  the 
dyspnea  and  the  rapidity  of  respiration  than  to  the  temperature.  Often 
there  is  slight  cyanosis. 

In  the  beginning  the  chest  is  filled  with  sibilant  and  sonorous  rales. 
In  twelve  or  twenty-four  hours  these  are  wholly  or  in  part  replaced  by 
moist  rales — coarse  or  fine,  according  as  they  are  produced  in  the  large 
or  medium-sized  tubes.  The  rales  are  always  best  heard  behind,  but  they 
are  present  all  over  the  chest.  The  sibilant  and  sonorous  breathing  may 
persist  throughout  the  attack  and  for  a  week  or  two  thereafter.  This 
prominence  of  the  spasmodic  or  asthmatic  element  in  bronchitis  is  char- 
acteristic of  infancy  and  early  childhood.  The  respiratory  murmur  is 
feeble ;  the  resonance  on  percussion  is  normal  or  slightly  exaggerated.  As 
the  case  progresses  toward  recovery,  the  finer  rales  are  the  first  to  dis- 
appear. 

At  the  onset  of  such  a  case  it  is  impossible  to  say  whether  the  disease 
will  be  limited  to  the  medium-sized  bronchi  or  will  extend  to  the  small- 
est bronchi  and  air  vesicles.     In  young  or  very  delicate  infants,  and  dur- 


482  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

ing  measles,  it  is  very  common  for  the  disease  to  spread  rapidly  to  the  air 
vesicles.  ■  In  other  cases,  usually  in  infants  under  six  months  old,  there 
may  develop  attacks  of  respiratory  failure  or  suffocation.  These  may 
occur  in  a  severe  case  at  any  time,  and,  because  of  the  infant's  inability 
to  empty  the  tubes  of  secretion,  the  dyspnea  steadily  increases  until  the 
respiratory  muscles  are  exhausted.  The  symptoms  which  follow  are 
usually  ascribed  to  pulmonary  collapse.  It  is,  however,  by  no  means 
certain  that  this  is  the  correct  explanation,  for  at  autopsies  made  in  such 
cases  the  lungs  are  usually  found  to  be  the  seat  of  acute  emphysema. 
The  clinical  picture  is  a  clear  one.  There  is  no  disposition  to  cough  or 
cry;  the  pulse  is  feeble;  the  respiration  very  rapid,  superficial,  often 
irregular;. the  skin  cyanotic,  and  often  clammy.  Finally,  there  may  be 
added  to  the  other  signs,  dulness,  apathy,  and  stupor.  Such  attacks  may 
come  on  quite  suddenly  even  in  robust  infants,  and  unless  the  treatment 
is  energetic,  death  often  follows  in  a  few  hours,  being  frequently  pre- 
ceded by  convulsions. 

The  usual  course  of  the  disease  in  infants  previously  in  good  health 
-is  that  the  severe  symptoms  continue  for  two  or  three  days  only,  after 
which  the  temperature  falls  to  100°  or  100.5°  F.,  and  gradually  becomes 
normal.  The  constitutional  symptoms  usually  decline  with  the  tempera- 
ture, and,  except  during  the  first  thirty-six  hours,  they  rarely  give  cause 
for  anxiety.  Eecovery  almost  invariably  occurs  unless  the  disease  ex- 
tends to  the  finer  bronchi. 

Bronchitis  is  principally  to  be  distinguished  from  bronchopneumonia. 
The  differential  diagnosis  is  more  fully  considered  under  that  disease. 
The  most  important  points  are  that  in  pneumonia  the  temperature  is 
higher  and  more  prolonged,  the  prostration  greater,  the  rales  very  often 
localized — being  heard  only  behind,  often  over  only  one  lung — the  dura- 
tion is  more  protracted,  and  all  the  symptoms  are  more  severe.  In 
nearly  all  cases  of  severe  bronchitis  in  young  children  some  pneumonia 
is  present. 

The  Beonchitis  of  Older  Children.— This  is  not  nearly  so  serious 
as  in  infants,  because  the  same  danger  does  not  exist  of  extension  of  the 
inflammation  to  the  flner  bronchi  and  air  cells. 

1.  The  Mild  Form. — This  is  very  common.  The  constitutional  symp- 
toms are  slight,  and  often  entirely  absent  after  the  first  day.  The  patient 
is  never  sick  enough  to  go  to  bed.  The  first  symptoms  are  cough  and 
soreness  or  a  sense  of  oppression  beneath  the  sternum.  The  cough  is 
always  worse  at  night.  It  is  at  first  tight,  hard,  and  racking;  later  it  is 
loose,  and  in  children  over  five  years  old  there  is  iisually  expectoration — 
first  of  white,  frothy  mucus,  but  after  a  few  days  it  becomes  more  abun- 
dant, and  of  a  yellow  or  yellowish-green  color,  from  the  presence  of  pus. 
The  physical  signs  are  only  coarse  rales,  at  first  dry,  and  later  moist,  but 


ACUTE  CATARRHAL  BRONCHITIS  483 

heard  over  both  sides  of  the  chesty  in  front  and  behind.  There  may  be 
some  disturbance  of  digestion,  anorexia,  constipation,  or  diarrhea.  The 
usual  duration  of  the  attack  is  from  one  to  two  weeks.  If  the  patient  is 
not  kept  indoors  the  disease  may  pass  into  a  subacute  form,  lasting  for 
several  weeks  as  a  protracted  "winter  cough,"  but  without  any  other  im- 
jjortant  symptoms. 

Such  prolonged  or  recurring  attacks  of  bronchitis  of  a  subacute  form 
should  suggest  influenza  or  tuberculosis.  A  positive  cutaneous  tuberculin 
reaction  renders  tuberculosis  probable.  A  careful  search  for  bacilli  in 
the  sputum  should  then  be  made.  Although  not  found  at  first,  if  present 
repeated  examinations  will  usually  disclose  them.  Influenza  can  be 
diagnosticated  with  certainty  only  by  sputum  cultures. 

2.  The  Severe  Form. — The  onset  is  abrupt,  with  fever,  chills,  pains 
in  the  back,  headache,  cough,  and  sometimes  pain  in  the  chest.  There  is 
a  feeling  of  tightness  or  constriction  beneath  the  sternum.  The  onset 
resembles  that  of  pneumonia,  except  that  the  symptoms  are  less  severe. 
The  temperature  for  the  first  two  or  three  days  ranges  betwen  100°  and 
103°  F.  It  is  generally  highest  ii\  the  first  twenty-four  hours.  The 
cough  resembles  that  of  the  mild  form,  but  it  is  usually  more  severe. 
The  expectoration  is  more  profuse,  and  occasionally,  in  the  early  stage,  it 
may  be  streaked  with  blood. 

The  coarse  rales  of  the  mild  form  are  present,  and  in  addition  there 
are  finer  rales — at  first  dry,  and  later  moist — heard  all  over  the  chest. 
Frequently,  wheezing  rales  are  heard  on  expiration.  The  duration  of  the 
attack  is  ordinarily  from  two  to  three  weeks,  the  patient  being  sick 
enough  to  be  confined  to  bed  for  three  or  four  days  only.  There  is  fre- 
quently a  cough  for  some  time  after  all  physical  signs  have  disappeared. 
Eelapses  are  easily  excited  by  any  indiscretion  before  the  patient  has 
quite  recovered. 

The  prognosis  in  the  primary  cases  is  good,  such  almost  invariably 
terminating  in  recovery,  and  very  exceptionally  passing  into  broncho- 
pneumonia ;  but  this  not  infrequently  happens  when  the  attack  compli- 
cates measles  or  pertussis. 

Treatment  of  Bronchitis. — To  remove  tlie  predisposition  to  bronchitis 
the  same  means  should  be  employed  as  those  mentioned  in  Acute  Ehino- 
Pharyngitis.  Children  Avith  tuberculous  antecedents,  and  those  who 
are  especially  prone  to  pulmonary  disease,  should,  if  possible,  spend  the 
winter  in  a  warm  climate.  The  sleeping  apartments  of  susceptible  in- 
fants should  not  be  too  cold — ^^never  below  55°  F. — but  they  should  be 
well  ventilated.  It  is  important  in  infants  and  young  children  that  mild 
attacks  of  bronchitis  should  not  be  neglected. 

Every  young  child  who  has  an  acute  catarrh  of  the  nose,  pharynx, 
larynx,  or  bronchi  should  be  kept  indoors.    In  every  such  catarrh  accom- 


484  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

panied  by  fever  the  child  should  be  kept  in  bed  while  the  fever  lasts,  even 
if  the  temperature  does  not  go  above  100.5°  F.,  and  is  accompanied  by- 
no  other  constitutional  symptoms.  A  very  large  number  of  the  cases  will 
recover  promptly  when  no  other  treatment  is  employed  than  to  keep  the 
child  in  bed.  Fresh  air  is  indispensable.  But  the  advantages  of  cold  air 
have  not  yet  been  demonstrated.  According  to  our  experience,  the  wide- 
open  windows  have  no  place  in  the  treatment  of  acute  bronchitis  in  in- 
fants or  young  children  in  the  winter  and  spring  season.  The  tempera- 
ture of  the  room  should  be  about  70°  F.  The  room  should  be  well 
ventilated  and  frequently  aired,  the  child  meanwhile  being  removed  to 
another  room.  There  is  a  great  advantage  in  changing  the  child's  posi- 
tion in  the  crib  and  from  the  crib  to  the  nurse's  arms.  Careful  attention 
should  be  given  to  feeding  and  to  the  condition  of  the  bowels.  A  cathar- 
tic, preferably  castor  oil,  should  be  administered  at  the  outset. 

Poultices  are  objectionable  and  should  not  be  employed.  Counter- 
irritation  is  very  valuable.  In  infants,  good  results  are  obtained  by  the 
frequent  use  of  a  mustard  paste  (see  chapter  on  General  Therapeutics). 
The  paste  may  be  repeated,  according  to  indications,  from  two  to  five 
times  a  day.     If  properly  used,  it  will  not  injure  the  skin. 

Inhalations  may,  in  the  great  majority  of  cases,  take  the  place  of  the 
administration  of  drugs  by  the  mouth,  a  very  great  advantage  in  infants. 
They  may  be  used  by  means  of  the  croup  kettle,  the  child  always  being 
placed  in  a  tent.  In  the  early  part  of  the  disease  inhalations,  like  simple 
aqueous  vapor  or  lime-water,  may  be  used.  Later  turpentine,  creosote, 
benzoin,  terebene,  or  eucalyptol  may  be  added.  Of  these,  creosote  usually 
gives  the  most  satisfaction.  Inhalations  are  to  be  used  for  ten  or  fifteen 
minutes  from  four  to  eight  times  a  day. 

In  infancy,  expectorants  may  advantageously  be  dispensed  with. 
For  older  children,  antimony  and  ipecac  may  be  used  in  the  first  stage. 
When  the  secretion  is  more  abundant,  creosote,  turpentine,  or  terebene 
may  be  given.  Small,  frequently  repeated  doses  usually  give  the  best 
results.  Opium  should  be  given  cautiously,  to  infants.  The  dry,  harass- 
ing cough  of  the  early  stage  sometimes  yields  to  nothing  so  quickly 
as  to  small  doses  of  Dover's  powder  (e.  g.,  one-tenth  of  a  grain  every 
two  hours  to  a  child  of  one  year).  The  use  of  emetics  to  get  rid  of 
bronchial  secretion  is  not  to  be  advised.  Stimulants  are  not  required 
in  most  of  the  cases.  The  indications  for  them  are  the  same  as  in  pneu- 
monia. When  there  is  much  dyspnea  of  the  asthmatic  type,  nothing  works 
as  well  as  epinephrin.  It  should  be  given  intramuscularly;  the  dose  is 
two  to  five  minims  of  the  1-1,000  solution.  The  effects  are  almost  im- 
mediate, but  often  only  transient. 

Should  attacks  of  suffocation  and  respiratory  failure  occur  in  infants, 
the  indications  are  to  excite  respiratory  movements  and  to  get  as  much 


FIBEINOUS  BRONCHITIS  485 

blood  as  possible  to  the  surface  and  the  extremities.  Flagellation  or 
spanking  and  the  use,  alternately,  of  hot  and  cold  douches  to  the  chest 
will  sometimes  induce  the  deep  respiratory  efforts  desired.  Other  useful 
measures  are  the  hot  mustard  l)ath  and  the  mustard  pack  applied  to  the 
entire  body.  Probably  the  most  effective  of  all  remedies  is  dry  cupping. 
The  chest  should  be  cupped  front  and  back  for  five  or  ten  minutes  every 
few  hours.  Oxygen  should  be  administered.  As  these  symptoms  are 
likely  to  recur  every  few  hours  for  a  day  or  two,  a  repetition  of  the 
treatment  may  be  needed.  For  such  patients  cold  air  is  injurious.  They 
should  be  kept  in  a  room  with  a  temperature  of  70°  to  72°  F. 

In  the  non-febrile  cases  in  older  children,  confinement  in  bed  is  un- 
necessary, but  they  should  be  kept  indoors.  In  the  early  stage,  with 
hard,  dry  cough,  one  of  the  best  remedies  is  brown  mixture  (the  mis- 
tura  glycyrrhizae  composita  of  the  U.  S.  P.).  It  will  be  found  advan- 
tageous in  most  cases  to  have  the  formula  made  up  with  one-half  the 
usual  amount  of  opium.  When  the  cough  is  especially  hard  and  dry 
inhalations  of  steam  are  indicated.  In  the  second  stage,  muriate  of 
ammonia  may  be  added  to  the  brown  mixture;  or  terebene,  two  or 
three  drops  upon  sugar,  may  be  given  four  or  five  times  a  day,  and  in- 
halations should  be  used  several  times  a  day. 

In  the  more  severe  cases  the  patients  should  be  kept  in  bed  and  a  coun- 
ter-irritant to  the  chest  employed.  For  the  general  discomfort,  pain, 
headache,  etc.,  nothing  is  better  than  phenacetin  and  Dover's  powder 
(two  grains  of  the  former  to  one-half  grain  of  the  latter  to  a  child  of 
five  years),  repeated  every  three  to  six  hours.  All  patients  should  be 
kept  in  bed  as  long  as  the  temperature  is  above  normal. 

After  all  physical  signs  and  constitutional  symptoms  have  disappeared, 
a  cough  contiiiues  sometimes  for  weeks.  Expectoration  is  scanty,  or  is 
wanting  altogether ;  the  cough  is  hard,  dry,  often  paroxysmal,  and  in  some 
cases  occurs  at  night  only.  For  this  condition  the  best  remedies  are  cod- 
liver  oil  and  creosote.  When  these  measures  are  not  effective,  a  change 
of  climate  should  be  advised. 


FIBRINOUS  BRONCHITIS  (Bronchial  Croup) 

Fibrinous  bronchitis  is  usually  seen  in  diphtheria,  as  an  extension 
from  the  larynx  or  trachea.  There  is,  however,  another  form  of  bron- 
chitis attended  by  a  fibrinous  exudate,  which  occurs  as  a  primary  disease. 
This  is  very  rare  in  children.  Weil  has,  however,  collected  twenty  cases 
of  the  primary  form.  The  etiology  is  obscure.  It  is  seen  at  all  ages, 
from  infancy  up  to  puberty,  and  it  may  be  either  acute  or  chronic.  From 
the  cases  thns  far  reported  it  would  appear  that  the  acute  form  is  rela- 


486  DISEASES  OF  THE  RESPIEATORY  SYSTEM 

tively  more  common  in  children  than  in  adults.  The  disease  may  be 
confined  to  certain  branches  of  the  bronchial  tree,  or  it  may  affect  all  the 
bronchi,  even  to  the  minute  subdivisions.  The  fibrinous  membrane  is 
found  loose  in  the  tubes  or  adherent.  There  are  generally  associated 
other  pulmonary  changes,  such  as  emphysema,  atelectasis  or  broncho- 
pneumonia. 

The  acute  form  somewhat  resembles  ordinary  catarrhal  bronchitis. 
The  diagnostic  features  are,  the  severity  of  the  dyspnea  and  the  expectora- 
tion of  tube  casts  from  th^  larger  bronchi,  or  elongated  cylinders  from 
the  smaller  ones,  the  former  resembling  macaroni,  the  latter,  vermicelli. 
The  expectorated  masses  are  often  in  balls  or  plugs,  and  their  peculiar 
character  is  not  recognized  until  they  are  placed  in  water.  The  casts 
are  dissolved  by  alkalis,  especially  by  lime-water.  After  the  expulsion  of 
a  large  cast,  improvement  in  all  the  symptoms  occurs.  They,  however, 
return  as  the  exudate  reappears.  The  ordinary  duration  of  acute  cases 
is  from  one  to  three  weeks. 

In  the  chronic  form  there  are  no  constitutional  symptoms,  but  only 
dyspnea  and  cough,  often  recurring  in  paroxysms,  with  the  expectora- 
tion of  fibrinous  casts.  The  patient  may  have  these  attacks  at  intervals 
of  a  few  days  or  weeks,  extending  over  a  period  of  months,  or  even  years. 
There  are  no  characteristic  physical  signs.  The  diagnosis  rests  upon 
the  peculiar  character  of  the  expectoration.  The  prognosis  in  acute  cases 
is  unfavorable,  the  mortality  being  75  per  cent  (Weil).  Chronic  cases 
are  not  dangerous  to  life. 

Treatment. — This  is  quite  unsatisfactory.  To  loosen  the  membrane 
and  facilitate  its  expulsion,  the  most  efficient  means  are  inhalations  of 
the  vapor  of  lime-water.  Pilocarpin  is  too  dangerous  for  use  with  small 
children.  Occasionally  emetics  are  of  value.  Improvement  in  some  of 
the  chronic  cases  has  resulted  from  the  use  of  iodid  of  potassium. 


CHRONIC  BRONCHITIS 

Chronic  bronchitis  is  not  a  very  common  disease  in  children,  partic- 
ularly in  young  children,  one  reason  being  that  chronic  emphysema,  so 
frequently  an  associated  condition  in  adults,  is  rather  rare  in  early 
life.  Chronic  bronchitis  always  accompanies  chronic  pulmonary  tubercu- 
losis and  chronic  interstitial  pneumonia,  with  or  without  the  occurrence 
of  bronchiectasis.  It  is  seen  in  chronic  cardiac  disease,  especially  with 
lesions  of  the  mitral  valve.  It  may  occur  as  a  late  symptom  of  hereditary 
syphilis.  Excluding  the  varieties  mentioned,  it  usually  follows  attacks 
of  acute  bronchitis,  the  process  becoming  chronic  because  of  the  patient's 
constitutional  condition  or  his  unhygienic  surroundings.     The  acute  at- 


ASTHMA  487 

tack  may  be  primary,  but  it  often  follows  measles  and  whooping-cough. 
Deformities  of  the  chest,  the  result  either  of  rickets  or  of  Pott's  disease, 
are  occasionally  a  cause. 

Symptoms. — The  only  constant  symptom  is  cough,  which  is  per- 
sistent, obstinate,  and  nearly  always  worse  at  night  or  early  in  the  morn- 
ing. It  often  occurs  in  paroxysms  strongly  suggestive  of  pertussis.  Ex- 
pectoration is  not  generally  abundant,  but  in  older  children  it  is  usually 
present,  and  in  a  few  cases  it  is  profuse.  A  copious  morning  expectora- 
tion of  fetid  pus  or  muco-pus  indicates  bronchiectasis.  There  is  no 
fever,  little  or  no  dyspnea,  and  although  the  patients  are  thin,  they  are 
not  emaciated,  and  in  many  cases  the  general  health  is  not  much  affected. 
There  may  be  coarse  mucous  rales,  or  no  physical  signs  whatever.  The 
duration  of  the  disease  is  indefinite,  depending  upon  the  cause.  All 
these  patients  are  better  in  summer  than  in  winter,  and  suffer  fre- 
quently from  exacerbations  of  acute  or  subacute  bronchitis. 

The  diagnosis  is  to  be  made  mainly  from  pertussis  and  tuberculosis. 
From  mild  attacks  of  pertussis  the  diagnosis  may  be  impossible  except 
by  the  course  of  the  disease.  Tuberculosis  may  be  suspected  if  the  ther- 
mometer shows  regularly  a  slight  evening  rise  of  temperature,  if  there  is 
much  anemia,  and  steady  loss  of  ilesh.  It  may,  however,  be  present 
without  any  of  these  symptoms.  A  positive  cutaneous  reaction  is  sug- 
gestive, but  a  certain  diagnosis  can  be  made  only  by  the  discovery  of 
tubercle  bacilli  in  the  sputum. 

Treatment. — The  first  indication  is  to  treat  the  primary  conditions 
upon  which  chronic  bronchitis  may  depend.  Attention  should  be  directed 
to  the  general  condition — rickets  and  malnutrition  each  receiving  its 
appropriate  treatment.  In  many  cases  a  change  of  climate  is  the  only 
thing  which  is  really  curative.  The  general  health  should  be  promoted 
as  much  as  possible  by  a  tonic  plan  of  treatment  which  may  advan- 
tageously include  the  use  of  cod-liver  oil.  The  results  obtained  from 
drugs  are  not  very  satisfactory  but  the  following  may  be  employed : 
potassium  iodid,  creosote  and  terebene,  the  last  two  being  given  both 
by  mouth  and  by  inhalation.  For  the  relief  of  cough  opiates  are  to  be 
avoided  as  much  as  possible. 

ASTHMA 

Asthma  is  characterized  by  attacks  of  severe  spasmodic  dyspnea,  which 
may  be  preceded,  accompanied,  or  followed  by  a  bronchitis  of  greater 
or  less  severity.  In  infancy,  the  association  of  asthma  with  bronchitis  is 
a  very  close  one,  and  the  cases  present  quite  a  different  clinical  picture 
from  the  disease  as  seen  in  older  children,  which  differs  in  no  essential 
points  from  the  asthma  of  adults. 


488  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Writers  differ  very  much  in  their  statements  regarding  the  fre- 
quency of  asthma  in  early  life,  mainly  because  of  a  want  of  agreement  in 
regard  to  what  shall  be  included  under  this  term.  The  asthmatic  attacks 
of  infants  are  considered  by  some  as  a  stage  of  bronchitis,  by  others  as 
distinct  from  that  disease.  Typical  attacks  resembling  those  of  adult  life 
are  rare  in  children,  and  extremely  so  before  the  fifth  year.  How- 
ever, of  225  cases  of  asthma  reported  by  Hyde  Salter,  the  disease  began 
before  the  tenth  year  in  nearly  one-third  the  number. 

Etiology. — The  general  or  constitutional  causes  are  the  same  in  chil- 
dren as  in  adults.  Asthma  is  often  hereditary.  It  frequently  occurs  in 
children  who  in  infancy  have  suffered  from  eczema.  The  local  cause 
may  be  any  form  of  irritation  in  the  nose  or  pharynx — hypertrophic  rhin- 
itis, adenoid  growths  of  the  pharynx,  hypertrophied  tonsils,  or  elongated 
uvula — or  in  the  bronchial  mucous  membrane,  as  a  result  of  previous 
attacks  of  acute  bronchitis.  It  is  probable  that  it  may  also  be  caused 
by  the  irritation  of  enlarged  bronchial  glands.  In  susceptible  children,  a 
paroxysm  may  be  excited  by  high  winds,  dust,  cold  and  damp  air,  indi- 
gestion, constipation  or  the  inhalation  of  substances  such  as  the  pollen 
of  certain  plants,  especially  rag-weed,  golden-rod  and  roses.  Contact 
with  animals,  especially  horses,  cats  and  dogs  may  also  initiate  an  attack. 
It  has  been  recently  shown,  by  Schloss  and  Talbot  particularly,  that 
certain  foods,  especially  eggs  and  rarely  milk,  pork  and  other  meats 
are  responsible  for  attacks  in  certain  children.  There  can  be  no  doubt 
that  this  susceptibility  to  the  pollen  of  plants,  to  contact  with  animals 
and  to  various  foods  is  a  phenomenon  closely  allied  to  that  of  anaphylaxis. 
Cutaneous  and  intracutaneous  tests  have  shown  not  only  the  production 
of  urticarial  wheals,  at  the  site  of  the  test,  but  have  also  initiated  attacks 
of  asthma.  In  certain  instances  the  susceptibility  to  these  protein  sub- 
stances is  inherited ;  in  others  it  is  perhaps  the  result  of  an  active  sensiti- 
zation, but  in  many  instances  there  is  no  sufficient  explanation  as  to  how 
the  child  has  become  sensitized.  The  constriction  of  the  bronchi,  which 
causes  many  of  the  symptoms  of  asthma,  is  probably  chiefly  due  to  the 
contraction  of  the  unstriped  circular  muscular  fibers  in  the  walls  of  the 
bronchi.  Swelling  of  the  mucous  membrane,  either  by  dilatation  of  the 
blood  vessels  or  by  exudation  of  the  serum  into  the  mucous  membrane 
itself  undoubtedly  is  a  factor  of  importance  in  some  instances. 

Symptoms. — Four  quite  distinct  clinical  types  of  asthma  are  seen  in 
children:  (1)  Cases  which  in  their  onset  simulate  attacks  of  bronchitis; 
(2)  those  in  which  asthmatic  symptoms  follow  an  attack  of  bronchitis, 
continuing  for  weeks  or  months,  but  not  necessarily  recurring;  (3) 
hay  fever,  or  the  periodical  form  whi(;h  occurs  every  summer;  (4)  that 
which  resembles  the  ordinary  adult  asthma,  with  the  nervous  element 
predominating.     The  prominence  of  the  catarrhal   symptoms   is  char- 


ASTHMA  489 

acteristic  of  all  forms  of  asthma  in  children,  the  first  two  varieties 
mentioned  being  peculiar  to  early  life. 

Attacks  Resembling  Acute  Bronchitis. — These  cases  are  rare,  but 
may  be  seen  even  in  infants.  The  onset  is  sudden,  with  moderate  fever, 
incessant  cough,  severe  dyspnea,  and  sometimes  cyanosis,  prostration, 
and  cold  extremities.  The  chest  is  filled  with  sonorous,  sibilant,  and 
soon  with  subcrepitant  rales.  Instead  of  running  the  usual  course  of 
bronchitis  of  the  finer  tubes,  the  symptoms  may  pass  away  very  rapidly, 
and  in  forty-eight,  sometimes  in  twenty-four,  hours  the  patient  may  be 
quite  well.  It  is  only  by  the  course  of  the  disease  and  by  recurring  at- 
tacks that  their  true  nature  can  be  recognized.  In  infants  this  form  of 
asthma  may  be  fatal. 

Cases  Folloiving  Attacks  of  Bronchitis — Catarrhal  Asthma. — This 
form  is  not  uncommon,  though  it  is  frequently  designated  by  some  other 
term  than  asthma — ^sometimes  as  spasmodic  bronchitis,  or  catarrhal 
spasm  of  the  bronchi.  The  symptoms  are,  however,  indistinguishable 
from  asthma,  and  they  evidently  belong  in  the  same  category.  This 
form  is  usually  seen  in  infants,  being  rare  after  the  third  year.  Many 
of  the  patients  are  rachitic ;  others  have  large  tonsils,  or  adenoid  growths 
of  the  pharynx;  while  in  still  others  there  is  every  reason  to  suspect 
the  presence  of  large  bronchial  glands.  Usually  there  is  nothing  pecu- 
liar about  the  antecedent  bronchitis;  in  most  cases  it  is  not  especially 
severe,  and  is  limited  to  the  larger  tubes.  The  febrile  symptoms  subside 
in  a  few  days,  but  the  cough  continues,  as  do  also  the  dyspnea  and 
wheezing.  When  the  symptoms  are  fairly  established  they  are  very 
uniform  and  characteristic.  The  respiration  is  accelerated,  usually 
to  50  or  60,  sometimes  to  70  or  80,  a  minute.  The  temperature  from 
time  to  time  may  be  very  slightly  elevated,  or  it  may  remain  normal. 
The  respiration  is  noisy,  labored,  and  accompanied  by  distinct  wheez- 
ing. 

On  auscultation,  there  is  prolonged  expiration  accompanied  by  loud, 
wheezing  and  sonorous,  or  sibilant  rales,  and  occasionally  coarse  moist 
rales  are  heard.  In  cases  which  have  lasted  some  time  a  moderate  amount 
of  emphysema  can  be  inferred  from  the  prominence  of  the  infraclavicular 
regions,  and  exaggerated  resonance  over  the  chest  in  front  and  the  de- 
pression of  the  bases  posteriorly. 

These  symptoms  and  signs  often  continue  for  three  or  four  weeks. 
While  they  are  constantly  present,  they  vary  in  intensity  from  time  to 
time,  being  usually  much  worse  at  night.  The  symptoms  are  always 
increased  by  exposure  to  a  cold,  damp  atmosphere,  by  any  fresh  acces- 
sion of  bronchitis,  and  often  by  trivial  digestive  disturbances.  The  cough 
is  not  usually  severe,  and  expectoration  in  most  cases  is  absent.  The 
general  health  is  often  but  little  affected.    With  recovery  from  the  astli- 


490  DISEASES  OF  THE  RESPIRATORY  SYSTEIM 

matic  symptoms  the  emphysema  usually  disappears  gradually,  although 
we  have  seen  severe  cases  in  which  it  persisted. 

What  proportion  of  these  children  afterward  develop  ordinary  asthma, 
we  are  unable  from  personal  experience  to  say.  Some  undoubtedly  do, 
but  in  others  which  we  have  been  able  to  follow,  recovery  has  seemed  to 
be  permanent.  This  would  appear  more  likely  in  those  cases  closely 
associated  with  rickets,  or  with  other  causes  which  disappear  spontane- 
ously with  time  or  as  a  result  of  treatment. 

Hay  Fever. — This  is  very  rare  before  the  seventh  year  and  but  few 
well-marked  cases  are  seen  before  the  tenth  j^ear.  In  its  clinical  aspects 
it  does  not  differ  essentially  from  the  disease  as  seen  in  adults,  except 
possibly  by  the  greater  prominence  of  the  bronchial  catarrh. 

Ordinary  Aiiacks  of  the  Adult  Type. — These  usually  occur  at  inter- 
vals of  a  few  weeks  or  months,  depending  upon  the  nature  of  the  excit- 
ing cause.  The  beginning  is  usually  at  night  with  dyspnea,  a  short,  dry 
cough,  and  loud,  wheezing  respiration.  Deep  recession  of  the  soft  parts 
of  the  chest  is  seen,  as  in  larjmgeal  stenosis.  There  is  prolonged  expira- 
tion, accompanied  by  loud,  sonorous,  sibilant  and  wheezing  rales,  and 
the  vesicular  murmur  is  very  feeble.  Later,  moist  rales  may  be  heard. 
After  many  attacks  emphysema  is  present.  This  occurs  more  rapidly 
than  in  adults,  and  may  be  extreme,  giving  rise  in  marked  cases  to 
serious  thoracic  deformity.  On  account  of  the  loss  of  sleep  and  interfer- 
ence with  nutrition,  the  general  health  may  become  seriously  impaired. 
Urticarial  wheals  are  not  infrequently  present  at  some  time  during  an 
attack. 

Diagnosis. — Typical  attacks  of  asthma  are  easily  recognized.  Some 
of  the  catarrhal  forms  seen  in  infancy,  however,  present  some  difficulty, 
and  a  positive  diagnosis  may  be  impossible  except  by  the  progress  of  the 
case.  The  presence  of  urticaria  speaks  strongly  for  asthma.  The  blood 
picture  in  asthma  is  characteristic  and  of  much  value  in  diagnosis. 
The  important  thing  is  the  presence  of  a  large  number  of  eosinophile 
cells.  They  may  form  as  high  as  15  to  20  per  cent  of  the  leucocytes. 
In  a  series  of  cases  examined  in  one  of  our  clinics  by  Wile,  the  average 
was  10.7  per  cent;  the  highest  observed  being  26  per  cent.  The  eosino- 
philia  is  greatest  at  the  height  of  the  attack.  The  blood  examination 
serves  to  differentiate  asthma  from  simple  bronchitis  and  from  tubercu- 
losis. The  existence  of  marked  eosinophilia  definitely  establishes  the 
asthmatic  character  of  some  of  these  attacks  in  infancy.  Eosinophile 
cells  are  commonly  found  in  the  sputum.  Charcot-Leyden  crystals  and 
Curschmann's  spirals  may  also  be  seen  but  much  less  frequently  and 
usually  only  in  the  sputum  of  older  children. 

Prognosis. — This  is  best  in  the  cases  of  catarrhal  asthma  in  infants, 
and  in  older  patients  when  it  depends  upon  some  local  cause  which  can 


ASTHMA  491 

be  removed,  as  when  the  disease  is  due  to  reflex  nasal  or  pharyngeal 
irritation.  In  the  majority  of  other  cases,  asthma  is  likely  to  become 
chronic  unless  the  child  is  removed  to  some  climate  in  which  the  attacks 
do  not  occur.  The  younger  the  child,  the  shorter  the  duration  of  the 
disease,  and  the  less  marked  the  hereditary  tendency,  the  better  the 
prognosis.  In  tho^'se  children  that  are  sensitive  to  the  pollen  of  plants 
and  to  certain  foods  there  is  reason  to  believe  that  specific  treatment  by 
immunization  may  be  of  benefit.  The  results  with  hay  fever  have  been 
encouraging  and  Talbot  was  able  to  prevent,  or  diminish  greatly,  the 
attacks  in  some  of  his  patients  especially  those  who  were  sensitive  to 

egg- 
Treatment.— The  nose  and  the  rhinopharynx  should  be  carefully 
examined  in  every  case  of  asthma,  and  any  pathological  condition  there 
present  should  receive  attention  as  the  first  step  in  the  treatment.  Im- 
portance, in  children,  should  be  attached  to  the  removal  of  adenoid 
growths  of  the  pharynx.  We  must  admit,  however,  to  have  seen  very 
feAV  cases  of  asthma  cured  or  even  greatly  improved  by  this  means. 
During  attacks,  the  best  means  of  relieving  the  symptoms  is  the  inhalation 
of  fumes  of  nitre  paper  or  stramonium  leaves.  Most  of  the  proprietary 
remedies  contain  these  ingredients.  The  sleeping  room  may  be  filled  with 
the  fumes  of  these  substances,  or  the  child  may  be  placed  in  a  tent  into 
which  the  fumes  are  introduced.  Emetics  may  be  employed  when  the 
attack  is  brought  on  by  indigestion.  To  prevent  the  recurrence  of  night 
attacks,  antipyrin  is  valuable  given  in  full  doses  at  bedtime — four  grains 
at  five  years  and  six  grains  at  ten  years.  Between  the  attacks  the  syrup 
of  hydriodic  acid  (for  a  child  of  five  years  one-half  teaspoouful,  t.i.d.) 
or  potassium  iodid  (gr.  ii  to  gr.  iv,  t.i.d.),  may  be  given  for  a  number 
of  weeks.  Tonics  are  often  useful.  Those  especially  valuable  in  asth- 
matic patients  are  cinchonidia  (gr.  ii,  t.i.d.)  and  arsenic  (gr.  1-100, 
t.i.d.).  They  may  be  advantageously  combined.  Cocain  used  locally 
in  the  throat  and  opium  by  mouth  or  hypodermically  will  often  cause 
a  cessation  of  attacks  but  are  objectionable  with  older  children  on  ac- 
count of  the  tendency  to  the  formation  of  a  drug  habit.  On  account  of 
their  susceptibility  to  the  drug,  cocain  is  dangerous  with  infants  and 
very  young  children. 

In  the  severe  acute  attacks  nothing  gives  so  much  immediate  relief  as 
the  use  of  epinephrin  intramuscularly — dose  fUv  to  fUviii,  for  a  child  of 
three  years. 

In  the  cases  of  catarrhal  asthma  following  bronchitis,  expectorants 
and  ordinary  cough  remedies  are  useless.  Cod-liver  oil  and  the  iodid  of 
potassium  are  valuable  in  some  of  the  cases.  Others  are  greatly  relieved 
by  the  regular  use  of  creosote  inhalations  several  times  a  day,  with  a 
nightly  dose  of  antipyrin.     The  fumes  of  nitre  and  stramonium  often 


492  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

afford  no  relief,  and  sometimes  the  cases  are  made  distinctly  worse  by 
them.  The  best  of  all  measures  is  to  send  the  child  at  once  to  a  warm, 
dry  climate. 

Very  careful  attention  should  be  given  to  the  diet ;  articles  to  be 
avoided  with  most  asthmatic  children  are  cream,  eggs,  and  all  sweets. 
For  all  children  who  have  had  repeated  attacks,  whether  in  the  form 
of  hay  fever  or  for  those  whose  asthma  is  chiefly  in  the  winter  and  spring 
and  excited  by  attacks  of  bronchitis,  the  most  important  thing  is  re- 
moval to  a  place  where  they  do  not  have  the  disease,  and  a  residence 
there  long  enough  to  break  up  the  tendency  to  recurrence.  This  will 
usually  require  several  years.  The  region  best  suited  to  most  asthmatics 
is  one  which  is  high,  dry,  and  moderately  warm.  Some  do  exceedingly 
well  at  the  seashore;  others  much  better  in  the  mountains.  Patients 
often  suffer  less  in  cities  than  in  the  country. 

Children  who  are  susceptible  to  the  odor  of  animals  should  be  kept 
from  contact  with  them.  Those  who  are  sensitive  to  proteins  of  certain 
foods  should  have  these  eliminated  from  the  diet  after  it  has  been  de- 
termined which  are  the  proteins  responsiljle.  Immunization  by  the  in- 
gestion of  very  small  quantities  of  the  proteins  has  been  practiced  by 
Schloss  and  Talbot  with  marked  success  in  some  instances.  The  method 
is  still  in  the  experimental  stage  and  should  be  employed  "nith  caution. 

Those  children  who  are  sensitive  to  pollen  should  spend  the  weeks  in 
which  the  plants  are  in  bloom  in  the  mountains  or  at  some  place  where 
they  are  not  exposed.  Distinct  benefit  has  been  obtained  by  immuniza- 
tion against  pollen  in  the  hay'  fever  and  asthma  of  adults.  It  is  as  yet  too 
early  to  say  what  the  effect  of  this  form  of  treatment  will  be  with  chil- 
dren. It  should  be  attempted  only  by  one  trained  in  the  methods  of 
immunity. 


CHAPTEE  IV 
DISEASES   OF    THE   LUNGS— (Continued) 

PNEUMONIA 

Ix  early  life  the  lungs  are  more  frequently  the  seat  of  organic  disease 
than  any  other  organs  in  the  body.  Pneumonia  is  very  common  as  a 
primary  disease,  and  ranks  first  as  a  complication  of  the  various  forms 
of  acute  infectious  disease  of  children.  It  is  one  of  the  largest  factors 
in  the  mortality  of  infancy  and  childhood. 


PNEUMONIA 


4«3 


Cases  of  acute  pneumonia  are  divided,  from  an  anatomical  point  of 
view,  into  two  principal  groups :  ( 1 )  bronchopneumonia,  also  known  as 
catarrhal  and  as  lobular  pneumonia;  (2)  lobar  pneumonia,  also  known 
as  croupous  and  as  fibrinous  pneumonia.  These  differ  little  from  each 
other  in  etiology,  but  considerably  in  the  products  of  inflammation,  the 
distribution  of  the  disease  in  the  lung,  and  somewhat  as  to  the  parts 
involved  and  the  nature  of  the  changes  in  them. 


*  '•  *^lt  •  '^  ♦ 


Fig.  46. — Bronchopneumonia.  The  picture  shows  at  its  center  one  entire  air  vesicle, 
and  at  its  margin  parts  of  four  or  five  other  vesicles ;  they  are  filled  with  large  epi- 
thelial cells  having  small  nuclei.  There  are  also  seen  leucocytes  with  intensely 
black  nuclei  and  narrow  protoplasm.  Between  the  cells  is  a  finely  granular  ma- 
terial, which  is  the  exudation  fluid  coagulated  during  the  hardening  process.  The 
alveolar  septa  are  somewhat  infiltrated. — Prom  Karg  and  Schmorl. 


In  bronchopneumonia  the  large  bronchi  are  the  seat  of  a  superficial 
inflammation,  while  in  those  of  small  size  the  entire  bronchial  wall  is 
affected;  the  exudation  into  the  air  vesicles  is  mainly  cellular,  being 
made  up  of  epithelial  cells,  leucocytes,  and  red  blood-cells  (Fig.  46), 
fibrin  being  either  absent,  or  present  only  in  small  amount.  In  many 
cases  there  are  marked  changes  both  in  the  alveolar  septa  and  in  the 
interstitial  tissue  of  the  lung;  resolution  is  often  imperfect,  and  there 
is  a  strong  tendency  for  the  inflammation  to  pass  into  a  chronic  form, 
involving  the  connective-tissue  framework  of  the  lung.  The  lesion  is 
widely  and  often  irregularly  distributed,  usually  being  most  marked  in 


494 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


the  vicinity  of  the  small  bronchi  from  which  the  inflammation  spreads, 
and  in  the  most  superficial  lobules  of  the  lung. 

In  lobar  pneumonia,  bronchitis,  when  present,  is  usually  superficial, 
the  walls  of  the  bronchi  being  very  slightly  or  not  at  all  affected;  the 
same  is  true  of  the  alveolar  septa.  The  principal  product  of  the  inflam- 
mation is  fibrin  (Fig.  47),  which  fills  the  alveoli  and  the  terminal  bron- 
chi, the  cells  being  relatively  few  and  chiefly  leucocytes.     The  process  is 


Fig.  47. — Lobar  Pneumonia.  In  the  air  vesicle  shown  in  the  picture  there  is  a  firm, 
close  network  of  fibrin,  in  the  meshes  of  which  are  leucocytes.  At  the  lower  part  the 
exudation  has  contracted  away  from  the  wall  in  consequence  of  the  process  of  hard- 
ening.— From  Karg  and  Schmorl. 


usually  sharply  circumscribed,  involving  an  entire  lobe  or  a  part  of  a 
lobe.  In  most  cases  it  clears  up  rapidly  and  completely,  there  being  but 
little  tendency  to  involve  the  framework  of  the  lung  in  a  chronic  process. 
While  in  typical  cases  the  two  forms  of  inflammation  are  quite  dis- 
tinct, there  are  seen  many  intermediate  forms  which  partake  of  the  char- 
acters of  both,  and  one  may  be  in  doubt,  even  after  a  microscopical  ex- 
amination, in  which  group  to  place  a  case.  It  not  infrequently  happens 
that  both  varieties  of  pneumonia  are  present  in  different  parts  of  the 
same  lung  or  in  both  lungs  at  the  same  time.  These  mixed  forms  are 
especially  frequent  during  the  second  and  third  years ;  but  during  the 
first  year,  and  after  the  third,  the  types  are  usually  well  marked. 


PNEUMONIA  495 

The  following  table  shows  the  relative  frequency  of  lobar  and  broncho- 
pneumonia in  three  hundred  and  seventy  cases/  nearly  all  taken  froro. 
one  institution  (New  York  Infant  Asylum).  They  include  all  the  cases 
of  acute  primary  pneumonia  occurring  during  seven  years : 

Under  six  months,  bronchopneumonia,  73  cases;  lobar  pneumonia,  11  cases. 

Six  to  twelve  "  "  96      "  "  "  29      « 

Second  year,  "  73      "  "  "  40      " 

Third        «  "  19      "  "  "  23      " 

Fourth     "  «  0      "  "  "  6      " 

Totals,  «  261      "         "  "         109      " 

Thus  it  will  be  seen  that,  of  the  cases  of  acute  pneumonia  occurring 
during  the  first  two  years,  twenty-five  per  cent  were  lobar  and  seventy- 
five  per  cent  were  bronchopneumonia. 

When  we  come  to  a  consideration  of  the  microorganisms  with  which 
the  different  forms  of  pneumonia  are  associated,  we  find  that  they  do 
not  correspond  to  the  anatomical  varieties.  Lobar  pneumonia  is  regu- 
larly associated  with  the  presence  of  the  pneumococcus,  rarely  with  Fried- 
lander's  bacillus,  but  in  a  large  number  of  cases  other  organisms  are 
also  found.  In  bronchopneumonia  there  is  almost  always  a  mixed  infec- 
tion. In  the  primary  cases  the  pneumococcus  is  usually  the  predominant 
organism,  but  it  is  commonly  associated  with  the  staphjdococcus  aureus. 
In  the  secondary  cases,  especially  when  pneumonia  follows  measles  or 
scarlet  fever,  the  streptococcus  is  usually  present,  such  cases  being  gen- 
erally of  a  severe  type.  In  the  pneumonia  of  diphtheria,  besides  the 
streptococcus  the  diphtheria  bacillus  is  frequently  found.  In  winter  the 
bacillus  of  influenza  may  be  the  only  organism  present,  but  it  is  usually 
associated  with  the  pneumococcus.  The  organisms  mentioned  are  found 
in  all  possible  combinations,  sometimes  one  and  sometimes  another  pre- 
dominating. With  any  of  them  the  bacillus  of  tuberculosis  may  be 
found. 

Much  interest  has  recently  been  aroused  in  the  different  types  of 
pneumococci  which  are  found  in  acute  pneumonia.^  Of  the  cases  studied 
thus  far  in  young  children,  type  iv  of  Cole's  classification,  has  been 
much  the  most  frequently  present;  but  all  the  forms  found  in  adults 
have  been  observed.  In  a  series  of  50  cases  studied  at  the  Babies'  Hos- 
pital nearly  75  per  cent  were  type  iv. 


^  The  division  was  here  made  according  to  the  predominant  clinical  or  patho- 
logical features.    Most  of  the  doubtful  cases  were  classed  as  bronchopneumonia. 

^  According  to  the  researches  of  Cole  of  the  Rockefeller  Institute  pneu- 
mococci may  be  divided  into  four  groups  or  types.  Nos.  r,  ii  and  in  have  definite 
individual  characteristics;  iv  includes  the  remainder  or  unclassified  group.  The 
differentiation  is  made  by  animal  inoculation  and  requires  from  twelve  to 
twenty-four  hours.    For  type  i  he  has  produced  a  serum  from  immunized  horses 


496  DISEASES  OF  THE  RESPIRATOEY  SYSTEM 

Some  idea  of  the  nature  of  the  infection  in  pneumonia  may  be 
gained  from  the  following  table.  The  sputum  cultures  represent  the 
pneumonias  of  one  winter  and  spring  in  the  Babies'  Hospital,  and  the 
post-mortem  cultures  from  those  of  two  seasons  in  the  same  institution : 


Sputum  cultures  from  124 
cases  of  pneumonia. 


Post-mortem  cultures  from  the 
lungs  in  76  cases  of  pneumonia. 


Staphylococcus  aureus . 

Pneumococcus 

Streptococcus 

Bacillus  influenzae 


in  116  cases 

"  94      " 

"  63      " 

"  47      " 


36  (alone  in  8) 
26  (  "  "  4) 
17  (  "  "  1) 
19  (    "       "  2) 


Why  the  same  exciting  cause  in  one  case  produces  bronchopneumonia, 
and  in  another  lobar  pneumonia  may  be  in  part  owing  to  the  difference 
in  the  structure  of  the  lung  at  the  different  ages,  especially  the  relatively 
large  size  of  the  bronchi  in  infancy.  Again,  in  very  young  and  in  feeble 
children,  the  process  tends  to  become  diffuse  and  the  products  are  chiefly 
cellular;  in  those  who  are  older  and  more  vigorous  it  is  likely  to  be 
circumscribed,  with  fibrin  as  its  chief  product;  in  the  intermediate  ages 
and  intermediate  conditions  the  types  are  often  mingled. 

The  immediate  source  of  infection  of  the  lungs  is  the  mouth  or  the 
rhinopharynx.  All  the  forms  of  bacteria  found  in  pneumonia  may  be 
found  in  these  cavities,  some  of  them  constantly,  others  only  at  certain 
times,  especially  during  an  attack  of  any  of  the  acute  infectious  diseases. 
Provided  the  other  conditions  are  favorable,  pneumonia  may  be  excited 
by  direct  contagion.  This  plays  a  small  part  in  inducing  primary  pneu- 
monia ;  there  seems,  however,  to  be  little  doubt  that  the  secondary  forms, 
especially  the  pneumonia  complicating  measles,  diphtheria  and  influenza, 
are  not  infrequently  communicated  in  this  way. 

which  has  been  shown  to  have  distinctly  curative  effects.  Thus  far  no  satis- 
factory serum  for  the  other  groups  has  been  produced.  As  the  serum  is-  not 
effective  in  infections  due  to  other  types  than  i,  it  is  of  little  assistance  in 
the  pneumonias  of  young  children  since  few  of  the  cases  of  pneumonia  at  this 
age  are  due  to  this  type  of  organism.  The  serum  is  not  j^et  available  for 
general  use. 

The  pneumococci  of  types  i  and  ii  are  seldom  found  except  in  the  mouths 
of  persons  suffering  from  pneumonia  or  those  in  contact  with  them.  Type 
IV  is  the  form  which  is  most  widely  diffused  and  is  frequently  found  in  the 
mouths  of  healthy  persons.  The  pneumonia  associated  with  type  iv  in  adults 
is  usually  of  the  mildest  variety  seen.  The  fact  that  this  is  the  type  of  or- 
ganism usually  found  in  the  pneumonias  of  children  probably  accounts  for  the 
low  mortality  from  primary  pneumonia  in  patients  over  two  years  of  age.  In 
infants  and  young  children,  however,  pneumonia  associated  with  type  iv  may 
be  very  severe. 


ACUTE  BRONCHOPNEUMONIA  497 

The  different  forms  of  pneumonia  which  will  be  considered  are:  (1) 
Acute  bronchopneumonia ;  (2)  acute  lobar  pneumonia ;  (3)  acute  pleuro- 
pneumonia; (4)  hypostatic  pneumonia;  (5)  chronic  bronchopneumonia. 

Tuberculous  bronchopneumonia  will  be  discussed  in  the  chapter 
devoted  to  Tuberculosis. 


ACUTE  BRONCHOPNEUMONIA 

(Catarrhal  Pneumonia;   Lobular  Pneumonia;   Capillary  Bronchitis) 

This  is  essentially  the  pneumonia  of  infancy.  Under  two  years,  the 
great  majority  of  the  cases  of  primary  pneumonia  are  of  this  variety,  and 
throughout  childhood  nearly  all  the  cases  of  secondary  pneumonia.  The 
term  bronchopneumonia  describes  a  lesion  rather  than  a  disease,  several 
quite  distinct  forms  of  infection  being  included  under  this  head.  Its 
mortality  is  high,  because  of  the  tender  age  of  the  patients  in  which  the 
primary  cases  occur,  and  also  because  when  secondary  it  complicates  the 
most  severe  forms  of  the  acute  infectious  diseases  of  children. 

Etiology. — The  distribution,  according  to  age,  of  436  cases  of 
bronchopneumonia  was  as  follows : 

During  the  first  year 224  cases,  or  53  per  cent. 

"         "    second  year 142      "       "33     "      " 

"    third        " 46      "       "11     "      " 

"    fourth      "    10      "       "     2     "      « 

«         "    fifth         "    4      "       "      1    "      " 

426  100 

After  four  years  bronchopneumonia  is  infrequent  as  a  primary  dis- 
ease, although  it  is  seen  throughout  childhood  as  a  complication  of  the 
infectious  diseases. 

Of  the  cases  referred  to,  38  per  cent  occurred  during  the  winter 
months,  31  per  cent  during  the  spring,  13  per  cent  during  the  summer, 
and  18  per  cent  during  the  autumn.  While,  therefore,  nearly  70  per  cent 
of  the  cases  occurred  in  the  cold  months,  bronchopneumonia  is  seen 
throughout  the  year. 

Bronchopneumonia  affects  all  classes,  but  is  most  frequent  in  chil- 
dren having  poor  hygienic  surroundings,  especially  in  inmates  of  institu- 
tions, and  in  those  previously  debilitated  by  constitutional  or  local  dis- 
ease. In  246  consecutive  cases  of  primary  pneumonia,  110  were  in  good 
condition  prior  to  the  attack,  and  126  were  delicate,  rachitic,  or  syphilitic. 

The  following  table  gives  a  good  idea  of  the  conditions  with  which 
acute  bronchopneumonia  is  most  frequently  seen ;  443  cases  were  classed, 
as  follows : 


498  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Primiry  ^ 164 

Secondary  to  bronchitis  of  the  large  tubes 41 

Complicating  measles 89 

"            pertussis 66 

"             diphtheria 47 

"            acute  ileocolitis 19 

"            scarlet  fever 7 

"            influenza 6 

"            varicella 2 

"             erysipelas  . 2 

443 

A  large  number  of  the  patients  had  previously  suffered  from  one  or 
.more  attacks  of  bronchitis,  and  fifteen  previously  had  bronchopneumonia. 

As  an  exciting  cause,  exposure  to  cold  must  still  be  classed  among  the 
potent  factors  of  primary  pneumonia.  The  organisms  concerned  in 
bronchopneumonia  have  been  discussed  in  the  previous  pages. 

Lesions. — The  term  bronchopneumonia  is  now  generally  adopted  as 
a  generic  one,  and  it  is  to  be  preferred  either  to  lobular  or  catarrhal 
pneumonia,  as  it  gives  prominence  to  the  bronchial  element  in  the  inflam- 
mation. The  process  may  begin  in  the  larger  tubes  and  gradually  extend 
to  those  of  smaller  caliber,  finally  involving  the  pulmonary  lobules  in 
which  these  tubes  terminate ;  or  it  may  extend  to  the  air  vesicles  which 
surround  the  tube  in  its  course  through  the  lung,  so  that  in  whatever 
direction  the  lung  is  cut,  there  are  seen,  surrounding  the  small  bronchi, 
zones  of  pneumonia  (Fig.  -iS).  In  other  cases  the  process  seems  to  begin 
almost  at  the  same  time  in  the  small  bronchi  and  the  air  vesicles,  as  both 
are  found  involved,  even  when  death  occurs  within  a  few  hours  of  the 
first  sjTuptoms. 

There  are,  however,  cases  in  which  the  parts  of  the  lung  affected 
bear  no  relation  to  the  bronchi — where  there  are  found  simply  smaller 
or  larger  areas  of  pneumonia  irregularly  scattered  through  the  lung, 
usually  near  the  surface  (Plate  A'lII).  From  the  distribution  of  the 
lesions  such  cases  might  better  be  termed  lobular  than  bronchopneu- 
monia. 

]\Iuch  has  been  said  in  the  past  about  pulmonary  collapse  from  ob- 
struction of  the  small  bronchi,  as  a  condition  antecedent  to  this  form  of 
pulmonary  inflammation.  So  far  as  our  observations  go,  there  has 
been  adduced  but  little  evidence  that  this  is  the  rule,  or,  indeed,  that  it 
often  occurs.  Even  in  autopsies  made  very  early  in  the  disease,  but  little 
collapse  is  found,  most  of  the  cases  supporting  the  view  of  Delafleld,  that 
when  the  disease  extends  from  the  bronchi  to  the  air  cells  it  involves 
those  surrounding  the  tube  quite  as  regularly  as  those  to  which  the  tube 
leads. 

^It  is  probable  that  a  number  of  cases  complicating  influenza  were  included 
among  these  primary  cases. 


PLATE  VIII 


Acute  BkonchopneumuxMa 
Primary  pneumonia  in  a  child  two  years  old,  showing  the  irregular  distribution  of 
the  consolidation  and  its  incomplete  character.     A  is  the  pleura  somewhat  thickened; 
B,  lung  tissue  which  is  practically  normal;  C  C  are  consolidated  areas,  scattered  through 
which  are  groups  of  air  vesicles  still  containing  air.     (Slightly  magnified.) 


ACUTE  BRONCHOPNEUMONIA 


499 


The  following  observations  are  made  from  a  study  of  170  autopsies  of 
U'hich  we  have  records,  microscopical  examinations  having  been  made  in 
about  one-third  of  the  number. 

Seat  of  the  Disease. — In  eighty-two  per  cent  of  the  autopsies  extensive 


Fig.  48. — Bronchopneumonia,  with  Thickening  of  a  Bronchus.  In  the  center  of 
the  picture  is  seen  a  small  bronchus,  B,  which  is  cut  somewhat  obliquely;  the  degree 
to  which  its  wall,  C,  is  thickened  is  well  shown.  It  is  partially  filled  with  pus,  its 
mucous  membrane  is  nearly  destroyed,  and  its  walls  greatly  thickened  from  infiltra- 
tion with  leucocytes.  This  infiltration  extends  to  the  lung  tissue  in  the  neighbor- 
hood; it  forms  a  peri-bronchitic  zone  of  pneumonia.  Elsewhere  in  the  picture  the 
lung  tissue.  A,  is  practically  normal.  D  is  a  small  blood-vessel.  E  is  another  smaller 
bronchus.  Throughout  the  lung  everywhere  accompanying  the  small  bronchi  similar 
changes  were  seen,  in  addition  to  which  there  were  present  some  large  areas  of  con- 
solidation. The  disease  was  of  four  and  a  half  weeks'  duration;  the  child,  five 
months  old. 


disease  was  found  in  both  lungs.  The  parts  most  affected  were  the  lower 
lobes  posteriorly;  next  to  this  the  posterior  part  of  both  the  upper  and 
lower  lobes.    The  left  lower  lobe  was  more  extensively  diseased  than  the 


500  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

right  in  over  two-thirds  of  the  cases.    If  the  pneumonia  is  in  front  only, 
the  right  apex  is  the  most  frequent  seat. 

There  are  a  certain  number  of  cases  which  appear  to  follow  tolerably 
well-defined  stages  of  congestion,  consolidation,  and  resolution ;  but  the 
disease  may  be  arrested  at  any  of  the  stages  and  the  child  recover,  or 
death  may  occur  at  any  stage  and  there  may  be  found  at  autopsy  difEer- 
ent  portions  of  the  lung  representing  all  the  stages  mentioned.  In  con- 
sidering, therefore,  the  lesions  of  bronchopneumonia,  it  seems  best  to 
describe  the  condition  in  which  the  lungs  are  found  at  the  various  periods 
when  death  is  likely  to  occur,  rather  than  to  attempt  to  describe  the 
different  stages  of  the  disease,  as  in  lobar  pneumonia. 

1.  The  Acute  Congestive  Form  {Acute  Bed  Piieumonia) . — This  is 
the  condition  in  which  the  lung  is  usually  found  if  death  occurs  during 
the  first  two  or  three  days  of  the  disease.  In  the  cases  severe  enough  to 
cause  death  in  the  first  twenty-four  hours,  very  little  can  be  seen  by  the 
naked  eye  except  acute  congestion.  The  vessels  of  the  pleura  are  dis- 
tended, and  there  may  be  small  superficial  hemorrhages.  Both  lower 
lobes  are  usually  heavy  and  dark  colored.  There  is  to  the  naked  eye 
no  consolidation.  All,  or  nearly  all,  the  lung  can  be  inflated.  On  sec- 
tion, there  is  found  intense  congestion  with  some  edema.  When  the 
process  has  lasted  a  little  longer  the  affected  areas  are  more  sharply 
defined.  These,  usually  the  posterior  portions  of  both  lungs,  are  of  a 
brownish-red  color,  and  appear  partially  consolidated,  although  with 
a  little  force  they  may  in  most  eases  be  inflated.  After  section,  pus  and 
mucus  flow  from  the  divided  bronchi,  and  the  whole  lung  may  be  more 
or  less  congested  or  edematous. 

The  microscope  alone  reveals  the  fact  that  these  are  not  cases  of  sim- 
ple pulmonary  congestion  or  bronchitis  of  the  finer  tubes.  In  one  case 
in  which  death  occurred  twelve  hours  from  the  first  symptoms,  well- 
marked  evidences  of  inflammation  of  the  air  vesicles  were  found.  In 
these  hyper-acute  cases,  the  microscope  shows  great  distention  of  all  the 
small  blood-vessels  of  the  affected  area,  and  small  or  large  extravasations 
of  blood  just  beneath  the  pleura,  into  the  alveoli  and  interstitial  tissue  of 
the  lung.  In  some  cases  these  hemorrhages  form  the  most  striking  feature 
of  the  lesion.  The  air  vesicles  are  partially,  some  almost  completely, 
filled  with  red  blood-cells,  swollen  and  desquamated  epithelial  cells,  and 
a  few  leucocytes  (Fig.  46).  The  red  blood-cells  predominate.  The  in- 
flammation may  be  diffuse,  involving  nearly  a  whole  lobe,  or  in  small 
areas  in  the  neighborhood  of  the  small  bronchi.  The  mucous  mem- 
brane of  the  large  and  small  bronchi  is  the  seat  of  catarrhal  inflamma- 
tion, and  the  walls  of  the  latter  are  infiltrated  with  round  cells. 

When  the  process  has  lasted  from  twenty-four  to  forty-eight  hours 
all  the  changes  described  are  more  marked,  but  the  red  color  of  the 


ACUTE  BRONCHOPNEUMONIA 


501 


inflammatory  products  still  persists.     Such  cases  give  during  life  only 
the  signs  of  congestion  and  bronchitis. 

3.  The  Mottled,  Red  and  Gray  Pneumonia. — This  is  the  usual  ap- 
pearance when  the  disease  has  lasted  somewhat  longer,  and  is  found  in 
most  of  the  cases  dying  between  the  fourth  and  fourteenth  days.  There 
are  usually  at  this  time  quite  large  areas  of  consolidation,  sometimes 
affecting  nearly  an  entire  lobe,  so  that  at  first  sight  the  case  may  resemble 


Fig.  49. — Acute  Bronchopneumonia.  In  the  center  is  shown  a  small  bronchus,  B, 
with  a  zone  of  pneumonia  about  it.  The  greater  part  of  the  section  is  made  up  of 
emphysematous  lung  tissue,  E  E,  showing  dilatation  of  the  alveolar  spaces  and  rup- 
ture of  some  of  the  alveolar  septa.  At  the  border,  AAA,  are  seen  the  margins  of 
consolidated  areas  of  lung. 


lobar  pneumonia.  This  is  sometimes  described  as  the  '^pseudo-lobar" 
form.  The  extent  of  these  areas  depends  largely  upon  the  duration  of 
the  disease.  In  most  cases  there  is  pleurisy  over  the  consolidated  por- 
tions. This  may  cause  the  lung  to  adhere  to  the  chest  wall,  the  firmness 
of  the  adhesions  depending  upon  the  duration  of  the  process.  The  sur- 
face of  the  lung  is  usually  of  a  mottled  red  and  gray  color ;  it  often  has 
a  coarsely  granular  feel,  due  to  the  consolidation  of  some  of  the  super- 
ficial lobules  of  the  lung.  On  section,  it  is  rarely  found  that  an  entire 
lobe  is  consolidated,  the  superficial  portion  being  most  affected,  while 


502  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

the  central  part  is  normal  or  only  congested.  The  color  is  mottled,  like 
that  of  the  surface.  In  some  places  the  consolidation  appears  complete; 
in  others  the  consolidated  areas  are  separated  by  healthy,  congested,  or 
emphysematous  lung  tissue  (Fig.  49).  The  gray  areas  surround  the 
small  bronchi  and  vary  in  size.     The  smallest  ones  look  very  much  like 


Fig.  50. — Bronchopneumonia.  Dense  infiltration  of  pus  cells  in  and  about  a  small 
bronchus;  under  a  low  power.  The  cavity  shown  in  the  specimen  is  a  cross-section 
of  one  of  the  small  bronchi,  which  is  partially  filled  with  pus  cells;  the  epithelium  is 
destroyed.  The  bronchial  wall  and  the  pulmonary  tissue  in  the  neighborhood  are  so 
densely  infiltrated  with  leucocytes  that  almost  every  trace  of  normal  structure  is 
effaced.  Child  fifteen  months  old,  disease  of  four  weeks'  duration.  Extensive  areas 
like  this  were  found  in  both  lungs. 

miliary  tubercles.  The  larger  ones  are  seen  where  the  process  has  existed 
for  a  longer  time  and  has  gradually  invaded  the  contiguous  air  cells.  If 
the  lung  is  cut  parallel  with  the  bronchi,  there  may  be  seen  small  gray 
striae  of  pneumonia  along  their  course  (Fig.  48,  C).  From  the  cut 
bronchi,  pus  flows  quite  freely  on  pressure.  The  bronchial  walls  are 
often  seen  to  be  thickened  even  by  the  naked  eye.     The  parts  affected 


ACUTE  BRONCHOPNEUMONIA  503 

are  usually  the  posterior  portions  of  the  lower  lobe  of  one  or  both  sides, 
the  remainder  of  the  lobes  being  congested  or  edematous,  while  in  front 
the  lung  is  emphysematous. 

Under  the  microscope  the  smaller  bronchi  (Fig.  48)  are  seen  to  be 
much  thickened  and  infiltrated  with  leucocytes.  The  gray  areas  sur- 
rounding the  bronchi  are  made  up  of  groups  of  air  vesicles,  which  are 
packed  with  leucocytes  (Fig.  50).  Fibrin  is  sometimes  seen  in  small 
amount,  also  red  blood-cells  and  desquamated  epithelial  cells,  but  the 
leucocytes  predominate.  Surrounding  the  areas  densely  infiltrated  are 
groups  of  air  vesicles  which  are  normal  or  congested,  or  which  show 
only  the  earlier  stages  of  the  inflammatory  process. 

3.  Gray  Pneumonia  {Persistent  Bronchopneumonia) . — This  form  is 
seen  in  protracted  cases  when  there  have  been  continuous  symptoms 
usually  for  from  three  to  six  weeks.  The  pleuritic  adhesions  are  more 
general  and  firmer.  The  amount  of  lung  involved  may  be  very  great, 
often  nearly  the  whole  of  both  lungs  posteriorly.  The  affected  lung  ap- 
pears completely  consolidated  and  slightly  enlarged.  On  section,  it  is 
of  a  nearly  uniform  gray  color,  sometimes  of  a  yellowish-gray.  On 
pressure,  pus  exudes  from  the  smaller  and  larger  bronchi.  The  bronchial 
walls  are  markedly  thickened,  and  in  some  places  there  may  be  a  slight 
dilatation  of  the  smaller  bronchi.  The  part  of  the  lung  not  consolidated 
may  be  almost  white,  owing  to  vesicular  emphysema.  In  some  cases 
there  is  also  interstitial  emphysema.  Small  cavities  containing  pus  may 
be  found  in  the  lung.  The  bronchial  glands  are  frequently  swollen  to 
the  size  of  a  large  bean,  and  are  of  a  reddish-gray  color. 

The  microscope  shows  that  the  air  vesicles  of  the  consolidated  por- 
tions are  distended  chiefly  with  leucocytes,  but  there  are  also  epithelial 
and  connective-tissue  cells.  The  alveolar  septa  may  be  so  much  thick- 
ened as  to  encroach  upon  the  alveolar  spaces  (Fig.  51).  Complete  reso- 
hition  is  then  impossible. 

Termination. — Death  may  occur  at  any  stage,  or  the  pathological 
process  may  be  arrested  at  any  stage  and  the  case  go  on  to  recovery. 
Eesolution  may  take  place  before  any  consolidation  recognizable  by  physi- 
cal signs  has  occurred;  in  such  cases  it  is  usually  rapid  and  complete. 
If  there  has  been  consolidation,  resolution  may  take  place  after  two  or 
three  weeks  and  be  complete,  or  it  may  be  delayed  for  five  or  six  weeks 
and  still  be  complete.  In  many  cases,  especially  those  in  which  it  is 
delayed,  resolution  is  only  partial,  and  there  are  relapses  or  recurring 
attacks.  After  the  first,  or  after  several  attacks,  there  may  develop  a 
chronic  interstitial  pneumonia;  or  simple  pneumonia  may  be  followed 
by  tuberculosis.  Such  cases  as  these  are  to  be  carefully  distinguished 
from  the  much  more  frequent  ones  in  which  the  bronchopneumonia  is 
tuberculous  from  the  outset. 


504 


DISEASES  OP  THE  RESPIRATORY  SYSTEM 


Associated  Lesions  of  the  Lungs. — Pleurisy  is  almost  invariaWy 
found  over  every  large  area  of  consolidation,  and  in  cases  of  more  than 
three  or  four  days'  duration;  while  in  most  of  those  fatal  within  the 
first  few  days  the  pleura  is  normal  or  only  congested.  It  is  seen  in 
all  grades  of  severity,  from  a  slight  gray  film  of  fibrin  that  can  hardly 
be  stripped  off,  to  a  yellowish-green  exudation  one-fourth  of  an   inch 


Fig.  51. — Persistent  Bronchopneumonia;  Highly  Magnified.  There  is  shown  at 
A  A  marked  thickening  of  the  alveolar  septa,  encroaching  upon  the  alveolar  spaces. 
All  the  alveoli,  B  B,  are  densely  packed  with  leucocytes.  A  similar  condition  also 
through  nearly  the  whole  of  the  affected  lung.  (For  history  and  temperature,  see 
Fig.  60.) 


thick.  A  small  amount  of  serum — two  or  three  ounces — in  the  pleural  sac 
is  common,  but  a  large  serous  effusion  is  very  rare.  Cases  in  which  there 
is  an  excessive  inflammation  of  the  pleura  are  considered  elsewhere 
under,  the  head  of  Pleuropneumonia.  Empyema  occurs  both  during  the 
stage  of  acute  inflammation  of  the  lung  and  while  this  is  subsiding, 
but  it  is  less  frequent  than  in  lobar  pneumonia. 

Bronchial  Glands. — In  all  the  recent  acute  cases  these  are  swollen 


ACUTE  BRONCHOPNEUMONIA  505 

and  red;  the  usual  size  is  tliat  of  a  pea  or  a  bean.  They  show  micro- 
scopically the  usual  changes  of  acute  hyperplasia.  In  protracted  cases, 
and  after  repeated  attacks,  they  may  be  two  or  three  times  the  size 
mentioned,  and  of  a  gray  color.  It  is  rare  that  they  are  large  enough 
to  give  rise  to  symptoms  unless  they  become  the  seat  of  tuberculous 
deposits. 

Emphysema. — This  is  one  of  the  regular  and  striking  features  of 
acute  brochopneumonia  in  infancy,  it  being  especially  marked  in  the 
protracted  cases.  It  is  usually  vesicular,  involving  the  greater  part  of 
the  upper  lobes  in  front  and  the  anterior  margin  of  the  lower  lobes.  Oc- 
casionally interstitial  emphysema  is  seen,  forming  either  large  striae 
upon  the  surface  of  the  lung,  or  blebs  of  considerable  size  along  the 
anterior  margin.  This  may  occur  even  in  cases  uncomplicated  by  per- 
tussis or  by  laryngeal  stenosis. 

Gangrene. — Gangrenous  areas  were  found  in  six  cases  of  the  series 
mentioned.  In  four  of  these  the  pneumonia  was  primary,  in  one  it 
followed  diphtheria,  and  in  one  ileocolitis.  It  occurred  in  scattered  areas 
of  a  grayish-green  color,  varying  from  one-fourth  of  an  inch  to  two 
inches  in  diameter. 

Abscesses  of  the  lung  are  by  no  means  uncommon.  They  were  noted 
in  seven  per  cent  of  the  autopsies.  They  are  usually  minute  and  mul- 
tiple, varying  in  size  from  one-sixth  to  one-half  inch  in  diameter.  Some- 
times a  portion  of  a  lobe  is  fairly  honeycombed  with  minute  abscesses. 
In  one  case  a  large  abscess  was  found  occupying  the  greater  part  of  a 
lobe,  the  symptoms  resembling  those  of  empyema.  Abscesses  are  usually 
found  in  regions  where  the  inflammatory  process  has  been  especially 
intense.  They  may  be  found  in  prolonged  cases,  in  those  of  unusual 
severity,  as  shown  by  excessively  high  temperature  and  rapid  extension 
of  the  disease,  and  in  very  delicate  subjects.  The  microscope  shows  that 
these  abscesses  usually  begin  as  an  accumulation  of  pus  in  the  small 
bronchi,  whose  walls  become  softened  and  break  down  on  account  of  the 
intensity  of  the  inflammation'.  They  may  be  superficial,  but  are  more 
commonly  in  the  interior  of  the  lung;  they  contain  yellow  pus  and 
sometimes  broken-down  lung  tissue.  Small  abscesses  can  not  be  recog- 
nized clinically;  the  large  ones  give  the  symptoms  and  signs  of  em- 
pyema. They  are  discussed  more  fully  elsewhere.  In  several  instances 
they  have  been  successfully  operated  on,  though  wrongly  diagnosticated. 

The  lesions  in  other  organs  will  be  considered  under  Complications. 

Symptoms. — Bronchopneumonia  has  no  typical  course.  The  cases 
differ  from  each  other  very  markedly,  but  they  may  be  divided  into  a 
few  quite  distinct  groups. 

1.  The  AcuTp]  Congestivp:;  Type. — This  may  be  seen  at  any  age,  but 
is  more  frequent  in  young  infants.     It  may  be  either  primary  or  sec- 


506  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

ondary,  being  not  uncommon  in  either  form.  Its  symptoms  are  few  and 
irregular,  and  the  disease  is  often  unrecognized.  The  entire  duration, 
may  be  only  twenty-four  hours.  High  temperature,  extreme  prostration, 
cyanosis,  and  rapid  respiration  may  be  the  only  symptoms.  The  tem- 
perature varies  between  104°  and  107°  F.,  usually  rising  steadily  until 
death  occurs.  The  prostration  is  extreme  from  the  outset,  the  patient 
being  overwhelmed  by  the  suddenness  and  severity  of  the  attack. 
Cyanosis  is  frequently  present,  and  is  almost  always  seen  shortly  before 
death.  The  respirations  are  from  60  to  80  a  minute,  but  in  most  cases 
not  strikingly  labored.  Cough  is  frequently  absent.  Cerebral  symptoms 
are  often  marked — dulness  and  apathy,  sometimes  quite  profound  stupor, 
and  not  infrequently  convulsions  Just  before  death.  The  physical,  signs 
are  few  and  inconclusive.  There  is  often  nothing  abnormal  except  very 
rude  breathing  over  both  lungs  behind ;  sometimes  the  breathing  on  one 
side  is  feeble,  and  on  the  other  much  exaggerated.  There  may  be  no 
rales  whatever,  and  no  change  in  the  percussion  note. 

The  suddenness  and  severity  of  these  symptoms  are  something  which 
it  is  hard  for  one  who  has  not  observed  them  to  appreciate.  We  have 
known  an  infant  to  die  in  twelve  hours  from  the  time  in  which  he  was 
apparently  in  perfect  health,  and  had  an  opportunity  to  confirm  the 
diagnosis  of  pneumonia  by  a  microscopical  examination  of  the  lung. 
The  diagnosis  can  not  be  positively  made  during  life,  and  in  most  of  the 
cases  the  disease  passes  under  some  other  name.  It  is  often  regarded  as 
malignant  scarlet  fever  or  measles  with  suppressed  eruption,  or  cerebro- 
spinal meningitis. 

If  the  children  are  sufficiently  strong  to  withstand  the  onset  of  vio- 
lent symptoms,  they  may  recover  completely  in  four  or  five  days,  the 
lung  clearing  up  very  rapidly.  In  other  cases  these  grave  symptoms  may 
abate  in  a  day  or  two,  to  be  followed  by  those  of  ordinary  broncho- 
pneumonia, which  runs  its  usual  course. 

The  symptoms  of  some  of  these  cases  may  be  explained  by  the  sudden 
intense  engorgement  of  the  lung,  which,  owing  to  the  small  size  of  the 
air  vesicles,  interferes  with  its  function  almost  as  much  as  does  consoli- 
dation. In  other  cases  the  symptoms  are  due  not  so  much  to  the  pul- 
monary condition  as  to  a  general  pneumococcus  infection.  We  have 
seen  cases  of  pneumonia  fatal  in  less  than  two  days  in  which  the  pneu- 
mococcus was  found  by  post  mortem  cultures  to  be  disseminated  through 
the  organs  of  the  body, 

2.  Acute  Disseminated  Bronchopneumonia  (Capillary  Bron- 
chitis).— Although  the  symptoms  in  this  class  of  cases  are  chiefly  due 
to  the  bronchitis,  there  are  always  evidences  of  pneumonia  to  be  found 
post  mortem.  These  are  not  very  common  cases.  The  process  begins 
as  an  inflammation  of  the  medium-sized  and  small  bronchi,  but  not  of 


ACUTE  BRONCHOPNEUMONIA  507 

the  finest  bronchi.  The  onset  is  acute,  with  fever,  very  rapid  and  labored 
breathing,  severe  cough,  moderate  prostration,  and  in  most  cases 
cyanosis. 

The  temperature  is  not  high,  usually  only  from  100°  to  102°  F.,  and 
it  often  continues  so  for  three  or  four  days.  The  pulse  is  rapid,  and  at 
first  is  full  and  strong.  The  respirations  are  exceedingly  rapid,  often 
from  80  to  100  a  minute.  There  is  dyspnea  with  marked  recession  of 
all  the  soft  parts  of  the  chest  during  inspiration.  Cough  is  always  pres- 
ent, usually  severe,  and  sometimes  almost  incessant.  The  prostration  is 
not  so  great  as  in  the  cases  previously  described,  and  the  development 
of  the  symptoms  is  much  less  rapid. 

There  are  at  first  sibilant  and  afterward  subcrepitant  rales  over  the 
entire  chest,  with  which  are  usually  mingled  coarser  moist  rales.  There 
are  no  evidences  of  consolidation.  The  respiratory  murmur  is  every- 
where feeble,  but  not  otherwise  altered.  Percussion  generally  gives  ex- 
aggerated resonance,  owing  to  the  emphysema  which  is  present,  the  note 
being  sometimes  almost  tympanitic. 

The  symptoms  may  gradually  increase  in  severity  until  death  takes 
place  by  the  third  or  fourth  day,  from  respiratory  or  cardiac  failure. 
There  is  usually  marked  cyanosis,  and  toward  the  end  rapidly  increasing 
prostration.  Just  before  death  the  temperature  often  rises  rapidly  to 
106°  or  107°  F.  At  the  autopsy  there  are  found  evidences  of  bronchitis 
of  the  tubes  of  all  sizes,  and  minute  zones  of  pneumonia  about  the  smaller 
bronchi.  The  kings  are  generally  in  a  state  of  hyper-inflation,  on  account 
of  which  they  do  not  collapse  on  opening  the  chest.  There  may  be  in 
addition  extensive  congestion  or  edema,  the  development  of  which  has 
been  the  immediate  cause  of  death. 

In  cases  which  do  not  prove  fatal  there  is  usually  by  the  third  or 
fourth  day  great  improvement  in  the  general  symptoms;  the  finer  rales 
may  disappear,  and  the  coarse  ones  become  more  and  more  prominent. 
By  the  end  of  a  week  there  may  be  complete  recovery.  Instead  of  this, 
there  may  be  a  continuance  of  the  constitutional  symptoms,  and  disap- 
pearance of  the  fine  rales  in  front  only,  while  behind  there  are  gradually 
added  to  them  the  signs  of  consolidation  in  one  of  the  lower  lobes  near 
the  spine.  From  this  time  the  case  may  progress  as  one  of  ordinary 
bronchopneumonia. 

The  prognosis  in  this  class  of  cases  is  very  much  better  than  in  the 
congestive  variety,  recovery  being  probable  unless  the  patients  are  very 
young  or  delicate  infants. 

3.  Bronchopneumonia  of  the  Common  Type. — When  primary, 
this  usually  begins  suddenly  with  symptoms  not  unlike  those  of  lobar 
pneumonia.  This  is  the  mode  of  onset  in  about  two-thirds  of  the  cases. 
In  only  about  ten  per  cent  is  the  pneumonia  preceded  by  bronchitis  of  the 


508  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

large  tubes.  In  these  the  symptoms  of  bronchitis  may  slowly  or  rapidly 
merge  into  those  of  pneumonia.  When  the  onset  is  sudden  it  is  marked 
by  high  fever,  frequently  by  vomiting,  rarely  by  convulsions.  In  addition 
there  are  rapid  respiration,  cough,  prostration,  and  sometimes  cyanosis. 
The  symptoms  are  more  distinctly  pulmonary  than  is  generally  the  ease 
in  lobar  pneumonia. 

The  temperature,  as  a  rule,  is  high;  rarely  is  it  continuously  so,  but 
it  is  of  a  remittent  type.  The  daily  fluctuations  often  amount  to  four  or 
five  degrees.  The  fever  usually  continues  from  one  to  three  weeks,  and 
subsides  gradually  rather  than  by  crisis,  though  crises  are  by  no  means 
rare.  Although,  as  a  rule,  we  expect  a  high  temperature  with  acute 
pneumonia,  this  is  not  invariable.  Primary  cases  may  run  their  course, 
and  even  terminate  fatally,  although  the  temperature  has  not  been 
above  101°  F.  We  have  records  of  several  such  cases.  A  low  temperature 
is  more  often  seen  in  young  and  delicate  infants  than  in  those  who  are 
older  and  more  robust. 

The  respirations  are  frequent  and  labored;  there  is  real  dyspnea. 
On  inspiration,  there  are  marked  recessions  of  all  the  soft  parts  of  the 
chest,  and  the  alae  nasi  dilate  actively.  The  usual  rapidity  of  the  respira- 
tions is  from  60  to  80  per  minute;  very  often,  however,  it  rises  to  100, 
and  on  several  occasions  we  have  seen  it  even  120.  Eespiration  generally 
seems  more  embarrassed  than  does  the  action  of  the  heart,  and  respiratory 
failure  is  a  more  frequent  cause  of  death  than  cardiac  failure.  The 
pulse  is  always  rapid — from  150  to  200  a  minute — and  when  so  it  is  often 
irregular.  The  pulse  rate  is  of  much  less  importance  than  its  character. 
Early  the  pulse  is  full  and  strong,  but  soon  it  becomes  soft,  compressible, 
and  weak. 

The  prostration  is  usually  moderate  for  the  first  day  or  two,  but. 
steadily  increases  as  the  lung  becomes  more  and  more  involved,  and 
toward  the  close  of  the  disease  may  be  extreme. 

Cough  is  much  more  constant  than  in  lobar  pneumonia,  and  more 
distressing;  sometimes  it  is  almost  incessant.  It  disturbs  rest  and  sleep, 
and  may  cause  vomiting  if  the  paroxysm  occurs  soon  after  eating.  There 
is  no  expectoration.  Mucus  is  sometimes  coughed  up  into  the  trachea,  or 
even  into  the  pharynx,  to  be  swallowed  again,  or  more  frequently  aspi- 
rated into  the  lung.  If  during  a  severe  paroxysm  the  patient  is  turned 
upon  his  face  or  inverted,  much  of  this  mucus  may  be  dislodged.  A 
strong  cough  is  a  good  symptom;  suppression  of  the  cough  is  a  bad 
symptom,  indicating  a  loss  of  the  reflex  sensibility  of  the  bronchial 
mucous  membrane  and  of  the  respiratory  center. 

Pain  in  the  chest  is  not  common,  and  is  rarely  an  annoying 
symptom.  Cyanosis  is  present  at  some  time  in  most  of  the  severe  cases. 
It  may  occur  at  the  onset,  or  at  any  time  during  the  course  of  the  disease. 


ACUTE  broxchopxeu:moxia 


509 


105° 

1     2 

3 

i 

5 

6 

7 

8 

9 

10 

11 

18 

13 

11 

15 

16 

101° 
103° 
102^ 
101° 
100° 
B9° 

A 

/ 

A 

\ 

/ 

^ 

I 

il 

N 

\ 

/ 

\ 

\ 

\ 

J 

V, 

/\ 

\ 

\      \ 

L- 

/ 

V 

It  is  usually  due  to  sudden  congestion  of  a  portion  of  the  lung  not 
previously  involved.  Eveji  when  slight,  it  is  always  a  danger-signal  of 
respiratory  failure,  and  when  present  only  in  the  finger  tips  or  lips 
indicates  that  the  patient  must  be  carefully  watched  and  energeti- 
cally treated.  In  the  severe  cases  the  whole  body  may  be  of  a  dull 
leaden  hue. 

Xervous  symptoms  at  the  onset  are  not  so  frequent  as  in  lobar  pneu- 
monia, convulsions  being  rare;  but  late  convulsions,  particularly  in  the 
pneumonia  which  complicates  pertussis,  are  frequent,  and  when  present 
the  disease  is  usually  fatal.  Delirium  may  occur  at  any  time  during  the 
attack.  In  infants  this  shows  it- 
self by  excitement  and  inability 
to  recognize  the  nurse  or  mother. 
Occasionally  patients  present 
marked  cerebral  symptoms 
throughout  the  disease  closely 
simulating  those  of  meningitis. 
As  elsewhere  stated,  the  nervous 
symptoms  depend  less  upon  the 
location  of  the  disease  than  upon 
its  extent,  the  intensity  of  the  in- 
fection, and  upon  the  susceptibil- 
ity of  the  patient,  such  symptoms 

l^eing  especially  common  in  rachitic  children  and  in  those  suffering  from 
pertussis. 

Gastro-enteric  symptoms  are  frequent  in  infancy,  and  are  of  much 
importance.  Often  there  are  from  four  to  six  stools  a  day,  of  a  green 
color,  containing  mucus  and  undigested  food.  These  symptoms  depend 
upon  the  feeble  digestion  which  is  associated  with  the  febrile  process, 
and  are  often  aggravated  by  improper  feeding  and  overmedication.  Vom- 
iting and  diarrhea  add  much  to  the  danger  of  the  attack.  In  summer 
this  complication  is  more  frequent  and  is  likely  to  be  more  severe.  Dis- 
tention of  the  stomach  or  intestines  from  gas  may  be  the  cause  of  dis- 
tressing symptoms,  owing  to  the  added  embarrassment  of  respiration 
produced  by  this  upward  pressure.'  In  infants  it  may  lead  to  attacks  of 
cyanosis  and  even  to  convulsions. 

The  blood  in  acute  bronchopneumonia  shows  regularly  the  changes 
of  a  moderate  secondary  anemia,  which  in  protracted  cases  becomes  very 
marked.  A  leucocytosis  is  almost  invariably  present.  In  an  average 
case  this  ranges  from  20,000  to  40,000.  It  sometimes  is  excessively  high 
without  any  apparent  reason.  We  have  several  times  seen  it  over  100,000. 
The  increase  is  chiefly  in  the  polymorphonuclear  cells  M^hich  usually 
form  from  sixty  to  eighty-five  per  cent  of  the  total  leucocytes.  With 
18 


Fig.  52. — Temperature  Curve  in  Typical 
Bronchopneumonia  of  the  Milder 
Form.  History. — Male,  sixteen  months 
old;  delicate  child;  previous  bronchitis; 
onset  gradual;  signs  of  consolidation  at 
left  base  on  fifth  day,  but  fine  rales  over 
both  lower  lobes  behind;  resolution  slow, 
rMes  persisting  for  a  long  time  in  both 
lungs. 


510 


DISEASES  OF  THE  RESPlRA'iORY  SYSTEM 


the  fall  in  temperature  the  leucocytosis  in  most  cases  rapidly  disappears, 
A  rapid  diminution  in  the  leucocytosis  may  indicate  a  marked  loss  of 
resistance  in  the  patient;  and  may  be  seen  with  either  a  high  or  a  low 
temperature.  In  the  pneumonia  which  complicates  pertussis,  the  in- 
crease in  the  white  cells  may  be  chiefly  of  the  lymphocytes. 


107° 
106° 
105° 
101° 
103° 
102° 
101° 
100° 
09° 

1 

2 

3 

1 

5 

6 

7 

8 

9 

10 

11 

.12    13 

u 

15 

16 

17 

18 

19 

20 

21 

22 

23 

21 

25 

26 

27 

28 

29 

30 

31 

32 

~~ 

— 

\ 

A 

1 

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r 

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y 

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08° 

1 

1 

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_ 

Fig.  53. — Temperature  Curve  of  Bronchopneumonia  with  a  Prolonged  Courser 
Recovery.  History. — Female,  eighteen  months  old;  in  fair  condition;  sudden  onset. 
Early  signs  were  localized,  fine  rales  over  left  base;  on  fifth  day  signs  of  consolidation 
at  left  base,  with  rales  on  both  sides  behind.  General  symptoms  of  moderate  severity. 
Signs  of  consolidation  disappeared  about  a  week  after  cessation  of  fever;  rales  per- 
sisted nearly  two  weeks  longer. 

Positive  blood  cultures  were  obtained  in  75  of  315  consecutive  cases 
of  bronchopneumonia  studied  at  the  Babies'  Hospital.  The  pneumococ- 
cus  was  found  in  47,  the  streptococcus  in  15  cases. 

The  urine  in  most  cases  is  scanty,  high-colored,  and  loaded  with 
urates.     A  trace  of  albumin  is  often  present  when  the  temperature  i& 


107° 

1     2 

3 

i 

5 

6 

7 

8 

9 

10 

11 

12 

13 

li 

15 

16 

17 

18 

19 

20 

21 

22 

23 

■^i 

25l26 

27 

28l29 

30 

31 

32 

33 

M 

106° 
105° 
10i° 
103° 
102° 
101° 
100° 
99° 

. 

I 

l\ 

, 

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11 

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A ' 

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v 

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- 

V 

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U 

H 

V^ 

. 

H 

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98° 

v 

^ 

v 

V 

h^- 

Fig.  54. — Temperature  Curve  of  Relapsing  Bronchopneumonia;  Recovery. 
History. — Male,  nineteen  months  old;  delicate.  Consolidation  on  sixth  day  in  left 
lower  lobe  behind;  two  days  later  small  area  of  consolidation  in  right  lower  lobe 
behind;  many  rales  both  sides;  eighteenth  day,  signs  of  consolidation  had  disap- 
peared, but  many  rales  persisted.  Accession  of  fever  on  nineteenth  and  twentieth 
days,  accompanied  by  extension  of  disease  as  shown  by  new  rales,  but  no  evidences  of 
consolidation  during  second  attack.     Slow  resolution  and  convalescence. 


very  high;  but  casts,  renal  epithelium,  and  a  large  amount  of  albumin 
are  rare. 

The  temperature  chart  shown  in  Fig.  52  is  a  good  example  of  a  very 
frequent  course  of  primary  pneumonia  of  moderate  severity  terminating 
in  recovery;  In  cases  of  this  type  the  constitutional  symptoms  are  not 
grave,  and  follow  very  closely  the  temperature  curve. 


ACUTE  BRONCHOPNEUMONIA 


511 


1     2 

3 

i 

5 

6 

7 

107° 
106° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 

/ 

. 

. 

1 

i  / 

11 

/ 

f 

Y 

/ 

/ 

/ 

1 

1 

1 1 

f 

u 

11 

y 

y 

The  next  chart  (Fig.  53)  illustrates  a  more  severe  but  not  uncom- 
mon course  of  the  disease  in  which  the  fever  is  prolonged.  The  usual 
duration  of  cases  of  this  type  is  between  three  and  four  weeks.  The 
irregular  fluctuations  of  the  temperature,  rarely  touching  the  normal  line, 
are  exceedingly  characteristic  of  bronchopneumonia. 

The  chart  shown  in  Fig.  54  is  that  of 
relapsing  pneumonia.  The  first  attack  was 
fairly  typical,  with  about  the  usual  dura- 
tion. Eesolution  had  begun,  and  was  ap- 
jjarently  progressing  favorably,  when  there 
was  a  return  of  the  fever,  accompanied  by 
new  signs  in  the  chest,  the  second  attack 
being  shorter  and  milder  than  the  first. 
Very  often  the  temperature  falls  to  normal 
without  any  signs  of  resolution,  and  after 
an  interval  varying  from  two  to  three  days 
to  a  week  there  is  a  recurrence  of  the  fever 
and  other  constitutional  symptoms,  the 
second  attack  frequently  proving  fatah 

A  frequent  course  in  fatal  cases  is  shown 
in  Fig.  55.  The  duration  of  the  disease, 
instead  of  being  five  days  as  in  this  case,  is 
often  only  three  or  four.  The  temperature 
at  first  fluctuates  widely,  then  rises  grad- 
ually until  death. 

Duration  of  the  Fever. — The  following 
figures  give  the  duration  of  the  fever  in  231  cases.     The  majority  were 
primary;  none  were  secondary  to  diphtheria,  and  only  a  few  complicated 
measles.     Of  the  169  cases  that  were  fatal — 


Fig.  55. — Temperature  Curve 
OF  Bronchopneumonia;  Fa- 
tal. History. — Male,  six 
months  old;  markedly  ra- 
chitic; sudden  onset.  Signs 
first  day  were  fine  moist  rales 
throughout  the  chest,  marked 
prostration,  and  cyanosis;  on 
third  day,  a  small  area  of  con- 
solidation in  upper  lobe  of  left 
lung  behind;  increasing  pros- 
tration, cyanosis,  and  death. 
Autoj}sy. — =No  pleurisy;  con- 
solidation at  left  apex  behind, 
and  posterior  two-thirds  of  left 
lower  lobe ;  consolidation  of 
right  apex  posteriorly,  lower 
lobe  intensely  congested. 


There  died  during  the  first  six  days 25.0  per  cent. 

"  "     between  the  seventh  and  twenty-first  daj's      .55 . 5    "       " 

"  "  "         "    twenty-first  and  sixtieth  days      19.5    "       " 

100.0    "       " 

Of  78  cases  which  recovered,  the  duration  of  the  fever  Avas — 


Less  than  seven  days 11.5  per  cent. 

From  seven  to  twenty-one  days 66.6    "       " 

"      twenty-one  to  ninety  days 21.9    "       " 

a  it 

100.0    "       " 

Pliysical  Signs. — In  considering  the  signs  of  bronchopneumonia,  it  is 
better  to  connect  them  with  the  different  conditions  in  the  lung  than  to 
group  them  in  stages,  as  in  lo%ar  pneumonia. 


512  DISEASES  OF  THE  RESPIEATORY  SYSTEM 

(a)  Without  Consolidation. — It  can  not  too  often  be  repeated  that 
bronchopneumonia  may  exist  without  signs  of  consolidation  at  any 
period  during  the  course  of  the  disease.  When  the  attack  is  primary,  the 
earliest  signs  are  due  to  congestion  of  the  lung  associated  with  bronchitis 
of  the  fine  tubes,  which  is  usually  localized,  but  which  may  be  general.. 
If  the  disease  has  followed  bronchitis  of  the  large  tubes,  its  signs  are 
added.  Congestion  of  the  lung  gives  feeble  breathing  over  the  affected 
area  and  occasionally  slight  dulness  or  diminished  resonance.  With  this 
are  found  coarse  sonorous,  and  finer  sibilant  rales,  due  to  congestion  and 
swelling  of  the  mucous  membrane  of  the  larger  and  smaller  bronchi 
respectively.  These  signs  are  soon  replaced  by  very  fine  moist  rales, 
which  are  usually  localized  in  one  of  the  lower  lobes  behind  (Fig.  56). 
These  localized  fine  rales  are  the  first  distinctive  sign  of  bronchopneu- 
monia. Soon  a  change  in  the  respiratory  murmur  is  heard  in  the  affected 
area,  which  becomes  feebler  in  intensity  and  higher  in  pitch.  Elsewhere 
in  the  chest  there  may  be  coarse  rales,  due  to  bronchitis  of  the  large  tubes. 
In  such  cases  the  areas  of  pneumonia  are  so  small  and  so  scattered  as  to 
give  in  themselves  no  additional  signs,  and  the  case  may  go  on  to  re- 
covery without  presenting  anything  more  distinctive  than  the  signs  men- 
tioned. 

(&)  With  Areas  of  Partial  Consolidation. — In  the  lung  at  this 
time  there  are  small  areas  of  consolidation,  generally  superficial  and 
separated  by  healthy  or  congested  lobules.  Percussion  in  these  cases 
may  give  negative  results  or  there  is  slight  dulness.  The  vocal  fremitus 
is  not  usually  altered.  The  fine  moist  rales  may  be  heard  over  quite  a 
large  area,  but  at  some  point,  usually  near  the  spine,  over  one  of  the 
lower  lobes,  they  are  sharper,  louder,  higher  pitched,  and  more  metallic, 
and  seem  close  under  the  ear  (Fig.  57).  Eespiration  is  feebler  here 
than  elsewhere,  and  bronchovesicular  in  quality,  approaching  bronchial 
breathing  more  and  more  as  the  consolidation  increases.  The  resonance 
of  the  voice  and  cry  is  exaggerated. 

(c)  With  Areas  of  Consolidation  More  or  Less  Complete. — On  pei- 
cussion  there  is  dulness,  but  surprisingly  little  in  comparison  with  the 
other  signs  of  consolidation  present.  It  is  due  to  the  fact  that  the 
consolidated  portion,  though  extensive,  does  not  involve  the  lung  to 
any  great  depth,  and  also  that  there  are  in  the  consolidated  area  many 
alveoli  which  still  contain  air  (Plate  VIII).  On  palpation  there  is 
usually  a  slight  increase  in  the  vocal  fremitus.  On  auscultation,  there 
are  still  present  the  evidences  of  bronchitis,  usually  only  behind,  but 
sometimes  over  the  entire  chest.  Coarse  and  fine  rales  are  inter- 
mingled. Over  the  consolidated  parts  are  heard  bronchial  breath- 
ing and  bronchial  voice.     At  the  center  of  these  areas  the  bronchial. 


Fig.  56. — First  Stage.  Coarse  rales  over  both 
lungs;  localized  fine  (subcrepitant)  rales  at 
the  left  base.     No  change  in  breath  sounds. 


Fig.  57. — Second  Stage.  Coarse  and  fine  rales 
over  both  lungs  behind ;  at  left  base  an  area 
of  partial  consolidation,  with  bronchovesic- 
ular  breathing,  exaggerated  voice,  and  very 
sharp  rMes. 


Fig.  58. — Third  Stage.  A  larger  area  of  partial 
consolidation,  and  in  the  center  a  small  area  of 
complete  consolidation.with  bronchial  breath- 
ing and  voice  and  slight  dulness.  Signs  over 
the  right  luug  similar  to  what  were  previously 
present  over  the  left. 


Fig.  59. — Fourth  Stage.  Extensive  disease  of 
both  sides;  large  area  of  complete  consoli- 
dation on  the  left,  with  dulness,  bronchial 
breathing  and  voice,  and  no  rales ;  surround- 
ing this,  bronchovesicular  breathing,  with 
many  riles.  Signs  in  the  right  lung  similar 
to  those  previously  present  over  the  left. 


Note. — The  large  circles  indicate  coarse  riles;  the  small  ones  finer  rales;  the  red  areas  indicate 
consolidation  partial  or  complete.  The  disease  may  stop  at  any  one  of  these  stages  and  resohition 
take  place. 

513 


514  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

breathing  is  pure  and  rales  are  iisuallr  absent,  but  at  the  margin 
rales  are  i^resent  and  the  breathing  approaches  the  bronchovesicular 
type  (Fig.  58).  The  signs  of  consolidation  are  rarely  sharply  circum- 
scribed as  they  are  in  lobar  pneumonia,  but  shade  off  gradually.  The 
consolidated  area  is  at  first  small,  usually  in  one  of  the  lo-^-er  lobes  near 
the  spine,  but  may  gradually  extend  until  nearly  the  whole  of  one  or 
eyen  both  lungs  behind  are  more  or  less  completely  solidified  (Tig.  59). 
The  signs  are  found  as  far  for-«'ard  as  the  axillary  line,  but  usually  stop 
there.  Friction  sounds  may  be  heard  oyer  the  consolidated  areas,  but 
yery  rarely  except  where  signs  of  complete  consolidation  are  present.  It 
is  often  impossible  to  obtain  any  idea  of  the  condition  of  an  infant's  lung 
during  quiet,  superficial  respiration.  Sometimes  over  a  part  which  is 
completely  consolidated  there  is  heard  only  yery  feeble  breathing,  or 
the  lung  may  be  almost  silent.  If,  howeyer,  the  child  is  made  to  cry 
or  to  take  a  deep  inspiration,  both  the  bronchial  breathing  and  rales  are 
distinctly  brought  out.  The  intensity  of  the  consolidation  increases  as 
the  disease  advances,  and  the  signs  become  more  and  more  like  those  of 
lobar  pneumonia.  During  resolution  there  is  first  a  disappearance  of 
the  signs  of  consolidation,  which  may  be  quite  rapid,  but  friction 
sounds  and  rales  of  all  kinds  often  persist  for  three  or  four  weeks 
longer. 

The  following  statistics  are  of  some  interest,  as  showing  the  frequency 
with  which  signs  of  consolidation  were  found,  and  the  day  when  they 
were  discovered.  Their  value  is  increased  by  the  fact  that  the  children 
were  under  observation  in  an  institution  at  the  time  they  were  taken 
sick,  and  that  in  all  the  fatal  cases — thirtv-six  in  number — in  which  signs 
of  consolidation  were  absent,  the  diagnosis  of  pneumenia  was  confirmed 
by  autopsy: 

Consolidation  noted  on  or  before  the  fourth  day 47  cases 

"  "      from  the  fifth  to  the  seventh  day 36      " 

"  "        "      the  eighth  to  the  twelfth  day. . . .  12      " 

_  "  "      after  the  twelfth  day 9      " 

No  signs  of  consoUdation 62      " 

166      « 

In  general,  it  must  be  borne  in  mind  that  in  many  cases  signs  of 
consolidation  are  never  present,  as  the  areas  of  pneumonia  are  small  and 
widely  scattered;  that  where  there  is  consolidation  it  is  usually  incom- 
plete, because  there  are  small  areas  of  healthy  lung  tissue  between  the 
hepatized  portions;  that  the  signs  of  consolidation  usually  shade  off 
gradually;  and  that  both  sides  are  almost  invariably  involved,  although 
one  side  usuallv  to  a  greater  decree  than  the  other. 


ACUTE  BROXCHOPNEUMOXIA 


515 


4.  The  Protracted  Form — Persistent  Broxchopxeumoxia. — 
This  is  seen  in  primary  cases,  especially  among  delicate  children,  and 
in  the  pneumonia  complicating  pertussis,  influenza  and  measles,  and  is 
the  form  which  often  follows  diphtheria.  The  onset  and  course  of  the 
disease  for  the  first  two  or  three  weeks  do  not  differ  from  an  ordinary 
attack  of  moderate  severity,  but  at  the  end  of  this  period  there  is  seen 
no  tendency  in  the  process  to  subside.  The  fever  continues,  although  it 
may  not  be  high,  but  by  physical  examination  it  is  found  that  the  areas  of 
consolidation  are  gradually  increasing  day  by  day,  until  sometimes  the 
greater  part  of  both  lungs  behind  are  involved.  The  air  vesicles  become 
so  distended  with  cells  that  the  signs  of  consolidation  are  more  complete 
than  in  ordinary  bronchopneumonia.     The  physical  signs  present  are 


107' 

106" 
105 
104 
103' 

10^' 

12 

3|4 

5 

6 

7 

8 

9  lOlllilS 

la 

14115116 

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19  20121122 

23 

24 

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L 

_ 

Fig.  60. — Temperature  Curve  of  Persistent  Bronchopneumonia.  Terminating 
Fatally.  History. — Male,  two  and  a  half  years  old;  healthy;  sudden  onset;  for  two 
weeks  the  only  signs  were  very  fine  moist  rales  throughout  both  lungs,  front  and  back. 
The  rMes  in  front  in  great  part  gradually  cleared  up ;  those  behind  persisted,  but  it  was 
not  until  the  thirty-fourth  day  that  positive  signs  of  consolidation  were  discovered  in 
the  left  lower  lobe  behind;  these  signs  gradually  extended,  and,  before  death,  were 
present  over  nearly  the  whole  left  lung  behind  and  over  the  right  lower  lobe.  There 
were  also  friction  sounds  over  both  lungs.  Autopsy. — Old  and  recent  pleurisy  with 
general  adhesions;  left  lower  lobe  completely  solid,  patches  of  consolidation  in  left 
upper  lobe.  Right  lower  lobe  about  one-half  consolidated,  with  patches  elsewhere. 
Bronchial  glands  large,  but  not  cheesy.  No  evidence  of  tuberculosis  upon  either 
gross  or  microscopical  examination  (see  Fig.  51). 


marked  dulness,  sometimes  almost  flatness;  there  is  bronchial  breathing 
which  is  exaggerated  in  intensity  until  it  resembles  cavernous  breathing, 
and  it  may  be  impossible  to  distinguish  between  them.  However,  the 
fact  that  it  is  heard  over  so  large  an  area,  that  it  shades  off  gradually, 
and  that  it  is  accompanied  by  friction  sounds,  usually  make  a  distinction 
possible. 

The  temperature  in  these  protracted  cases  for  the  first  two  or  three 
weeks  is  from  100°  to  105°  F. ;  but  after  this  time  it  is  generally  lower 
—from  100°  to  102°  or  103°  F.  The  course  is  not  at  all  regular,  but 
marked  by  frequent  exacerbations  and  remissions.  The  general  symp- 
toms are  those  of  progressive  asthenia.  There  is  continued  wasting, 
anemia,  and  steadily  increasing  prostration.  The  appetite  is  lost,  often 
there  is  an  aversion  to  food,  and  vomiting  is  easily  excited  if  food  or 
stimulants  are  forced.  The  stools  show  that  even  what  food  is  taken  is 
very  imperfectly  digested  and  assimilated.  The  skin  becomes  dry  and 
loses  its  elasticity ;  bed-sores  may  form :  fine  punctate  hemorrhages  are 


516 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


seen  over  the  abdomen,  sometimes  over  the  chest  and  extremities.  This 
condition  is  always  a  very  bad  symjDtom,  and  recovery  from  pneumonia 
is  very  seldom  seen  when  it  is  present. 

Death  takes  place  from  slow  asthenia,  usually  after  five  or  six  weeks, 
but  the  attack  may  be  prolonged  for  eight  or  ten  weeks.  The  general 
symptoms,  the  temperature,  and  the  wasting  strongly  suggest  tubercu- 
losis, and  such  is  the  diagnosis  often  made. 

Although  the  majority  of  the  cases  in  which  the  fever  lasts  over  four 
weeks  run  the  fatal  course  just  described,  such  apparently  hopeless  cases 
occasionally  recover.     The  temperature  gradually  falls  lower  and  lower, 

until  it  remains  at  the  normal 
point.  For  some  time  after  this, 
often  two  or  three  weeks,  little 
change  can  be  seen  either  in  the 


107° 
106° 
105° 
1W° 
10S° 
102° 
101° 
100° 
99° 

1 

2 

3 

i 

5 

6 

7 

8 

9 

10 

11 

12 

13 

U 

15 

16 

/ 

,    I 

1 

A 

r 

--> 

\ 

^ 

/ 

,A 

J 

/ 

, 

J 

V 

A 

/ 

V 

98° 

^ 

^      y 

Fig.  61. — Temperature  Curve  of  Fatal 
Bronchopneumonia,  Complicating  Per- 
tussis. History. — Male,  six  months  old; 
delicate;  pertussis  for  three  weeks.  Early 
signs  of  bronchitis  of  large  tubes  only;  on 
the  eleventh  day  signs  of  consolidation  in 
right  upper  lobe.  Increasing  prostration, 
cyanosis,  and  death.  Autopsy. — Large 
areas  of  consolidation  in  right  middle  and 
upper  lobes,  small  scattered  spots  through- 
out left  lung. 


general  symptoms  or  in  the 
physical  signs.  Gradually  the 
appetite  returns,  the  child  is 
brighter  and  begins  to  take  an 
interest  in  his  surroundings,  the 
cough  abates,  and  little  by  little 
the  signs  in  the  lungs  clear  up, 
and  the  child  may  recover  com- 
pletely. Convalescence,  how- 
ever, is  always  slow,  and  may 
be  interrupted  by  relapses,  it 
being  many  months  before 
health  is  fully  restored.  Although  the  signs  of  consolidation  disappear  in 
a  few  weeks,  rales  are  apt  to  persist  for  a  much  longer  time.  It  is  prob- 
able in  such  cases,  even  though  all  signs  of  disease  disappear  from  tlie 
chest,  that  the  lung  does  not  become  normal.  Eelapses  and  second  at- 
tacks are  always  possible  and  indeed  frequently  occur.  The  area  in- 
volved in  the  relapse  always  includes  that  part  of  the  lung  in  which  reso- 
lution was  delayed.  The  general  health  may  be  so  undermined  that 
the  child  never  regains  his  former  vigor;  yet  in  a  surprising  number 
of  these  cases  recovery  seems  to  be  complete.  Protracted  cases  of  a  mild 
type  are  sometimes  seen,  and,  although  the  tmperature  persists  for  a 
number  of  weeks,  it  is  never  high.  The  course  of  the  disease  suggests 
tuberculosis. 

5.  Secondary  Pneumonia. —  {a)  Complicating  Pertussis. — It  is  not 
often  that  pneumonia  develops  during  the  first  two  weeks  of  this  dis- 
ease. The  most  frequent  time  is  from  the  third  to  the  fifth  week,  when 
the  patient  has  become  exhausted  from  the  previous  severity  of  the  per- 
tussis.    In  two-thirds  of  our  cases  the  development  of  the  pneumonia 


ACUTE  BRONCHOPNEUMONIA  517 

was  gradual,  following  bronchitis  of  the  larger  tubes.     The  temperature 
chart  shown  in  Fig.  61  well  illustrates  this  course. 

When  the  onset  is  sudden,  the  symptoms  do  not  differ  essentially  from 
tliose  of  primary  pneumonia.  The  temperature  of  pertussis-pneumonia 
is  usually  not  high,  in  a  very  large  number  of  cases  not  rising  above 
103.5°  F.,  and  ranging  most  of  the  time  from  101°  to  103°  F.  These 
cases  are  very  apt  to  be  prolonged,  the  fever  often  lasting  for  three  or 
four,  and  sometimes  even  for  six  weeks.  The  physical  signs  of  consoli- 
dation may  persist  for  a  long  time  after  the  temperature  has  become 
normal,  and  yet  the  child  may  recover  entirely.  We  have  seen  one  case 
in  which  recovery  apparently  complete  occurred  after  the  signs  of  con- 
solidation had  persisted  for  six  months,  and  another  in  which  they  had 
persisted  for  over  eight  months.  Very  often  the  signs  continue  during 
the  entire  attack  of  pertussis.  Cerebral  symptoms  are  common,  espe- 
cially toward  the  close  of  the  disease.  Of  fifty-four  fatal  cases,  twenty- 
five  had  convulsions,  and  in  twenty-two  this  was  the  mode  of  death. 
Only  one  case  which  developed  convulsions  recovered. 

(b)  Complicating  Measles. — In  a  small  number  of  cases  the  pneu- 
monia begins  simultaneously  with  the  invasion  of  measles,  but  generally 
not  until  the  eruption  appears.  Instead  of  gradually  falling  to  normal 
with  the  fading  of  the  eruption,  the  temperature  continues  high.  Any 
of  the  clinical  types  of  primary  pneumonia  may  occur  in  measles,  the 
acute  congestive  variety,  which  is  fatal  in  two  or  three  days,  being 
especially  common.  In  its  course  and  duration  the  pneumonia  of 
measles  resembles  the  severe  form  of  primary  pneumonia.  The  broncho- 
pneumonia of  scarlet  fever  differs  in  no  way  from  that  of  measles. 

(c)  Complicating  Diphtheria. — In  many  cases  this  does  not  give  a 
distinct  clinical  picture  of  its  own,  its  symptoms  being  mingled  with 
those  of  diphtheritic  bronchitis,  with  which  it  is  frequently  associated. 
In  others  the  forms  resemble  those  seen  in  measles.  The  majority  of 
cases  occur  as  a  complication  of  diphtheria  of  the  larynx,  although  it  is 
not  infrequent  in  the  septic  cases  in  which  only  the  upper  air  passages  are 
involved.  Pneumonia  after  laryngitis  may  develop  within  two  days 
from  the  beginning  of  laryngeal  symptoms,  and  run  a  rapid  course;  or 
it  may  come  as  late  as  the  second  or  third  week.  In  a  child  wearing  an 
intubation  tube,  the  diagnosis  of  pneumonia  presents  difficulties,  owing  to 
the  alteration  in  the  respiratory  sounds  and  the  existence  of  the  loud 
tracheal  rales  which  obscure  the  usual  auscultatory  signs.  Although 
pneumonia  may  be  apparent  by  symptoms,  its  situation  may  be  difficult 
to  determine.  The  most  important  signs  for  diagnosis  are  the  diminished 
respiratory  murmur,  localized  rales,  and  dulness  on  percussion. 

(d)  Complicating  Influenza. — Without  doubt  many  cases  usually  re- 
garded as  primary  are  really  secondary  to  influenza,  particularly  when 


518 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


that  disease  is  prevalent.  While  the  pneumonia  of  influenza  nuiv  dilfei 
in  no  essential  points  from  the  primary  form,  there  are  tj^pes  which  are 
quite  characteristic.  In  one  variety  the  cases  are  of  short  duration,  fre- 
quently lasting  but  three  or  four  days,  but  with  high  and  often  widely 
fluctuating  temperature,  the  general  symptoms  being  of  only  moderate 
severity.  A  second  type  is  a  prolonged  pneumonia  with  exacerbations 
and  remissions,  which  may  last  for  two  or  three  months  with  quite 
extraordinary  fluctuations  of  temperature  (Fig.  63).  A  third  form  is 
the  recurrent  type  of  pneumonia,  of  which  a  child  may  have  several 


DAY 

1 

2 

3 

4 

5 

6 

7 

T 

9 

10 

T7 

12 

13 

T7 

^ 

16 

17 

IB 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

34 

DATE 

< 
1- 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 
96° 

i 

/ 

1 

A 

> 

V 

A 

s 

A 

^ 

/ 

h 

A 

A 

A 

\ 

r   ] 

K 

V 

A 

^ 

f\ 

1 

/■^ 

\ 

l\ 

' 

r 

A 

A 

l\ 

/ 

/ 

\ 

/ 

y 

A 

,/ 

V 

S, 

1 

\ 

n 

V 

\, 

\j 

/ 

\ 

/ 

I 

V 

\ 

_ 

_____ 

Fig.  62. — Bronchopneumonia  Complicating  Influenza;  Death.  History. — Delicate 
infant,  7  months  old,  bronchitis  and  otitis  four  weeks  before.  Acute  onset,  early 
signs  of  consolidation  in  right  lung;  double  paracentesis  for  otitis  on  13th  day; 
small  area  of  consolidation  in  left  lung  on  16th  day.  Sputum  cultures  repeatedly 
showed  B.  influenzae.  Signs  in  lungs  not  much  changed;  death  from  exhaustion. 
Autopsy. — Usual  lesions  of  bronchopneumonia  of  moderate  extent  in  both  lungs.  No 
other  lesions  of  importance.  Cultures  from  lungs  showed  the  B.  influenzae  but  no 
pneumococci. 


distinct  attacks  in  a  single  season,  although  in  the  interval  neither 
signs  nor  symptoms  entirely  disappear.  In  a  certain  number  of  these 
cases  a  chronic  form  of  pneumonia  ultimately  develops. 

(e)  Complicating  Ileocolitis. — This  is  usually  a  somewhat  subacute 
form  of  pneumonia  which  is  scarcely  recognizable  except  by  the  physical 
signs.  It  is  seen  in  the  protracted  cases  of  ileocolitis  and  occurs  late 
in  its  course.  Very  often  pneumonia  is  not  suspected  during  life,  the 
constitutional  symptoms  being  sufficiently  explained  by  the  intestinal 
lesions,  although  the  autopsy  discloses  the  fact  that  death  was  due  in 
part  to  pneumonia. 

Complications. — Most  of  those  relating  to  the  lungs  have  been  de- 
scribed with  the  lesions.  Pleurisy  will  be  separately  considered.  Pul- 
monary emphysema  is  always  present  to  a  greater  or  less  degree,  but 
can  not  be  made  out  by  physical  signs.  In  very  rare  instances  subcuta- 
neous emphysema  has  been  seen.  Abscess  and  gangrene  can  seldom  ])e 
recognized  by  physical  signs.  Pneumothorax  occurs  even  in  infancy,  but 
is  very  infrequent  except  as  a  result  of  puncture  of  the  chest.     Otitis  is 


ACUTE  BRONCHOPNEUMONIA  519 

exceedingl}'  common,  and  one  should  be  constantly  on  the  lookout  for 
it.    It  is  recognized  only  by  examination  of  the  ear  with  a  speculum. 

Meningitis  may  complicate  acute  bronchopneumonia.  It  has  oc- 
curred in  about  two  per  cent  of  our  cases.  It  is  in  all  respects  similar  to 
that  occurring  with  lobar  pneumonia.  Meningeal  hemorrhage  we  have 
seen  only  once,  and  it  was  the  cause  of  death  in  a  patient  eleven  months 
old,  who  a  few  days  before  was  seized  with  convulsions,  followed  by  a. 
gradually  increasing  stupor,  which  continued  until  death.  The  hemor- 
rhage covered  the  entire  convexity  of  the  brain.  Endocarditis  is  ex- 
tremely rare;  it  was  not  observed  in  any  of  our  cases.  Acute  pericarditis 
is  also  rare  unless  there  is  an  extensive  pleurisy.  When  it  occurs  it  is 
usually  with  pneumonia  of  the  left  side.  Complications  referable  to 
the  digestive  tract  are  quite  common.  Herpetic  stomatitis  is  frequent, 
and  occasionally  the  ulcerative  variety  is  seen.  Thrush  often  occurs  in 
the  protracted  cases  among  very  young  infants.  Gastro-enteritis  is  not 
very  common,  considering  the  frequency  of  vomiting  and  diarrhea,  these 
depending  usually  upon  functional  derangement.  Nephritis  is  rare;  it  is 
usually  of  the  acute  exudative  variety,  and  very  seldom  severe  enough 
to  affect  the  prognosis. 

Old  lesions  of  tuberculosis — cheesy  nodules  in  the  lungs  and  some- 
times in  the  pleura — are  not  infrequently  met  with  in  patients  dying  of 
acute  pneumonia  of  a  non-tuberculous  character. 

Diagnosis). — An  acute  onset  with  continuous  high  fever,  rapid  res- 
piration, and  cough,  should  always  lead  one  to  suspect  pneumonia.  When 
to  these  symptoms  are  added  prostration  and  a  leucocytosis,  the  diag- 
nosis of  pneumonia  is  almost  certain.  Cases  of  the  acute  congestive  type 
are  the  ones  most  frequently  unrecognized,  and  in  many  of  these  cases 
a  positive  diagnosis  is  impossible  during  life.  Many  atypical  cases  of 
pneumonia  are  seen,  particularly  in  young  infants.  An  unusual  tem- 
perature course  is  perhaps  the  symptom  most  likely  to  lead  to  a  mistake. 
While  this,  as  a  rule,  is  high  and  remittent,  sometimes  it  is  not  so,  and 
it  may  be  but  little  above  normal.  Eapid  respiration  is  almost  always 
present,  but  cough  may  be  very  slight,  especially  in  infants.  In  very 
young  infants,  the  diagnosis  often  rests  upon  the  prostration,  cyanosis, 
and  rapid  respiration,  the  other  acute  inflammatory  symptoms  being 
absent.  Only  the  physical  signs  of  the  disease  can  positively  settle  the 
question  of  diagnosis. 

When  pneumonia  follows  bronchitis  of  the  large  tubes,  whether  the 
bronchitis  is  primary  or  complicates  one  of  the  infectious  diseases,  the 
extension  of  the  disease  to  the  lungs  is  usually  marked  by  three  symp- 
toms— a  steadily  rising  temperature,  more  frequent  respirations,  and  in- 
creasing prostration.  It  may  l)e  twelve  or  twenty-four  hours  before  the 
change  is  indicated  by  the  physical  signs. 


520 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


At  the  outset,  pneumonia  can  not  be  positively  diagnosticated  from, 
severe  bronchitis.  Such  a  bronchitis  often  begins  with  severe  pulmonary 
symptoms  and  a  temperature  of  103°  or  104°  F. ;  but  this  high  tempera- 
ture is  of  short  duration,  usually  falling  after  twenty-four  or  forty-eight 
hours  to  100°  or  101°  F.  The  prostration  is  much  less  and  all  the 
symptoms,  possibly  excepting  the  cough,  less  severe.  The  only  physical 
signs  are  coarse  rales,  which  are  heard  throughout  the  che^t. 

The  same  rules  apply  to  bronchitis  of  the  smaller  tubes.  The  rales  are 
heard  both  in  front  and  behind,  and  usually  over  both  sides.  If  with  such 
rales  the  temperature  continues  to  rise  for  three  or  four  days  in  succession 

above  103°  F.,  it  may 
be  assumed  that  pneu- 
monia is  present,  pro- 
vided there  is  no  other 
disease  which  might  ex- 
plain the  temperature. 
If  the  signs  of  bronchi- 
tis are  limited  to  a  sin- 
gle lung,  or  to  one  lung 
posteriorly,  the  exist- 
ence of  bronchopneu- 
monia may  be  regarded 
as  certain.  Localized 
bronchitis,  then,  is  al- 
ways to  be  interpreted 
as  bronchopneumonia, 
provided  tuberculosis 
can  be  excluded. 

The  differential  di- 
agnosis of  bronchopneumonia  from  lobar  pneumonia  will  be  considered 
in  connection  with  the  latter  disease.  On  account  of  the  remittent  tem- 
perature, bronchopneumonia  may  be  confounded  with  malarial  fever;  or 
malaria  may  be  suspected  as  a  complication.  An  examination  of  the 
blood  will  remove  the  doubt. 

Both  the  acute  and  the  persistent  forms  of  simple  bronchopneumonia 
may  be  confounded  with  the  tuberculous  form;  the  points  of  distinction 
are  considered  in  the  chapter  on  Tuberculosis. 

The  X-ray  is  of  value  in  detecting  tlie  presence  of  consolidation 
before  this  can  be  made  out  by  physical  signs.  (See  Fig.  63.)  Small 
scattered  areas  of  bronchopneumonia  cannot  be  differentiated  from  tu- 
berculosis. Large  areas  of  consolidation  do  not  differ  in  their  appear- 
ance from  those  of  lobar  pneumonia. 

Prognosis. — Bronchopneumonia  is  always  a  serious  disease,  and  in  an 


Fig.  63. — Bronchopneumonia.  Infant  8  months  old; 
areas  of  consolidation  in  both  lungs,  especially  marked 
at  the  left  apex  and  the  root  of  the  right  lung.  The 
only  physical  signs  were  scattered  rS.les. 


ACUTE  BRONCHOPNEUMONIA 


521 


infant  dangerous  to  life.  The  prognosis  depends  upon  the  age,  sur- 
roundingSj  and  previous  condition  of  the  patient,  upon  the  nature  of  the 
infection,  whether  the  disease  is  primary  or  secondary,  and,  if  the  latter, 
upon  the  character  of  the  primary  disease.  In  private  practice  the  mor- 
tality from  bronchopneumonia  is  from  ten  to  twenty  per  cent,  depend- 
ing upon  the  conditions  mentioned.  One  whose  knowledge  of  broncho- 
pneumonia is  derived  from  observations  in  private  practice  can,  however, 
form  but  little  idea  of  the  frequency  and  severity  of  this  disease  in  hos- 
pitals and  asylums  for  infants  and  young  children,  particularly  when  it 
occurs  with  epidemics  of  measles,  diphtheria,  or  pertussis.  The  statis- 
tics in  the  following  table  are  taken  from  the  records  of  two  institutions, 
and  fairly  represent  the  results  seen  in  such  places  in  children  under 
three  years : 


Forms  of  Pneumonia. 


Cases. 

Deaths. 

Percentage 
Mortality. 

194 

96 

49.4 

29 

19 

65.5 

89 

56 

62.9     . 

66 

54 

81.8 

7 

7 

100.0 

47 

47 

100.0 

19 

18 

94.7 

6 

1 

16.6 

2 

2 

100.0 

2 

2 

100.0 

461 

302 

65.5 

Primary  bronchopneumonia 

Following  bronchitis  of  the  large  tubes . 
Secondary  to  measles 

"  "   pertussis 

"  "   scarlet  fever 

"   diphtheria 

"  "   ileocolitis 

"  "   epidemic  influenza 

"  "   varicella 

"  "  erysipelas 


Totals. 


The  mortality  varies  with  the  age  of  the  patient,  being  highest  dur- 
ing the  first  year,  and  diminishing  steadily  thereafter,  as  shown  by  the 
following  table  giving  the  result  in  346  cases : 


Age. 

Cases. 

Percentage 
Mortality. 

During  the  first  year 

202 

102 

33 

6 

3 

66 

"         "    second  year 

55 

«         "    third        "    

33 

"    fourth      "    

16 

«         "    fifth          "    

In  this  table  are  included  no  cases  secondary  to  measles,  scarlet 
fever,  or  diphtheria. 

Probably  the  best  of  all  guides  to  the  nature  and  severity  of  the  in- 
fection is  the  temperature.  An  excessively  high  temperature  usually 
indicates  a  severe  type  of  infection.     Some  idea  of  this  may  be  gained* 


522 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


from  these  figures,  gi'^iiig  the  highest  temperature  and  the  mortality  in 
two  hundred  and  thirty-one  cases,  not  inehiding  cases  with  measles  or 
diphtheria : 


Highest  Temperature. 


Percentage 
Mortality. 


106°  F.  or  over .  .  , 
105°  or  105.5°  F. 
104°  or  104.5°  F. 
102°  to  103.5°  F. 
99.5°  to  101.5°  F 


85.5 
60.0 
49.0 
60.0 
71.0 


The  high  mortality  of  the  cases  with  unusually  low  temperature  is 
due  to  the  fact  that  they  nearly  aways  were  seen  in  infants  wdth  very 
feeble  vitality.  The  outlook  in  eases  with  a  steadily  high  temperature — 
between  102.5°  and  104:°  F. — is  usually  more  favorable  than  in  those 
with  wide  fluctuations,  such  as  100°  to  105.5°  F,  As  a  rule,  the  danger 
from  the  disease  increases  steadily  with  every  degree  of  temperature 
above  101.5°  F. 

An  important  factor  in  the  prognosis  is  the  previous  condition  of  the 
patient.  The  association  with  rickets  is  unfavorable,  both  on  account 
of  the  feeble  muscular  power  of  these  children  and  their  thoracic  de- 
formities. Marked  and  persistent  tympanites  is  always  an  unfavorable 
symptom.  As  a  rule,  second  attacks  are  more  serious  than  the  primary 
ones,  especially  if  the  interval  between  them  is  short. 

In  making  the  prognosis  in  any  given  case,  the  symptoms  to  be  con- 
sidered are  the  height  and  course  of  the  temperature,  the  presence  or 
absence  of  nervous  symptoms,  the  condition  of  the  organs  of  digestion, 
the  presence  of  cyanosis  and  the  extent  of  the  disease  as  shown  by  the 
physical  signs.  We  have  not  found  the  examination  of  the  blood  to  aid 
greatly  in  prognosis.  The  leucocyte  count  varies  widely  and  often  with- 
out apparent  reason.  Blood  cultures,  however,  are  of  some  assistance. 
In  our  hospital  cases  which  gave  positive  blood  cultures,  the  mortality 
was  70  per  cent,  while  in  those  which  gave  negative  cultures  it  was 
44  per  cent. 

Convulsions  occurring  early  in  the  disease  do  not  affect  the  prognosis ; 
but  of  thirtv-seven  cases  in  which  convulsions  occurred  at  a  late  period 
all  but  one  proved  fatal. 

So  long  as  the  nutrition  of  the  patient  can  be  well  maintained,  no 
protracted  case  is  hopeless,  no  matter  how  extensive  the  local  disease 
may  be;  but  the  existence  of  vomiting,  diarrhea,  or  persistent  tym- 
panites makes  the  issue  doubtful,  even  though  the  other  symptoms  are 
favorable. 


ACUTE  BRONCHOPNEUMONIA  523 

Treatment. — The  most  important  part  of  prophylaxis  is  to  give  care- 
ful and  early  attention  to  every  attack  of  bronchitis  in  an  infant,  for 
every  such  attack  should  be  regarded  as  a  possible  precursor  of  pneu- 
monia. It  is  striking  that  one  sees  bronchopneumonia  so  seldom  in 
private  practice  among  the  better  classes,  even  though  bronchitis  is  very 
frequent;  while  among  hospital  and  dispensary  patients,  where  bron- 
chitis is  very  often  neglected,  bronchopneumonia  is  constantly  seen. 
Cases  of  measles  and  diphtheria  which  are  complicated  by  pneumonia 
should,  if  possible,  be  carefully  isolated  from  others,  and  wards  in  which 
they  are  treated  should  be  thoroughly  disinfected  before  they  are  used 
for  simple  cases. 

The  hygienic  treatment  of  bronchopneumonia  is  important,  and 
usually  it  receives  too  little  attention.  It  is  much  the  same  as  that  of 
cases  of  acute  bronchitis  already  discussed.  What  was  said  in  that  con- 
nection regarding  the  necessity  for  fresh  air  and  the  caution  as  to  very 
cold  air,  may  be  here  repeated.  The  cold-air  treatment  is  not  admis- 
sible in  very  young  or  delicate  infants,  nor  in  cases  of  disseminated 
pneumonia  (capillary  bronchitis).  The  best  results  from  this  treat- 
ment are  seen  in  the  cases  with  extensive  consolidation  and  with  the 
minimum  amount  of  bronchitis,  and  it  is  to  be  highly  recommended  in 
the  pneumonia  of  the  severe  acute  infections — diphtheria,  measles,  and 
scarlet  fever.  The  dress  and  protection  of  the  patient  with  the  cold-air 
treatment  are  discussed  under  Lobar  Pneumonia. 

Older  children  with  pneumonia  should  be  kept  in  bed.  Infants  for 
a  considerable  part  of  the  time  may  be  held  in  the  nurse's  arms.  A 
frequent  change  of  position  in  all  cases  is  essential;  no  child  should  be 
allowed  to  lie  for  hours  directly  on  the  back.  The  general  rules  pre- 
viously laid  down  for  feeding  all  sick  children  should  be  followed  here. 
As  a  rule,  medicine  should  not  be  administered  in  the  food. 

The  same  local  treatment  may  be  employed  as  in  cases  of  bronchitis. 
Oounter-irritation,  best  by  means  of  the  mustard  paste,  may  be  em- 
ployed from  three  to  six  times  daily.  It  is  of  the  greatest  value  in  'the 
■early  stage  of  acute  pulmonary  congestion,  and  during  attacks  of  cardiac 
or  respiratory  failure.     Poultices  should  not  be  used. 

Alcohol  may  be  needed  in  pneumonia  secondary  to  diphtheria, 
measles,  or  scarlet  fever,  also  in  many  primary  cases.  Its  use  has  been 
greatly  abused  in  this  disease.  Although  there  is  little  doubt  that  it  is 
at  times  of  much  benefit,  there  is  considerable  doubt  as  to  its  mode  of 
action.  The  dose  is  to  be  regulated  by  the  condition  of  the  patient.  Not 
over  one-half  ounce  daily  should  be  given  to  an  infant  of  one  year. 

Of  the  circulatory  stimulants,  caffein,  camphor,  and  digitalis  may  be 
used,  and  are  recommended  in  the  order  named. 

For  a  child  of  one  year  the  following  doses  are  suitable :  Caifein,  gr. 


524  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

^  to  gr.  i  every  three  hours;  camphor  is  especially  valuable  for  quick 
effect ;  TH,  iij  to  v  of  a  ten  per  cent  solution  in  oil  may  be  given  hypoder- 
mically;  digitalis,  the  fluid  extract  is  generally  to  be  preferred  as  more 
reliable  than  the  tincture,  TTl,  i  may  be  given  every  four  hours.  For 
immediate  effect  in  sudden  heart  or  respiratory  failure,  nothing  com- 
pares with  epinephrin  given  intramuscularly — doses  fU  ij  to  TTl  v  of  a 
1-1,000  solution;  atropin,  also  used  hypodermically,  is  sometimes  useful 
— dose,  gr.  4^^.  Oxygen  may  be  given  continuously,  but  always  mixed 
with  atmospheric  air.  It  sometimes  seems  to  benefit  greatly  cases 
Avith  marked  cyanosis;  often  it  does  no  good.  Gentle  friction  of  the 
chest  wall,  without  disturbing  the  patient,  is  sometimes  useful  in  stimu- 
lating the  respiratory  muscles,  especially  in  protracted  cases. 

It  should  be  remembered  that  the  normal  range  of  temperature  in 
bronchopneumonia  is  from  101°  to  10-1. 5°  F.  This  temperature  is  not 
in  itself  exhausting,  and  the  chances  of  recovery  are  not  improved 
by  reducing  it  so  long  as  it  remains  within  these  limits.  Too  much 
can  not  be  said  in  condemnation  of  the  practice  of  giving  the  coal-tar 
products  in  full  doses  for  the  reduction  of  temperature.  In  small  doses 
they  are  often  useful  to  allay  nervous  irritability,  restlessness,  and 
promote  sleep. 

Antipyretic  measures  are  indicated  in  cases  of  hyperpyrexia,  which 
we  may  define  as  105°  F.  or  over,  especially  when  extreme  nervous  symp- 
toms exist.  In  these  circumstances,  the  most  certain,  the  most 
within  our  control,  and  hence  the  safest  antipyretic,  is  cold.  It  may  be 
used  by  the  evaporation  bath,  the  cold  pack,  sponging,  cold  com- 
presses, or  an  ice-bag  applied  to  the  chest.  (See  chapter  on  General. 
Therapeutics.) 

I^ot  all  children  bear  cold  well,  and  in  its  use  and  frequency  of  repe- 
tition one  must  be  guided  by  its  effect  upon  the  child's  general  condition 
as  well  as  upon  the  temperature.  When  Avith  hyperpyrexia  we  have 
general  cyanosis,  cold  surface,  feeble  pulse,  shallow  respiration,  and 
stupor,  cold  is  contraindicated  and  a  hot  mustard  bath  should  be  used. 

Inhalations  are  of  more  value  in  relieving  cough  and  in  promoting^ 
bronchial  secretion  than  any  other  means  we  possess.  The  same  sub- 
stances are  to  be  used,  and  in  the  same  way  as  mentioned  in  the  article- 
on  Bronchitis. 

The  nervous  symptoms, — restlessness,  loss  of  sleep,  etc., — ^are  often 
best  controlled  by  cold  or  tepid  sponging ;  in  other  cases  by  small  doses 
of  phenacetin — i.e.,  one  grain  every  three  hours  to  a  child  of  six  months. 
Opium  is  to  be  avoided  unless  there  is  severe  pain,  which  is  very  rare; 
or  when  the  incessant  cough  is  not  relieved  by  inhalations.  Codein  may 
be  given  in  doses  of  gr.  -gV  every  three  or  four  hours  to  a  child  of  one 
year,  or  morphin  in  half  this  dose. 


ACUTE  BROXCHOPNEUMONIA  .     525 

Sudden  attacks  of  general  collapse  with  cyanosis  are  frequent  in 
severe  eases  of  bronchopneumonia.  They  may  come  on  at  any  period  in 
the  disease.  When  occurring  in  the  early  stage,  if  promptly  and  ener- 
getically treated,  recovery  may  take  place,  but  when  they  come  on  in  the 
late  stages  they  are  usually  fatal.  They  may  be  due  to  acute  congestion 
or  edema  of  the  lung  not  previously  involved,  or  to  circulatory  failure. 
The  most  eflficient  treatment  is  the  use  of  dry  cups  or  the  hot  mustard 
bath,  the  administration  of  epinephrin  and  caffein  or  camphor  hypoder- 
mically,  and  to  give  oxygen  continuously. 

When  the  fever  continues  for  five  or  six  weeks,  with  no  disposition 
on  the  part  of  the  disease  to  subside,  one  should  continue  the  sustain- 
ing treatment  adopted  in  the  earlier  part  of  the  disease — careful  feed- 
ing and  judicious  stimulation,  but  most  of  all  should  these  patients  be 
given  the  benefit  of  the  fresh-air  treatment.  Some  apparently  hopeless 
cases  recover ;  but,  unfortunately,  in  the  majority  the  continuance  of  the 
pneumonic  process  is  in  itself  evidence  of  the  weakened  vitality  of  the 
patient,  and,  though  he  may  live  a  long  time,  usually  such  attacks  prove 
fatal. 

When  the  fever  has  disappeared,  and  there  is  only  a  persistence  of 
the  physical  signs  and  the  general  cachexia,  the  cases  are  more  hopeful. 
Here,  a  change  of  air  is  more  important  than  all  other  means  of  treat- 
ment. If  in  the  winter  or  spring  the  child  can  be  removed  to  a  warm, 
dry  climate  where  he  can  be  kept  in  the  open  air,  or,  in  the  summer, 
he  can  be  taken  to  the  mountains,  immediate  improvement  is  often  seen, 
followed  by  rapid  recovery.  With  the  change  of  air  a  general  tonic  plan 
of  treatment  should  be  followed,  cod-liver  oil,  arsenic,  and  iron  being 
used,  according  to  the  indications  in  each  particular  case. 

One  should  never  declare  one  of  these  cases  of  protracted  pneumonia 
to  be  hopeless,  nor  should  he  be  too  ready  to  assume  that  tuberculosis 
is  present  because  the  child  is  wasted  and  anemic,  and  the  physical  signs 
have  persisted. 

No  specific  treatment  of  pneumonia  has  yet  been  proposed  which  can 
be  recommended  for  general  use. 


526 


DISEASES  OF  THE  RESPIPxATORY  SYSTEM 


CHAPTEK  V 

DISEASES    OF    THE    LUNGS.— {Continued) 


LOBAR  PNEUMONIA 

(Fibrinous  Pneumonia ;  Croupous  Pneumonia) 

Etiology. — Age. — Lobar  pneumonia  may  occur  at  any  age.  We  have 
seen  it  in  an  infant  of  three  months;  but  it  is  not  until  after  the  first 
year  that  it  begins  to  be  frequent.  After  the  third  year  most  of  the 
cases  of  primary  pneumonia  are  of  this  variety. 

Of  500  cases  the  ages  were  as  follows : 


Age. 

Cases. 

Per  cent. 

During  the  first  year 

76 
309 
104 

11 

15 

From  the  second  to  the  sixth  year 

62 

"       "    seventh  to  the  eleventh  year 

21 

"       "    twelfth  to  the  fourteenth  year 

2 

Totals 

500 

100 

Season. — In  136  cases  the  seasonal  occurrence  was  as  follows : 


Season. 

Cases. 

Per  cent. 

In  the  three  winter  months 

48 
62 

35 

«     "       "      spring       "        

46 

"     «       "      summer    "        

4 

"      "       "      autumn    "       

15 

Totals 

136 

100 

Lobar  pneumonia,  in  children  therefore,  as  in  adults,  occurs  most 
frequently  during  the  spring  months.  March  and  April  show  the 
largest  number  of  cases. 

Previous  Condition.- — In  our  hospital  cases,  eighty-two  per  cent  of 
the  children  were  previously  in  good  condition,  and  only  eighteen  per 
cent  were  delicate,  rachitic,  or  syphilitic.  This  observation  has  been 
borne  out  by  our  experience  in  private  practice,  viz.,  that  as  a  rule  lobar 
pneumonia  affects  children  who  were  previously  healthy.  Or  to  state  tlie 
matter  differently,  if  a  strong  child  contracts  pneumonia  it  is  nearly 
always  of  the  lobar  variety. 


LOBAR  PNEUMONIA 


527 


Previous  Disease. — Previous  attacks  of  pneumonia  are  observed  in 
but  a  small  proportion  of  cases.  It  was  noted  only  five  times  in  160  cases. 
In  the  vast  majority  of  cases  lobar  pneumonia  is  a  primary  disease,  al- 
though it  occasionally  occurs  as  a  complication  of  pertussis,  measles, 
typhoid  or  scarlet  fever,  and  even  diphtheria — chiefly,  however,  in  chil- 
dren over  three  years  old. 

Epidemics  of  lobar  pneumonia  we  have  never  witnessed,  although  on 
several  occasions  we  have  seen  two  children  in  a  family  attacked  either 
simultaneously  or  in  rapid  succession.  Exhaustion,  fatigue,  and  ex- 
posure are  to  be  ranked  as  associated  exciting  causes. 

In  addition  to  other  causes,  there  is  required  for  the  production  of 
the  disease  the  presence  and  growth  of  the  pneumococcus.  Associated 
with  it  are  often  found  the  staphylococcus  aureus  and  occasionally  the 
bacillus  of  influenza.  The  bacillus  of  Friedlander  is  very  seldom  the 
exciting  cause  of  pneumonia  in  children.  It  was  foimd  but  once  in  blood 
cultures  of  87  cases  in  the  Babies'  Hospital. 

Lesions. — Tlie  Seat  of  the  Disease. — In  950  cases  in  children  under 
fourteen  years,  this  was  as  follows : 


Seat  of  Disease. 

Personal 
Cases. 

Collected 
Cases. 

Totals. 

Right  lung,  upper  lobe  only 

39 

8 
26 
13 

137 
4 

142 
64 

176 

«         «     middle    "       "    

12 

"         «     lower       "       «    

168 

"         "     more  than  one  lobe 

77 

Totals,  right  lung 

86 

347 

433 

Left  lung,  upper  lobe  only 

25 

49 
9 

68 

214 

29 

93 

"       "     lower      "       "    

263 

"       "     more  than  one  lobe 

38 

Totals,  left  lung 

83 

.-^11 

394 

Both  lungs,  upper  lobes 

"'3 
9 

13 
38 
60 

13 

«         "        lower       "     

41 

"         "       elsewhere 

69 

Totals,  both  lungs 

12 

HI 

123 

The  right  lung  was  thus  affected  in  45.5  per  cent;  the  left  lung  in 
41.5  per  cent;  both  lungs  in  13  per  cent.  In  the  order  of  frequenc)'',  the 
disease  involves,  first,  the  left  base;  second,  the  right  apex;  third,  the 
right  base;  fourth,  the  left  apex.  The  disease  affects,  as  a  rule,  a  single 
lobe,  and  often  only  a  circumscribed  portion  of  a  lobe. 

The  anatomical  changes  resemble  those  seen  in  the  adult  lung.  There 
is  an  exudation  into  the  alveoli  and '  smaller  bronchi  of  fibrin,  serum, 
leucocytes,  and  red  blood-cells  (Fig.  47).     There  is  usually  in  addition 


528  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

an  inflammation  of  the  mucous  membrane  of  the  larger  bronchi  and 
of  the  pleura.  The  f  requeue}^  and  severity  of  the  pleurisy  is  a  peculiarity 
of  the  lesion  in  children. 

In  the  first  stage,  that  of  congestion,  the  portion  of  lung  involved  is 
dark-colored,  heavy,  and  edematous,  and  shows  under  the  microscope  a 
serous  and  cellular  exudation  into  the  air  vesicles,  with  swelling  of  the 
epithelial  cells  lining  the  alveoli. 

In  the  second  stage,  that  of  red  hepatization,  there  is  usually  some 
exudation  upon  the  pulmonary  pleura,  generally  a  thin  layer  of  fibrin, 
giving  it  a  dull  look.  The  lung  itself  is  of  a  uniform  dark-red  color.  It 
is  solid  and  cuts  like  liver.  It  looks  as  if  it  had  been  inflated  to  its 
utmost  extent  and  then  injected  with  a  material  which  had  solidified. 
The  consolidated  area  is  sharply  defined.  Under  the  microscope  the  air 
vesicles  are  seen  to  be  distended  with  an  exudation  which  is  chiefly  fibrin, 
but  with  some  leucocytes,  red  blood-cells,  and  desquamated  epithelial 
cells.  The  cells  are  chiefly  leucocytes,  and  are  usually  more  abundant 
than  in  the  pneumonia  of  adults. 

In  the  third  stage,  that  of  gray  hepatization,  the  lung  is  more  moist, 
and  the  inflammatory  products  are  partly  decolorized.  This  change 
takes  place  irregularly  throughout  the  lung,  giving  it  a  mottled 
appearance. 

The  fourth  stage,  that  of  resolution,  follows  gray  hepatization,  and 
consists  in  the  degeneration  and  liquefaction  of  the  products  of  inflam- 
mation, which  are  ultimately  carried  away  by  the  lymphatics  in  great 
part,  only  a  small  amount  being  pushed  out  into  the  bronchi  and  re- 
moved by  coughing. 

The  duration  of  the  stage  of  congestion  is  from  a  few  hours  to  sev- 
eral days;  that  of  the  stage  of  red  hepatization  from  two  days  to  two 
or  three  weeks.  This  is  the  condition  in  which  the  lung  is  most  often 
seen  at  autopsy.  The  stage  of  gray  hepatization  is  commonly  shorter. 
Eesolution  usually  begins  when  the  temperature  falls  to  normal,  but 
occasionally  it  inoj  be  delayed  for  several  days.  It  is  generally  complete 
in  about  a  week. 

Variations  in  the  Lesions. —  (1)  Instead  of  clearing  up  at  the  usual 
time,  the  lung  may  remain  consolidated  for  several  weeks,  and  then  re- 
solve. (2)  The  stage  of  gray  hepatization  may  be  followed  by  a  great 
exudation  of  pus  cells,  which  may  everywhere  infiltrate  the  affected 
lung;  or  these  may  be  circumscribed  so  as  to  form  a  single  large 
abscess  or  many  small  ones.  (3)  There  may  be  small  areas  of  gan- 
grene. All  these,  three  conditions  are  rare  in  young  children.  (4) 
There  may  be  excessive  pleurisy,  or  pleuropneumonia.  This  is  found 
at  autopsy  in  about  one-half  the  cases,  and  will  be  separately  considered 
elsewhere. 


LOBAR  PNEUMONIA 


529 


The  lesions  in  the  other  organs  are  for  the  most  part  due  to  the 
pneumococcus.  There  may  be  pericarditis,  especially  with  pneumonia  of 
the  left  side  if  complicated  by  excessive  pleurisy.  This  is  seen  even  in 
infants.  The  pericardial  inflammation  closely  resembles  that  of  the 
pleura.  There  is  a  very  abundant  exudation  of  fibrin  and  pus,  coating 
both  surfaces  of  the  pericardium.  Acute  meningitis  is  rather  rare.  It  is 
an  acute  purulent  inflammation,  with  a  very  abundant  exudation  of 
greenish-yellow  fil^rin  and  pus,  chiefly  at  the  convexity.  Less  frequently 
peritonitis  is  present.  Acute  parotitis  and  acute  arthritis  are  seen  as 
rare  complications  of  pneumonia.  In  most  of  the  complicated  cases  the 
other  lesions  are  second  to  those  in  the  lungs ;  but  they  may  begin  simul- 
taneously with,  or  even  precede,  the  pneumonia.  In  severe  and  rapidly 
fatal  cases  with  meningeal  or  peritoneal  complications,  a  general  pneu- 
mococcus sei^ticemia  is  usually  present. 

The  heart  is  generally  found  in  diastole,  with  the  cavities,  especially 
those  of  the  right  side,  distended  with  soft  clots.  There  may  be  found 
ante-mortem  tb^rombi,  which  may  extend  into  the  pulmonarj^  artery  or 
the  aorta. 

Symptoms. — (1)  Tlie  Typical  Course. — A  child  three  or  four  years  of 
age,  after  a  few  hours  of  slight  indisposition,  is  suddenl}^  taken  with 
vomiting,  followed  by  a  rapid  rise  in  temperature.  He  is  dull  and  heavy, 
complains  of  headache  and  general  weakness,  refuses  food,  and  is  easily 
persuaded  to  remain  in  bed.  Pie  has  the  appearance  of  being  quite  ill, 
even  after  a  few  hours.  Occasionally  sharp  pain  in  the  side  is  complained 
of.  The  skin  is  dry;  there  are  marked 
thirst,  restlessness,  and  the  other  symptoms 
which  accomjDany  fever.  The  temperature 
is  found  to  be  104°  F.,  or  even  higher;  the 
respirations  40  to  50  a  minute;  the  pulse 
full,  strong,  and  120  to  130.  On  the  second 
day  the  patient  is  no  better.  The  tempera- 
ture remains  high ;  the  tongue  is  coated ;  the 
anorexia  continues;  the  pain  is  more  severe; 
cough  is  present  and  may  be  quite  frequent. 

After  the  second  or  third  day  the  patient 
is  usually  more  comfortable,  and  sleeps  bet- 
ter, but  may  be  disturbed  by  the  cough.  x4.t 
times  there  is  restlessness,  and  at  night  there 
may  even  be  slight  delirium.  The  respira- 
tion  continues    rapid   and   the   temperature 

high.  These  general  symptoms  show  very  little  change  until  the  sixth  or 
seventh  day,  when,  after  a  long  sleep,  which  has  been  more  natural  than 
before,  tlie  patient  wakes,  decidedly  improved  as  to  all  his  symjitoms. 


105° 
lOi'' 
103° 
102° 
101° 
100° 
99° 

1     2 

3 

i     5  1  0  t  7 

» 

.   A 

r-l 

IT  r 

Al^WaI 

if 

■  UZIi 

V 

1 

^ 

s/ 

93° 

'-' 

Fig.  64. — Typical,  Tempera- 
ture Curve  of  Lobar 
Pneumonia.  History  . — 
Male,  throe  years  old;  in  fair 
condition;  sudden  onset; 
signs  of  consolidation — - 
bronchial  respiration  and 
voice,  and  dulness — over  left 
lower  lobe  behind,  not  dis- 
tinct until  the  morning  of  the 
fifth  day.  On  the  seventh 
day  the  lung  was  resolving. 


530  DISEASES  OF  THE  RESriRATORY  SYSTEM 

There  is  less  fever,  aud  the  temperature  continues  to  fall  rapidly  until 
it  touches  the  normal  line,  or  it  may  even  go  below  this.  As  the  fever 
subsides  the  pulse  drops  to  90  or  100,  and  the  respirations  to  25  or  30  a 
minute.  The  appetite  soon  returns,  and  convalescence  is  usually  rapid. 
In  a  week  the  patient  is  out  of  bed,  and  in  a  week  or  two  more  he  is  oiit 
of  doors.  This  is  the  course  seen  in  fully  two-thirds  of  all  the  cases  of 
lobar  pneumonia  at  this  age. 

(2)  Pneumonia  of  Short  Duration. — Instead  of  running  the  usual 
course  of  from  five  to  eight  days,  cases  are  seen  in  which  the  duration  is 
only  three  or  four  days,  although  the  physical  signs  indicate  that  the 
process  in  the  lung  passes  through  the  usual  stages.  These  difEer  from 
the  ordinary  tjipe  chiefly  in  their  duration.     They  are  always  mild. 

(3)  Abortive  Pneumonia. — This  form  of  the  disease  is  rarely  seen 
in  hospitals,  but  it  is  not  infrequent  in  private  practice  where  the  phy- 
sician is  summoned  at  the  earliest  signs  of  illness.  The  onset  is  precisely 
like  that  of  ordinary  pneumonia,  and  may  even  be  as  severe  as  the  aver- 
age case.  The  physical  examination  of  the  chest  gives  all  the  signs  of 
the  first  stage  of  the  disease,  but  on  the  second  or  third  day  the  physician 
is  greatly  surprised  to  find  that  the  temperature  has  fallen  to  normal, 
and  that  all  the  physical  signs  have  disappeared.  The  process  in  such 
cases  does  not  seem  to  go  beyond  the  first  stage  of  congestion;  there  is 
no  evidence  of  hepatization  of  the  lung.  The  course  is  often  such  as  to 
lead  the  physician  to  the  opinion  that  he  has  made  a  mistake  in  his 
diagnosis.  This  type  of  pneumonia  corresponds  with  abortive  types  of 
other  infectious  diseases  so  frequently  met  with  in  children.  The  tem- 
perature curve  in  such  a  case  is  shown  in  Fig.  67.  The  diagnosis  of 
these  cases  is  always  attended  with  some  uncertainty.  There  can  be  no 
doubt  that  many  of  the  unexplained  high  temperatures  of  brief  duration 
which  are  seen  in  children  are  from  this  cause.  Exactly  why  it  is  that 
the  disease  sometimes  terminates  in  this  way  can  not  always  be  explained. 
It  may  be  because  the  resistance  of  the  patient  is  greater  than  usual,  or 
the  virulence  of  the  pneumococcus  is  less. 

(•i)  The  Prolonged  Course. — Althoiigh  usually  lasting  about  a  week, 
it  is  not  rare  for  pneumonia  to  continue  ten,  twelve,  or  even  fifteen  days. 
This  prolonged  course  is  usually  due  to  the  fact  that  the  disease  spreads 
from  one  part  of  the  lung  to  another,  or  even  to  the  opposite  lung,  in- 
volving in  succession  two,  three,  or  more  lobes.  This  is  sometimes  known 
as  "creeping"  pneumonia;  it  is  always  severe  and  the  outlook  is  gen- 
erally unfavorable.  A  prolonged  temperature  with  physical  signs  lim- 
ited to  a  single  lobe  should  always  suggest  complications,  most  frequently 
empyema,  occasionally  pericarditis. 

(5)  Hyperacute  Pneumonia. — Pneumonia  may  very  rarely  be  fatal 
in  the  first  forty-eight  hours.     The  onset  is  sudden,  frequently  with  con- 


LOBAR  PNEUMONIA  531 

Avulsions.  The  prostration  is  extreme  and  in  a  few  hours  the  child  may 
be  pulseless.  Delirium  or  deejj  coma  is  the  rule.  There  may  be  no 
cough  and  no  symptoms  or  physical  signs  pointing  to  a  pulmonary  lesion. 
The  respiration  may  be  slow  and  very  deep  like  the  breathing  in  the 
air  hunger  of  acidosis.  The  system  seems  overwhelmed  by  the  intensity 
of  the  toxemia.  Unless  one  has  seen  autopsies  upon  patients  with  this 
form  of  pneumonia  it  seems  impossible  to  believe  that  the  course  could 
differ  so  from  the  type  of  disease  usually  observed.  The  diagnosis  can 
only  be  suspected  unless  consolidation  of  the  lung  can  be  mad^  out. 
This  type  of  pneumonia  is  not  found  in  infancy.  In  a  few  such  cases 
a  complicating  acidosis  has  been  shown  to  be  present  by  laboratory  tests. 

(6)  Cerebral  Pneumonia. — This  term  was  first  applied  by  Eilliet 
and  Barthez  to  cases  of  pneumonia  in  which  the  cerebral  symptoms  pre- 
dominate.    They*  will  be  considered  later. 

Onset. — Prodromal  symptoms  of  more  than  a  few  hours'  duration  are 
quite  rare.  The  onset  of  lobar  pneumonia  is  almost  invariably  abrupt, 
with  well-marked  symptoms — vomiting,  diarrhea,  chill,  or  convulsions. 
Vomiting  is  altogether  the  most  frequently  seen.  In  summer  particu- 
larly, there  may  be  vomiting  and  diarrhea.  A  distinct  chill  is  rare  in  a 
child  under  five  years  of  age,  and  is  not  very  common  even  in  older  chil- 
dren. Convulsions  are  not  very  infrequent,  being  seen  in  about  five  per 
cent  of  the  cases.  Their  occurrence  depends  upon  the  suddenness  of  the 
invasion  and  the  susceptibility  of  the  patient. 

Cougli. — This  is  present  in  most  of  the  cases  throughout  the  disease, 
but  often  is  not  marked  for  the  first  day  or  two.  It  is  seldom  a  dis- 
tressing symptom.  A  disposition  to  suppress  the  cough  on  account  of 
pain  is  very  frequently  noticed. 

Expectoration. — This  is  rarely  seen  in  early  childhood,  and  practi- 
cally never  under  five  years  of  age.  Children  of  ten  or  twelve  may  have 
the  same  expectoration  as  adults — white  and  viscid,  or  brownish-red  early 
in  the  disease,  yellow  and  abundant  toward  its  close.  This  shows  the 
presence  of  the  pneumococcus  in  great  numbers. 

Pain. — Headache  and  general  muscular  pains  in  the  back  and  ex- 
tremities are  freqtient  during  the  invasion.  The  characteristic  pain,  how- 
ever, is  pleuritic.  It  is  not  necessarily  felt  in  the  region  of  the  affected 
lung,  and  often  not  in  the  chest  at  all.  It  is  frequently  referred  to 
the  loin,  the  epigastrium,  or  to  any  region  to  which  the  intercostal 
nerves  are  distributed.  Pain  in  the  right  iliac  fossa  associated  with 
extreme  tenderness  and  some  rigidity  may  lead  to  the  suspicion  of 
appendicitis  when  in  reality  the  pain  is  referred  from  the  inflamed 
pleura. 

Prostration. — This  is  one  of  the  characteristic  features  of  pneumonia. 
The  patient  is  generally  willing  to  go  to  bed  on  the  first  day  of  the 


532 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


107° 

1 

2 

3 

4  1-5 

6 

7 

8 

9 

10 

11 

12 

13 

11 

15 

16 

17  lis  il9i20  1 

106° 
105° 
104" 

ioa° 

102° 
101° 
100° 
99° 

1 

A 

. 

A 

h 

^ 

A 

ft 

r 

\ 

/ 

f 

\ 

' 

J 

1 

\ 

' 

\ 

/ 

, 

\ 

1 

\ 

98° 
97° 

A 

U'X-).^ 

_ 

V 

1 

Fig. 


65. — Lobar  Pneumonia  with  Remittent  Tem- 
perature. History. — Female,  eighteen  months 
old;  in  fair  condition;  sudden  onset;  repeated 
examinations  of  chest  made,  but  no  abnormal 
signs  until  the  ninth  day,  when  there  were  very  rude 
respiration  and  slight  dulness  at  the  right  apex,  in 
front;  on  the  twelfth  day  all  the  signs  of  consoli- 
dation at  the  same  point,  no  rales;  four  days  after 
the  crisis  the  lungs  were  clear. 


attack^  and  shows  little  desire  to  leave  it  while  the  disease  continues. 
Ambulatory  cases  are  not  common  in  children. 

Respiration. — This  is  always  accelerated,  and  generally  out  of  propor- 
tion to  the  pulse.  The 
normal  ratio  of  the  res- 
jDiration  to  the  pulse  is 
one  to  four;  in  pneu- 
monia, frequently  one  to 
two.  The  respiration  is 
not  labored  and  not  quite 
panting,  although  this 
term  is  sometimes  used 
to  describe  it.  It  is 
jerky.  There  is  a  short 
inspiration,  then  a  mo- 
mentary pause,  followed 
by  a  quick  expiration, 
which  is  accompanied  by 
a  short  moan.  This  expiratory  moan  is  very  characteristic.  The  rapidity 
of  respiration  is  usually  in  proportion  to  the  amount  of  lung  involved, 
but  it  is  also  modified  by  the  temperature,  as  the  respirations  often  drop 
from  60  to  30  in  the 
course  of  a  few  hours  at 
the  crisis. 

Pulse. — In  the  early 
part  of  the  disease  this 
is  frequent,  full,  and 
strong,  from  120  to  150 
a  minute.  Later  it  may 
be  weak,  small,  compres- 
sible, and  sometimes  ir- 
regular. It  is  much  more 
rapid  in  the  child  than  in 
the  adult,  160  and  180 
being  often  seen  in  cases 
not  especially  severe.  The 
pulse  rate  is  of  less  im- 
portance than  its  charac- 
ter. 

Temperature. — The  typical  temperature  curve  of  lobar  pneumonia 
(Fig.  61)  is  characterized  by  an  abrupt  rise  usually  to  101°  or  105°  F., 
and  by  daily  fluctuations  generally  within  the  limits  of  two  or  three 
degrees  until  the  crisis,  at  whicli  time  the  temperature  falls  to  normal. 


107° 

1 

2 

3 

i 

5 

6 

7 

8     9 

10    11 

12 

13 

U    15 

16    17 

18 

19 

20 

100° 
105° 
101° 
103° 
102° 
101° 
100° 
!)9° 

jl 

Am  ' 

Y     ^ 

l\ 

'1  ^ 

A 

/li 

fl 

^7 

AM  Ik 

\ 

J  .   II 

1  Wl 

V 

sr 

\ 

i 

I  1 

t 

r 

\ 

1 

'1 

93° 
97° 
96° 

y6° 

91° 

\  .'A 

N 

/\ 

'— 

^v. 

lA 

p 

1 

r 

— 

" 

i 

!  ' 

1 

1  [ 

1 

Fig.  66. — Lobar  Pneumonia  with  Subnormal  Tem- 
perature after  the  Crisis.  History. — Female, 
nineteen  months  old ;  fairly  healthy;  sudden  onset; 
sj'mptoms  typical  but  physical  signs  delayed ;  con- 
solidation in  left  mammary  region  on  the  eighth 
day;  on  the  ninth  in  right  lung  middle  lobe;  on  the 
eleventh  day  a  pseudocritical  drop  followed  after 
twentj'-four  hours  of  apyrexia  bj'  a  further  rise, 
which  was  accompanied  by  signs  of  extension  of  the 
disease  in  the  right  lung.  Resolution  rapid  after 
crisis. 


LOBAR  PNEUMONIA 


533 


106  ^  _ 
105'    _ 
104° 
103- 
102° 
101°   _ 
100° 
99- 

1 

i     3 

1 

5  1  6 

7 

8 

9 

10 

11 

12 

13 

11 

15  16 

17 

ti 

A 

1 

A 

f 

Si  V 

/ 

/ 

^1   IJV/_ 

^ 

y 

iiA 

V 

A 

\. 

I, 

K^  Ay^ 

'J»° 

=^ 

r 

_ 

:l 

_ 

"^ 

'■ 

usually  in  the  course  of  twenty-four  hours.  After  this  time  it  does  not 
go  above  the  normal  line.  Such  a  curve  is  seen  in  the  majority  of  cases 
over  three  years  of  age. 

In  children  under  three  years  of  age  it  is  not  uncommon  for  the  tem- 
perature to  be  of  a  more  or  less  remittent  type  (Fig.  65). 

These  wide  fluctuations  often  lead  to  great  difficulty  in  diagnosis, 
particularly  if  the  physical  signs  appear  late,  as  they  not  infrequently 
do.  It  is  probable  that  most  of  them  are  to  be  explained  as  mixed 
infections. 

The  chart  shown  in  Fig.  66  illustrates  three  features  which 
are  often  seen  in  pneumonia:  (1)  A  temperature  which  early  in  the 
disease  is  steadily  high  and 
as  the  day  of  crisis  ap- 
proaches becomes  remittent; 
(2)  a  secondary  rise  after 
being  normal  for  twenty-four 
hours,  which  was  due  in  this 
instance  to  an  extension  of 
the  disease  to  a  new  part  of 
the  lung;  (3)  a  fall  to  a 
point  considerably  below 
normal  at  the  time  of  the 
crisis.  In  this  case  the  tem- 
perature fell  in  the  course  of 
eighteen  hours  from  105°  to 
95°  F.,  and  later  still  lower; 
it  was  two  days  before  it  fi- 
nally remained  at  the  normal 
point.  A  fall  to  96.5°  or 
97°  F.  at  the  time  of  crisis  is  not  uncommon. 

In  the  foregoing  cases  the  fever  terminated  by  crisis.  In  Fig.  67  is 
shown  one  ending  by  lysis.  This  is  a  mode  of  termination  much  more 
frequent  in  young  children  than  in  those  who  are  older.  Thus,  in  93 
of  our  own  cases,  nearly  all  of  wliich  were  in  children  under  three  years 
of  age,  the  fever  ended  by  crisis  in  -1:9,  and  by  lysis  in  -14 ;  while  in  552 
collected  cases,  the  majority  of  which  were  in  older  children,  396  ended 
by  crisis,  and  126  by  lysis. 

The  table  on  the  following  page  shows  the  day  of  crisis  in  567  cases 
of  lobar  pneumonia  in  children  who  recovered.  From  this  it  will  be 
seen  that  the  most  frequent  critical  day  is  the  seventh,  and  that  in  sixty- 
six  per  cent  of  the  cases  it  was  from  the  fifth  to  the  eighth  day.  The 
causes  of  a  post-critical  rise  in  the  temperature  are  chiefly  two — exten- 
sion of  the  disease  to  a  new  area,  or  the  development  of  pleurisy,  which  is 


Fig.  67. — Abortive  Pneumonia  in  Left  Lung, 
foltowed  by  typical  pneumonia  in  right 
Lung,  Terminating  by  Lysis.  History. — 
Male,  seventeen  months  old,  healthy;  sudden 
onset,  on  the  second  day  disseminated  fine 
rales  in  both  lungs  behind,  and  over  left  lower 
lobe  very  feeble  respiration,  high-pitched — 
i.  e.,  some  bronchitis,  with  congestion  (?)  of 
left  base.  On  the  third,  fourth,  and  fifth 
days,  general  symptoms  gone  and  signs  nearly 
disappeared.  On  the  sixth  day  all  symptoms 
of  t)neumonia,  and  on  the  seventh  distinct 
consolidation  of  right  base,  rest  of  chest 
clear.  Subsequent  course  typical,  resolution 
rapid  and  complete. 


Eleventh       daj' 

Twelfth           "    

....     18  cases. 

7      " 

Thirteenth      "    

8      " 

Fourteenth     "    

7      " 

Fifteenth         "      

1  case. 

Eighteenth      "    

3  cases, 

534  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

apt  to  be  purulent.  Less  frequently  it  is  due  to  otitis,  meningitis,  peri- 
carditis, or  gastro-enteritis.  In  fatal  cases  the  temperature  is  generally 
high  until  the  end.  In  general,  it  may  be  said  that  the  temperature  is 
considerably  higher  in  children  than  in  adults;  in  the  majority  of  cases 
it  reaches  105°  F.,  the  usual  range  being  from  102°  to  105°  F.  In  15 
of  137  cases,  or  eleven  per  cent,  it  reached  106°  F.  or  over. 

The  Day  of  Crisis 

Second  day 3  cases. 

Third       "    22  " 

Fourth     "    43  " 

Fifth        "    88  " 

Sixth        "    83  " 

Seventh  "    132  " 

Eighth     "    73  "               Twenty-first  "    1  case. 

Ninth       "    55  "               Twenty-sixth "   1     " 

Tenth      "    22  " 

Gastro-enteric  Symptoms. — These  are  more  common  in  infants  than 
in  older  children.  At  the  onset  there  is  frequently  vomiting,  some- 
times also  diarrhea.  A  continuance  of  the  vomiting  is  rare,  and  is 
generally  due  to  improper  feeding  or  medication.  It  may  be  a  very 
serious  complication.  Diarrhea  is  also  rare,  except  at  the  onset  and 
in  summer  cases.  Great  tympanites  is  a  distressing  symptom,  and  when 
present,  it  is  a  bad  prognostic  sign.  Throughout  the  disease  there  are 
anorexia,  coated  tongue,  and  the  usual  symptoms  of  high  fever. 

Nervous  Symptoms. — Cerebral  symptoms  are  frequent  and  very  often 
misleading.  Pneumonia  is  often  ushered  in  by  convulsions,  which  may 
be  repeated  two  or  three  times  jn  the  course  of  the  first  twenty-four 
hours.  They  are  sometimes  followed  by  drowsiness  or  stupor,  sometimes 
by  active  delirium.  Cerebral  symptoms  may  predominate  for  several 
days.  There  may  be  opisthotonus,  dilated  or  contracted  pupils,  irregular 
pulse,  retracted  abdomen,  and,  in  fact,  almost  every  symptom  of  menin- 
gitis. Lumbar  puncture  in  these  cases  usually  shows  an  excess  of  cerebro- 
spinal fluid  under  high  tension  and  it  may  contain  a  few  pneumococci. 
Occasionally  the  decubitus  en  chien  de  fusil,  or  gun-hammer  position,  is 
assumed.  These  are  often  described  as  cases  of  cerebral  pneumonia,  and 
in  many  of  them  pneumonia  is  not  suspected  until  the  fourth  or  fifth 
day  of  the  disease,  sometimes  not  until  the  crisis  occurs,  when  the  rapid 
disappearance  of  all  these  nervous  symptoms  indicates  their  origin. 
Early  convulsions  are  not  generally  followed  by  an  especially  severe  type 
of  the  disease,  only  one  of  seven  such  cases  proving  fatal.  On  the  other 
hand,  cases  with  late  convulsions  are  usually  fatal,  as  they  indicate  either 
a  very  severe  form  of  the  disease  or  the  development  of  a  serious  com- 
plication, usually  meningitis. 

Delirium  is  much  more  frequent  tlian  convulsions,  and  is  seen  in 


LOBAE  PNEUMONIA  535 

nearly  one-fourth  of  the  cases.  Generally  it  is  slight  and  noticed  only 
at  night  or  when  the  temperature  is  very  high.  It  is  most  pronounced 
at  the  height  of  the  disease.  Other  nervous  symptoms  belonging  to  the 
typhoid  state  are  occasionally  seen,  but  only  in  the  most  severe  forms  of 
the  disease. 

It  is  impossible  to  establish  any  relation  between  the  seat  of  the 
disease  in  the  lungs  and  the  occurrence  of  cerebral  symptoms.  They 
are  more  frequent  in  children  under  five  years  than  in  those  who 
are  older,  and  depend  upon  the  suddenness  of  the  invasion,  the  in- 
tensity of  the  infection,  and  the  susceptibility  of  the  child.  Late  in 
the  disease  they  may  indicate  exhaustion,  toxemia,  or  complicating 
meningitis.  The  usual  nervous  symptoms — restlessnesSj  headache,  sleep- 
lessness, etc. — are  nearly  always  proportionate  to  the  height  of  the 
temperature. 

Urine. — Throughout  the  febrile  period  of  the  disease  the  urine  is 
scanty,  high-colored,  with  a  high  specific  gravity,  usually  loaded  with 
urates  and  with  marked  diminution  of  the  chlorids.  A  moderate  acetone 
reaction  is  very  common.  In  a  small  proportion  of  cases  a  trace  of 
albumin  may  be  found,  and  occasionally  a  few  hyaline  casts.  Evidences 
of  serious  renal  disease  are  seldom  found  in  lobar  pneumonia  in  early 
life. 

Shin. — The  face,  in  pneumonia,  is  usually  flushed,  sometimes  on  both 
sides  and  sometimes  only  on  one;  in  other  cases  it  is  pale,  but  not  in- 
dicative of  pain.  Cyanosis  is  rare  except  toward  the  close  of  the  disease 
and  is  usually  a  sign  of  respiratory  failure.  Herpes  of  the  lips  or  face 
is  quite  frequent. 

Blood.- — A  marked  polymorphonuclear  leucocytosis  is  a  characteristic 
feature  of  lobar  pneumonia ;  the  exceptions  are  in  very  mild  cases  or  very 
severe  infections  with  little  or  no  reaction.  The  increase  begins  shortly 
after  the  onset  and  continues  during  the  stage  of  exudation,  generally 
reaching  its  maximum  shortly  before  the  crisis,  when  it  declines  rapidly. 
The  usual  number  of  white  cells  in  an  average  case  of  pneumonia  in 
a  young  child  is  from  25,000  to  40,000,  but  it  is  not  rare  for  the  count 
to  run  up  to  50,000  or  even  60,000.  We  have  seen  it  over  100,000  several 
times.  The  absence  of  leucocytosis  in  a  strong  child  who  is  acutely  ill 
is  always  strong  presumptive  evidence  against  pneumonia.  A  well- 
marked  leucocytosis  is  of  much  value  in  differentiating  pneumonia  from 
typhoid  fever.  Positive  blood  cultures  were  obtained  in  the  Babies'  Hos- 
pital in  14  per  cent,  of  108  cases  studied.  Otten  found  almost  exactly 
the  same  proportion  in  a  study  of  70  cases.  These  observations  indicate 
that  positive  cultures  are  much  less  frequent  than  in  the  pneumonia 
of  adults. 

Physical  Signs. — The  earliest  signs  in  pneumonia  are  due   to   the 


Fig.  68. — First  Stage.  Congestion  of  left 
lower  lobe,  with  crepitant  rales.  Feeble 
breathing  of  a  rude  character,  with  slight 
dulness. 


Fig.  69. — In  the  center  of  the  area,  a  small 
spot  of  pure  bronchial  breathing  and  voice; 
surrounding  this  an  occasional  crepitant 
rale,  with  bronchovesicular  breathing  and 
slight  dulness. 


Fig.  70. — Second  Stage.  Complete  consolidation  of  left  lower  lobe.  Pure  bronchial  breathing  and 
bronchial  voice;  marked  dulness;  increased  vocal  fremitus,  and  at  the  lower  part  a  few  friction 
sounds. 

Note. — During  resolution  the  signs  take  the  inverse  order:  those  of  Fig.  70  give  place  to 
those  of  Fig.  69,  and  these  in  turn  to  those  of  Fig.  68.  In  addition,  many  coarse  rales  may  be 
heard. 


536 


LOBAR  PNEUMONIA 


537 


acute  congestion  of  the  affected  lung  or  lobe,  in  consequence  of  which 
less  air  enters  this  portion  and  more  air  the  rest  of  the  lungs.  Percus- 
sion gives  diminished  resonance  or  slight  dulness,  often  of  a  somewhat 
tympanitic  character  over  the  affected  area,  and  exaggerated  resonance 
over  the  remainder  of  this  lung  and  over  the  opposite  lung.  Ausculta- 
tion over  the  affected  lobe  gives  feeble  respiratory  murmur,  rather  high 
in  pitch;  sometimes  there  may  be  so  nearly  an  absence  of  all  breath- 
sounds  as  to  suggest  fluid.  ,  The  normal  respiratory  murmur  over  the 
healthy  portions  of  the  lungs  is  intensified.  In  children  this  exag- 
gerated breathing  is  not  infrequently  mistaken  for  bronchial  breathing. 


Fig.  71. — Lobae  Pneumonia.      Child  2|  years  old.     Lobar  pneumonia  of  right  upper 
and  middle  lobes,  at  the  height  of  the  disease  with  all  the  usual  signs  of  consolidation. 


and  the  physician  may  be  led  into  the  error  of  locating  the  pneumonia 
upon  the  wrong  side.  Exaggerated  breathing  differs  little  from  nor- 
mal breathing  except  in  intensity.  Bronchial  breathing  is  higher  in 
pitch,  tubular  in  character,  and  is  heard  with  nearly  equal  intensity, 
both  on  expiration  and  inspiration.  If  the  chest  is  frequently  .aus- 
cultated, crepitant  or  fine  subcrepitant  rales  may  usually  be  heard  at  some 
period  at  the  end  of  full  inspiration,  but  often  they  are  present  but  for 
a  few  hours,  and  they  may  be  missed  altogether.     (Figs.  68,  69,  70.) 

A  study  of  cases  of  lobar  pneumonia  by  the  X-ray  shows  that  con- 
solidation occurs  early,  and  that  it  first  affects  the  surface  of  the  lung, 
gradually  extending  inward  as  the  disease  progresses  (Fig.  71).  Bron- 
chial breathing  is  not  usually  obtained  until  the  consolidation  has  reached 
the  hilus  of  the  lung.    Feeble  breathinor  and  slight  dulness  occur  earlier. 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

In  the  second  stage,  that  of  consolidation,  no  air  enters  the  air  vesi- 
cles of  the  affected  portion  of  the  lung.  There  is  found  here  exaggerated 
vocal  fremitus,  and  marked  dulness,  but  very  rarely  flatness.  Over 
the  rest  of  this  lung  there  is  exaggerated,  sometimes  even  tympanitic, 
resonance;  this  is  especially  frequent  at  the  apex  of  the  lung  in  front, 
when  there  is  consolidation  at  the  base  behind.  Under  these  conditions 
cracked-pot  resonance  may  sometimes  be  obtained.  Over  the  healthy 
lung  there  is  exaggerated  resonance.  Over  the  consolidated  portion 
there  is  bronchial  l)reathing  and  bronchial  voice,  the  area  over  which 
they  are  heard  being  sharply  defined.  Eales  are  usually  absent,  but  there 
may  be  pleuritic  friction  sounds. 

In  the  stage  of  resolution  there  is  a  gradual  disappearance  of  the 
signs  of  consolidation.  The  pure  bronchial  is  replaced  by  broncho- 
vesicular  breathing,  the  vesicular  element  gradually  predominating. 
Moist  rales  of  all  varieties  are  heard.  Usually  the  most  persistent  signs 
are  slight  dulness  or  diminished  resonance,  with  a  respiratory  murmur 
which  is  feebler  than  normal  and  a  little  higher  in  pitch;  sometimes  there 
are  also  dry  friction  sounds.  These  signs  may  persist  for  two  or  three 
weeks. 

Exceptional  Pliysical  Signs. — While  in  the  majority  of  cases  the  signs 
of  consolidation  are  distinct  on  or  before  the  fourth  da}',  in  not  a  few 
they  may  be  delayed  much  longer.  Of  eighty-two  cases  in  which  the  day 
was  noted  on  which  consolidation  was  found,  it  was  not  until  the  fifth 
day  or  later  in  one-fourth  the  number.  In  six  of  them,  although  care- 
fully and  repeatedly  examined,  no  consolidation  was  found  until  the 
seventh  day  or  later  and  in  one  case  not  until  the  twelfth  day.  These 
cases  of  delayed  or  concealed  physical  signs  have  often  been  regarded  as 
examples  of  central  pneumonia.  That  pneumonia  may  exist  only  in  the 
center  of  a  lung  for  a  number  of  days  is  extremely  improbable.  At 
autopsy  we  have  very  frequently  seen  superficial  pneumonia  but  never 
central  lobar  pneumonia.  X-ray  studies  have  shown  conclusively  that 
with  a  superficial  consolidation  no  bronchial  breathing  may  be  heard 
even  though  the  consolidation  may  be  fairly  extensive.  When  the  proc- 
ess extends  toward  and  reaches  the  hilus  of  tne  lung  bronchial  breathing 
is  readily  heard.  It  is  the  superficial  pneumonia,  then,  that  escapes 
detection  rather  than  the  central.  There  are,  however,  two  regions  in 
which  pneumonia  may  exist  and  yet  not  be  accessible  by  our  means  of 
physical  examination,  viz.,  at  the  apex  of  the  lung  in  the  part  covered  by 
the  shoulder,  and  along  the  posterior  border  of  the  lung  where  it  lies 
against  the  vertebrae.  It  is  quite  common  in  cases  with  late  physical 
signs  that  the  first  distinctive  evidences  of  disease  are  found  high  in  the 
axilla,  or  beneath  the  clavicle  in  front,  and  these  regions  should  be  closely 
watched  in  all  doubtful  cases. 


LOBAR  PNEUMONIA  .  539 

Complications. — The  occnrreuce  of  dry  pleurisy  over  the  consolidated 
portion  of  the  hmg  is  so  constant  that  it  can  hardly  be  considered  a  com- 
plication. A  slight  serous  exudation  of  two  or  three  ounces  is  very 
common  and  often  develops  rapidly.  In  the  most  severe  cases  of  pleurisy 
there  is  an  excessive  exudation  of  fibrin  and  pus.  This  has  occurred 
in  about  eight  per  cent  of  our  cases.  This  variety  is  known  clinically 
as  pleuropneumonia,  and  will  be  considered  seiDarately.  Pericarditis 
is  uncommon.  It  is  seen  more  often  in  infants  than  in  older  children. 
It  most  frequently  -develops  at  the  height  of  the  j^neumonia  rather 
oftener  when  this  affects  the  left  lung  than  the  right ;  it  occurs  in  pleuro- 
pneumonia much  more  often  than  in  the  simple  form.  The  jjericarditis 
is  usually  of  the  fibrinopurulent  type.  It  may  sometimes  be  discovered 
by  physical  signs;  but  rarely  gives  rise  to  any  new  symptoms.  Endo- 
carditis is  extremely  rare,  though  now  and  then  it  occurs  upon  valves 
previously  the  seat  of  a  chronic  lesion.  Meningitis  is  rare,  and  generally 
develops  late  in  the  disease.  It  is  nearly  always  ushered  in  by  repeated 
attacks  of  vomiting  or  convulsions.  Its  course  is  short  and  progressive. 
Peritonitis  causes  few  new  symptoms  except  abdominal  distention,  pain, 
and  tenderness.  Parotitis  and  arthritis  are  very  rare  and  are  easily 
recognized. 

Course  and  Termination. — In  the  great  majority  of  cases  lobar  pneu- 
monia terminates  either  in  perfect  recovery  or  in  death.  '\A'Tien  ending 
in  recovery,  resolution  commonly  begins  immediately  upon  the  cessation 
of  the  fever,  and  is  complete  in  about  a  week.  Delayed  resolution  is  not 
common  in  children;  chronic  pneumonia  and  tuberculosis  are  rare 
sequelae,  but  empyema  is  very  frequent.  Its  symptoms  sometimes  develop 
immediately  after  the  pneumonia,  the  temperature  continuing  high;  or 
there  may  be  an  interval  of  a  few  days  before  the  development  of  the 
pleural  symptoms.  Some  pleuritic  adhesions  probably  remain  in  every 
case  in  which  there  has  been  much  dry  pleurisy,  and  when  severe  and  ex- 
tensive, these  may  be  the  cause  of  subsequent  symptoms,  like  any  other 
dry  pleurisy. 

Death  from  uncomplicated  ^^neumonia  may  be  due  to  exhaustion,  or 
to  circulatory  failure,  with  or  without  failure  of  the  respiration.  The 
signs  of  circulatory  failure  sometimes  develop  quite  rapidly  in  cases 
which  are  apparently  doing  well.  The  symptoms  are :  coldness  of  the 
hands  and  feet,  then  of  the  legs  and  arms;  a  rapid,  compressible,  and 
sometimes  irregular  pulse;  muscular  weakness  and  pallor,  but  usually 
no  cyanosis.  The  symptoms  of  respiratory  failure  are:  very  rapid  super- 
ficial respirations,  sometimes  100  a  minute;  blueness  of  the  lips  and 
finger  nails;  often  a  leaden  hue  of  the  whole  body;  there  are  loud 
tracheal  rales,  and  recession  of  all  the  soft  parts  of  the  chest  on 
inspiration. 


540 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


Death  may  occur  early  in  the  disease,  when  the  pneumonia  has 
spread  rapidly,  involving  both  lungs.  In  most  of  the  uncomplicated 
fatal  cases,  death  results  from  failure  of  the  circulation  at  about  the  end 
of  the  first  week.  In  the  complicated  cases  death  usually  occurs  in  the 
second  week;  but  we  have  known  fatal  meningitis  to  develop  as  late  as 
the  end  of  the  fourth  week. 

Diagnosis. — The  most  characteristic  clinical  and  pathological  differ- 
ences between  broncho-  and  lobar  pneumonia  are  shown  in  the  following 
table: 


BRONCHOPNEUMONIA 

1.  Often  secondary. 

2.  Under  two,  chiefly  under  one 
year. 

3.  Occurs  more  frequently  in  del- 
icate and  debilitated  children. 

4.  Bacteria — in  primary  cases,  usu- 
ally the  pneumococcus ;  in  secondary 
cases,  usually  mixed  infection. 

5.  Products  of  inflammation  chiefly 
cellular;  process  often  diffuse. 

6.  Onset  often  gradual,  sometimes 
insidious,  especially  when  secondary. 

7.  No  typical  course;  fever  often 
lasts  three  or  four  weeks;  rarely  ter- 
minates by  crisis. 

8.  Involves  both  lungs  as  a  rule, 
most  frequently  lower  lobes  posteriorly. 

9.  Signs  of  bronchitis  mingled  with 
those  of  consolidation;  rales  in  other 
parts  of  the  same  lung,  or  in  the  oppo- 
site lung,  throughout  the  disease. 

10.  Consolidation  later — fourth  to 
seventh  day:  there  may  be  none;  apt 
to  be  incomplete;  shades  off  gradually. 

11.  Resolution  slow,  one  week  to 
two  months;  often  incomplete;  strong 
tendency  to  become  chronic. 

12.  Relapses  and  second  attacks 
frequent. 

13.  Sequelae :  Empyema,  chronic  in- 
terstitial pneumonia,  sometimes  tuber- 
culosis. 

14.  Prognosis  always  serious  from 
the  age  and  the  circumstances  in 
which  disease  occurs. 

15.  Hospital  mortality  50  per  cent  of 
primary  cases,  65  per  cent  of  all  cases. 


LOBAR  PNEUMONIA 

1.  Almost  always  primary. 

2.  Most  common  between  three  and 
eight  years. 

3.  More  often  in  those  previously 
healthy. 

'4.  The  pneumococcus,  very  often 
alone. 

5.  Chieflj^  fibrin;  process  circum- 
scribed. 

6.  Onset  sudden,  with  well-marked 
symptoms. 

7.  Typical  course;  crisis,  usually 
from  fifth  to  eighth  day. 

8.  Usually  one  lobe  or  a  part  of  a 
lobe;  left  base  most  frequently,  right 
apex  next. 

9.  Rales  only  early,  and  during  reso- 
lution; frequently  no  signs  in  opposite 
lung. 

10.  Consolidation  earlier;  second  or 
third  day.  Consolidation  complete; 
area  usually  sharply  defined. 

11.  Resolution  rapid,  usually  com- 
plete within  a  week. 

12.  Both  are  rare. 

13.  No  sequelae  except  empyema. 


14.  Prognosis  good;  rarely  fatal  ex- 
cept from  complications  —  empyema, 
meningitis,  pericarditis. 

15.  Mortality  about  4  per  cent  of 
all    cases. 


LOBAR  PNEUMONIA  541 

In  the  majority  of  cases  the  symptoms  are  plain  and  the  physical 
signs  so  typical  that  it  is  difficult  to  overlook  pneumonia  if  any  degree 
of  care  is  used  in  the  examination  of  the  patient.  The  difficulties  in  diag- 
nosis are  due  to  the  great  variation  in  the  general  symptoms,  and  to  the 
late  appearance  of  the  physical  signs.  The  error  usually  made  is  to  mis- 
take pneumonia  for  some  other  disease,  rather  than  to  mistake  some 
other  disease  for  pneumonia.  On  account  of  its  frequency  in  children, 
pneumonia  should  always  be  excluded  before  accepting  any  other  ex- 
planation of  a  continuously  high  temperature.  The  rule  should  be  fol- 
lowed, in  all  cases  of  acute  illness,  of  making  a  thorough  examination  of 
the  chest  daily  until  the  diagnosis  is  clear.  If,  to  high  temperature, 
rapid  respiration  and  marked  leucocytosis  are  added,  one  should  always 
suspect  pneumonia,  no  matter  what  the  other  symptoms  may  be.  It 
not  infrequently  happens  that  the  general  symptoms  are  quite  charac- 
teristic and  yet  the  physical  signs  appear  late.  In  such  cases  pneumonia 
should  always  be  looked  for  high  in  the  axilla  or  just  beneath  the  clavi- 
cle, since  it  is  particularly  in  the  cases  of  apex  pneumonia  that  this 
obscurity  is  likely  to  exist. 

In  their  onset,  scarlet  fever,  tonsillitis,  and  gastro-enteritis  may  all 
resemble  pneumonia.  Scarlet  fever  is- recognized  by  the  sore  throat  and 
the  characteristic  eruption  on  the  second  day;  tonsillitis,  by  the  local 
symptoms.  In  infancy,  pnevimonia  often  begins  with  vomiting  and 
sometimes  there  is  also  diarrhea,  which  may  lead  one  to  mistake  the 
disease  for  gastro-enteritis.  The  constitutional  symptoms  of  influenza 
often  closely  resemble  those  of  pneumonia;  the  diagnosis  is  frequently 
in  doubt  for  several  days  until  definite  physical  signs  of  pneumonia 
make  their  appearance.  From  all  other  general  diseases,  pneumonia  is 
to  be  differentiated  by  the  physical  signs. 

Pneumonia  with  marked  cerebral  symptoms  sometimes  resembles 
cerebrospinal  meningitis.  In  both  we  may  have  the  abrupt  onset,  con- 
vulsions, delirium  or  stupor,  opisthotonus,  prostration,  and  marked  leu- 
cocytosis. The  only  positive  means  of  differential  diagnosis  are  by  the 
physical  signs  in  pneumonia,  and  the  findings  from  lumbar  puncture  in 
cerebrospinal  meningitis. 

The  question  sometimes  arises  in  pneumonia  with  cerebral  symptoms, 
whether  or  not  pneumococcus  meningitis  also  exists.  If  the  nervous 
symptoms  are  present  from  the  beginning,  there  is  probably  no  menin- 
gitis. If  they  develop  suddenly  during  the  course  or  toward  the  close 
of  the  disease,  meningitis  should  be  suspected.  The  only  positive  means 
of  differentiation  is  by  lumbar  puncture. 

Lobar  pneumonia  is  to  be  differentiated  from  a  pleuritic  effusion. 
The  most  common  mistake  is  to  confound  empyema  with  unresolved 
pneumonia.    In  pneumonia  rarely  if  ever  do  the  signs  point  to  involve- 
19 


542  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

ment  of  an  entire  lung.  There  is  increased  vocal  fremitus,  dulness, 
bronchial  voice  and  breathing,  and  occasional  rales  or  friction  sounds. 
In  empyema  the  whole  lung  is  often  atfected,  there  is  displacement  of 
the  heart,  flatness  on  percussion,  diminished  or  absent  vocal  fremitus, 
and  although  bronchial  voice  and  breathing  are  present,  they  are  usually 
distant  and  feeble.  There  are  no  rales  or  friction  sounds.  In  doubtful 
cases  an  exploratory  puncture  should  always  be  made.  Serous  effusions 
give  the  same  physical  signs  as  empyema. 

The  X-ray  may  be  of  marked  assistance  in  diagnosis.  The  shadow 
of  consolidation  in  lobar  pneumonia  is  usually  clear  and  sharply  cir- 
cumscribed.    It  is  often  wedge  shaped  as  shown  in  Fig.  71. 

Prognosis. — There  is  probably  no  disease  in  which  tlie  jDatient  ap- 
pears so  ill,  and  yet  so  often  recovers  completely,  as  lobar  pneumonia 
in  children  over  three  years  old.  Of  1,295  collected  cases,  chiefly  from 
hospital  practice,  there  were  but  39  deaths,  a  mortality  of  three  per  cent. 
In  187  eases  of  our  own  there  were  21  deaths,  a  mortality  of  eleven  per 
cent.  In  only  one  of  the  fatal  cases  was  the  child  over  two  years  old.  The 
difference  between  the  mortality  among  our  cases  and  the  general  mortal- 
ity given,  is  due  to  the  fact  that  a  large  proportion  of  the  first  group  were 
observed  in  children  under  two  years,  while  of  the  collected  cases,  the 
vast  majority  were  in  older  children.  Combining  the  above  figures,  we 
have  a  total  of  1,482  cases  with  60  deaths,  a  mortality  of  four  per  cent. 
In  nearly  all  our  cases  death  was  due  either  to  complications  or  to  very 
extensive  disease,  as  when  both  lungs  were  involved,  or  nearly  the  whole 
of  one  lung.  In  only  one  case  was  an  uncomplicated  pneumonia  of  a 
single  lobe  fatal. 

The  prognosis  depends  upon  the  age  of  the  patient,  the  intensity  of 
the  infection,  as  shown  by  the  temperature,  nervous  symptoms  and  pulse, 
the  presence  or  absence  of  complications,  and  the  extent  of  the  local 
disease.  These  factors  are  to  be  taken  into  consideration  rather  than 
any  special  symptoms.  Early  convulsions  do  not  materially  affect  the 
prognosis.     Late  convulsions  are  always  very  unfavorable. 

The  occurrence  of  vomiting,  diarrhea,  or  marked  tympanites  late  in 
the  disease  is  always  unfavorable. 

A  temperature  range  between  102°  and  105°  F.  is  the  rule,  and 
within  these  limits  the  fever  does  not  affect  the  prognosis.  Even  very 
high  temperature  does  not  increase  the  danger  from  the  disease  as  much 
as  might  be  expected.  Of  fifteen  cases  in  which  the  temperature  reached 
106°  F.  or  over,  all  but  three  recovered;  while  of  six  cases  in  which  it 
was  106.5°  or  over,  only  one  died.  The  highest  recorded  temperature  in 
our  cases— 107.5°  F. — was  in  a  patient  who  recovered.  A  transient  rise, 
even  though  the  temperature  may  go  very  high,  is  seldom  serious. 
Much  more  serious  is  a  fever  which  remains  steadily  alcove  105°  F.,  as 


LOBAR  PNEUMONIA  543 

in  most  cases  this  accompanies  either  very  extensi.ve  disease  or  pleuro- 
pneumonia. The  continuance  of  the  fever  after  the  tenth  day  is  a  bad 
symptom;  for,  although  the  crisis  may  be  postponed  until  the  twelfth 
day  and  occur  normally,  such  a  prolonged  temperature  is  an  indication 
of  a  new  focus  of  disease  or  the  development  of  complications.  In  a 
severe  attack,  the  extension  of  the  disease  to  another  lobe  after  the  fifth 
day  is  unfavorable.  If  resolution  does  not  begin  soon  after  the  tem- 
perature becomes  normal,  the  development  of  empyema,  or  some  other 
pulmonary  complication,  should  be  apprehended. 

The  results  of  blood  cultures  have  some  prognostic  value.  Of  108 
hospital  cases  the  mortality  of  15  with  positive  cultures  Avas  33  per  cent; 
of  93  with  negative  cultures  it  was  but  8  per  cent. 

Treatment. — The  specific  treatment  of  lobar  pneumonia  has  not  yet 
reached  a  point  where  it  is  to  be  advised  with  children.  In  considering 
the  management  of  this  disease  several  cardinal  facts  are  to  be  kept  in 
mind.  It  is  a  self-limited  disease,  having  a  strong  tendency  to  recovery 
in  the  great  majority  of  cases  regardless  of  the  treatment  adopted.  The 
fatal  cases  are  almost  always  in  children  under  two  years  of  age;  the 
rare  deaths  in  older  ones  are  usually  due  to  complications.  There  is 
as  yet  no  treatment  which  can  be  relied  upon  to  abort  an  attack  of  pneu- 
monia or  shorten  its  course.  It  follows,  therefore,  that  the  indications 
are,  so  far  as  possible,  to  make  the  patient  comfortable  during  his 
illness,  to  watch  for  complications,  and  to  treat  the  individual  symptoms 
as  they  arise. 

In  the  majority  of  cases,  hygienic  treatment  is  all  that  is  required. 
The  patient  should  be  kept  in  bed,  no  matter  how  mild  the  attack;  he 
should  be  disturl)ed  as  little  as  possible.  Most  children  with  pneumonia 
get  too  much  treatment.  There  seems  to  be  a  decided  advantage  not 
only  in  fresli  air,  but  in  cold  air.  Patients  in  cold  rooms  sleep  better, 
cough  less,  and  altogether  seem  more  comfortable  than  when  care- 
fully housed  to  prevent  their  "taking  cold."  Wide-open  windows  are 
desirable  even  though  the  room  temperature  is  constantly  as  low  as 
50°  P.  The  patient  should  be  properly  protected  by  blankets,  flannel 
wrapper,  woolen  stockings,  and  at  times  a  hot-water  bag  at  his  feet. 
Pood  should  be  given  at  regular  intervals,  usually  not  oftener  than 
every  four  hours.  It  should  not  be  forced  when  the  patient  is  suffering- 
only  from  thirst,  especially  early  in  the  attack,  when  the  appetite  is 
often  completely  lost.     Water  should  l)c  allowed  freely  at  all  times. 

These  measures,  careful  nursing,  an  occasional  dose  of  codein  (gr. 
^J-Q-  to  a  child  of  three  years)  when  the  patient  is  very  restless,  fretful,  or 
sleepless,  an  ice-cap  to  the  head,  and  cold  sponging  when  the  tempera- 
ture makes  him  uncomfortable,  are  usually  all  that  is  necessary,  except 
to  keep  a  sharp  lookout  for  complications. 


544  DISEASES  OF  THE  RESPIRATORY  SYSTELM 

Special  symptoms  may  require  treatment.  When  not  severe,  the 
nervous  sj'miDtoms  may  he  controlled  hy  codein  alone  or  in  comhination 
with  small  doses  of  phenacetin  or  the  hromids.  Sometimes  sponging 
with  tepid  water  is  better  than  drugs.  Severe  nervous  symptoms,  such 
as  delirium,  stupor,  great  restlessness  with  impending  convulsions,  when 
associated  with  high  temperature,  call  for  ice  to  the  head,  cold  sponging, 
or  the  cold  pack  or  bath.  Pain,  if  moderate,  may  be  relieved  by  counter- 
irritation,  by  a  mustard  paste,  by  dry  cups,  an  ice-bag,  or  by  a  hot  poul- 
tice; if  severe,  codein  may  be  used  in  addition.  The  cough  is  rarely 
severe  enough  to  require  treatment.  When  it  is  so  severe  as  to  prevent 
sleep,  small  doses  of  Dover's  powder  or  codein  should  be  given.  Anti- 
pyretic measures  are  not  necessarily  called  for  even  if  the  temperature 
is  very  high.  Some  nervous  children  are  less  disturbed  by  the  tempera- 
ture than  by  the  means  used  to  reduce  it.  Under  such  conditions  the 
temperature  should  be  closely  watched,  but  not  necessarily  interfered 
with  unless  other  symptoms  develop.  The  nervous  symptoms  are  a  bet- 
ter guide  than  the  thermometer  to  the  use  of  antipyretics.  Cold  we  be- 
lieve to  be  the  safest  and  most  certain  antipyretic  \ve  possess.  It  may 
be  used  as  a  cold  sponge  bath,  the  cold  pack  or  an  ice-bag  to  the  chest. 
There  is  no  objection  to  the  bath  except  the  prejudice  of  the  laity. 
While  cold  is  applied  to  the  trunk  the  extremities  should  be  closely 
watched,  and  heat  applied  if  necessary.  The  duration  of  the  pack  or 
bath,  and  the  frequency  of  their  use,  will  depend  upon  the  individual  case. 
In  the  majority  of  cases  stimulants  are  not  required.  They  are  called 
for  "when  the  pulse  is  weak,  compressible,  and  rapid,  when  the  face  is 
pale  and  the  extremities  are  cold.  The  same  stimulants  are  to  be  em- 
ployed, and  in  the  same  way,  as  in  bronchopneumonia.  Circulatory  and 
respiratory  stimulants  are  usually  required  in  larger  quantity  at  the  time 
of  and  just  after  the  crisis ;  they  are  to  be  used  as  in  bronchopneumonia. 


PLEUROPXEUAIONIA 

Under  this  term  are  included  cases  of  pneumonia  with  an  excessive 
amount  of  pleurisy,  the  two  processes  uniting  to  produce  a  single  clinical 
type  of  disease. 

In  nearly  all  cases  of  lobar  pneumonia  there  is  a  certain  amount  of 
inflammation  of  the  pulmonary  pleura,  and  also  in  those  cases  of  broncho- 
pneumonia which  are  accompanied  by  any  marked  degree  of  consolida- 
tion. In  both  of  these  conditions  the  pleurisy  is  usually  co-extensive 
with  the  consolidation.  But  in  certain  cases,  in  both  forms  of  pneumonia, 
the  amount  of  jdeurisy  is  excessive,  and  this  so  modifies  the  symptoms 
and  course  of  the  disease  as  to  require  for  them  a  separate  consideration. 


PLEUROPNEUMONIA  545 

In  some  it  apj^ears  that  the  inflammatory  process  begins  almost  simul- 
taneously in  the  lung  and  in  the  pleura;  while  in  others  the  pleurisy 
follows  the  pneumonia.  These  cases  are  almost  invariably  due  to  the 
pneumococcus,  although  in  some  there  is  a  mixed  infection. 

In  398  hospital  cases  of  pneumonia  there  were  27,  or  6.8  per  cent, 
which  could  be  classed  as  pleuropneumonia,  the  diagnosis  being  con- 
firmed either  by  autopsy  or  operation.  Of  190  fatal  cases,  12.5  per  cent 
were  cases  of  pleuropneumonia.  Most  of  these  hospital  patients  were 
under  three  years  of  age,  and  the  disease  is  more  frequent  at  this  period 
than  in  older  children. 

Lesions. — Of  these  27  cases,  17  were  classed  as  bronchopneumonia 
and  10  as  lobar  pneumonia.  The  left  lung  was  more  frequently  affected 
than  the  right  in  the  proportion  of  three  to  two.  In  most  of  the  cases 
the  pleura  covering  the  entire  lung  was  involved,  even  though  the  pneu- 
monia affected  but  a  single  lobe,  or  only  a  part  of  a  lobe.  In  nearly 
half  the  cases  both  lungs  were  involved,  but  one  to  a  very  much  less 
extent  than  the  other.  In  a  small  number  of  cases  the  pleurisy  was 
limited  to  the  posterior  surface  of  the  lung. 

In  pleuropneumonia  both  the  vi&ceral  and  the  parietal  pleura  are 
coated  with  a  layer  of  yellowish-green  fibrin,  in  thick,  shaggy  masses, 
causing  adhesions  of  the  lung  to  the  chest  wall,  the  diaphragm,  and  the 
pericardium  (Plate  IX).  The  exudation  varies  between  one-eighth 
and  one-half  of  an  inch  in  thickness.  It  can  often  be  stripped  from  the 
lung  or  scraped  from  the  chest  wall  by  the  handful.  In  its  meshes  small 
pockets  may  form,  which  contain  only  a  few  drops,  or  sometimes  a  dram, 
of  pus,  or  less  frequently,  serum.  This  is  the  condition  in  which  the  lung 
is  usually  found  when  death  has  occurred  at  the  height  of  the  disease.  If 
the  process  has  lasted  longer,  larger  collections  of  pus  may  be  present. 
The  lung  itself  shows  the  usual  changes  of  pneumonia,  and  if  there  has 
been  any  considerable  accumulation  of  fluid,  there  are  in  addition  the 
evidences  of  compression.  The  disproportion  between  the  changes  in  the 
pleura  and  those  in  the  lung  may  be  striking.  Frequently  the  pulmonary 
lesions  are  relatively  insignificant. 

With  pleuropneumonia  of  the  left  side,  the  pericardium  is  frequently 
involved.  The  lesions  closely  resemble  those  of  the  pleura.  Meningitis 
and  peritonitis  are  by  no  means  rare,  and  in  most  of  the  fatal  cases  a 
general  pneumococcus  septicemia  is  present.  The  organisms  may  be 
found  in  the  blood  in  great  numbers  during  life  or  post  mortem. 

An  inflammation  of  the  intensity  described  is  very  often  fatal  in  the 
acute  stage,  if  the  patient  is  a  child  under  two  years  old.  Occasionally 
at  this  age,  and  very  frequently  in  older  children,  we  see  the  later  stages 
of  the  process.  The  most  frequent  course  is  for  more  and  more  pus  to 
be  poured  out  from  the  inflamed  pleura  until  the  chest  is  filled,  the  case 


546  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

becoming  thus  one  of  empyema.  Sometimes  the  fluid  is  serous  instead 
of  purulent,  but  this  is  very  rare  in  infancy.  In  other  circumstances 
the  exudation  is  partly  absorbed^  but  the  greater  part  becomes  organized 
so  as  to  form  a  thick  jacket  of  fibrous  tissue  which  binds  the  lobe  or  lung 
to  the  chest  wall  and  interferes  seriously  with  its  subsequent  full  expan- 
sion.    Chronic  interstitial  pneumonia  may  follow. 

Symptoms. — There  is  little  which  distinguishes  a  case  of  pleuropneu- 
monia except  the  severity  of  all  the  constitutional  symptoms;  the  tem- 
perature is  often  higher,  the  prostration  gTeater,  and  the  patient  in  every 
way  impresses  one  as  being  more  seriously  ill  than  with  ordinary  pneu- 
monia. Sometimes  the  thoracic  pain  is  more  severe  and  more  constant 
than  is  usual  in  pneumonia. 

In  the  early  stage  i^leuritic  friction  sounds  are  unusually  j)romi- 
nent ;  after  two  or  three  days  the  signs  of  consolidation  come  out  clearly 
in  most  cases,  but  still  accompanied  by  loud  friction  sounds.  After  the 
fibrinous  exudation  is  very  abundant,  the  signs  are  often  obscure  and 
confusing,  and  there  ma}^  be  at  no  time  well-defined  signs  of  consolida- 
tion. There  is  usually  a  mingling  of  the  signs  of  consolidation  with  those 
of  effusion.  There  is  marked  dulness,  and  sometimes  flatness.  The 
vocal  fremitus  is  apt  to  be  diminished,  and  it  may  be  absent.  Bronchial 
voice  and  breathing  are  heard,  but  they  are  not  distinct  as  in  consolida- 
tion; they  are,  however,  feeble  and  distant,  as  over  fluid.  There  are 
usually  coarse,  moist  rales  but  these  may  be  absent.  The  signs  may  be 
found  over  one  entire  lung,  or  they  may  be  limited  to  the  posterior  region, 
and  even  to  a  single  lobe.  They  resemble  those  present  over  fluid,  with 
one  exception — viz.,  the  heart  is  not  displaced.  If  an  exploratory  punc- 
ture is  made,  nothing  is  found ;  occasionally  the  exploring  needle  happens 
to  strike  one  of  the  small  pockets  of  pus  in  the  meshes  of  the  fibrin,  and 
a  few  drops  of  pus  are  withdrawn.  If  an  incision  is  made  under  the 
supposition  that  the  case  is  one  of  empyema,  no  more  pus  may  be  found, 
the  surgeon  coming  upon  the  fibrinous  masses  as  soon  as  the  chest  is 
opened.  There  is  scarcely  any  condition  in  the  chest  giving  signs  more 
puzzling  than  those  just  enumerated.  They  are,  however,  easily  explained 
by  the  pathological  condition. 

Pro^osis. — The  prognosis  in  pleuropneumonia  is  much  worse  than 
in  simple  pneumonia.  In  infants  the  outlook  is  very  bad,  the  majority  of 
the  cases  being  fatal  during  the  acute  stage.  Very  young  children  may 
be  overwhelmed  with  the  extent  and  the  intensity  of  the  inflammation, 
and  die  in  four  or  five  days.  In  children  over  two  years  old  the  most 
frequent  result  is  for  the  case  to  go  on  to  empyema,  which  with  proper 
treatment  usually  terminates  in  recovery.  Where  there  is  organization  of 
the  fibrin  with  the  production  of  extensive  adhesio)is,  the  ultimate  result 
often  is  not  so  favora1:)le  as  when  empyema  develops.     Convalescence  is 


PLATE  IX 


a  to 


S  53 


<!    «i 


o    ^  2 


^  .2 


HYPOSTATIC  PNEUMONIA   ■  547 

usually  slow,  and  the  patients  are  liable  to  exacerbations  of  pleurisy; 
they  may  suffer  for  years  from  the  partial  crippling  of  one  lung. 

Treatment. — Cases  of  pleuropneumonia  are  to  be  managed  like  the 
ordinary  cases  of  pneumonia  of  the  severe  type.  In  somC;,  the  excessive 
pain  may  call  for  more  active  counter-irritation  and  a  freer  use  of  opium 
than  in  other  forms  of  pneumonia,  and  the  greater  prostration  may  re- 
quire that  stimulants  be  given  earlier  and  in  larger  quantities. 


HYPOSTATIC   PNEUMONIA 

This  can  not  often  be  recognized  clinically,  but  it  is  very  frequently 
seen  upon  the  post-mortem  table.  It  represents  an  inflammatory  process 
of  a  low  grade  and  is  seen  to  some  degree  in  almost  every  case  where  an 
infant  has  died  of  chronic  disease.  It  is  particularly  frequent  in  those 
who  have  died  of  marasmus.  It  invariably  occupies  a  strip  along  the 
posterior  border  of  both  lungs,  and  usually  of  both  the  upper  and 
lower  lobes.  This  is  from  one  to  two  inches  wide,  of  a  uniform  dark 
red  color,  and  is  sharply  outlined.  The  pleura  is  not  involved,  and  the 
remainder  of  the  lung  may  be  normal,  congested,  or  slightly  emphysem- 
atous. On  section,  it  is  seen  that  the  pneumonic  area  is  quite  superficial, 
rarely  involving  the  lung  to  a  greater  depth  than  half  an  inch.  Under 
the  microscope  there  is  found  a  distention  of  the  small  blood-vessels  in 
the  affected  area,  and  the  air  vesicles  are  filled  with  many  red  blood-cells, 
epithelial  cells,  and  a  few  leucocytes.  Between  the  areas  of  consolidation 
are  groups  of  air  vesicles  which  are  normal,  congested,  or  collapsed.  It  is 
a  lobular  rather  than  a  bronchopneumonia.  The  lesions  in  this  form 
of  pneumonia  are  probably  the  result  of  venous  stasis,  owing  to  the  child's 
recumbent  position. 

At  autopsy  the  condition  may  be  confounded  with  atelectasis.  Little 
significance  is  to  be  attached  to  the  finding  of  hypostatic  pneumonia  at 
autopsy,  and  it  alone  sliould  never  be  regarded  as  a  sutficient  cause  of 
death,  although  it  is  perluips  the  only  lesion  present.  During  life  it 
may  give  rise  to  fine  moist  rales,  which  are  heard  along  the  spine, 
iisually  upon  both  sides;  but  there  is  seldom  either  dulness  or  bronchial 
Ijrcathing.     The  treatment  is  that  of  the  primary  disease. 


CHRONIC   BRONCHOPNEUMONIA— CHRONIC  INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS 

Chronic  bronchopneumonia  is  an  inflammation  of  the  connective- 
tissue  framework  of  the  lung,  involving  the  stroma,  the  alveolar  septa, 
the  walls  of  the  bronchi,  and  the  pleura.  It  is  usually  accompanied  by 


548  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

cylindrical  dilatation  of  the  bronchi — bronchiectasis.  Chronic  pneu- 
monia may  occur  in  the  well  nourished  and  apparently  robust  but,  is  more 
common  in  the  delicate.  While  seen  at  all  ages  its  beginning  is  usua,lly 
before  the  fifth  year. 

Etiology. — In  children,  as  in  adults,  this  process  is  most  frequently 
associated  with  pulmonary,  tuberculosis ;  but  in  early  life  it  is  not  an  in- 
frequent condition  apart  from  tuberculosis.  The  non-tuberculous  cases, 
as  a  rule,  are  preceded  by  an  attack  of  acute  bronchopneumonia,  some- 
times by  several  such  attacks,,  separated  by  longer  or  shorter  intervals. 
Foreign  bodies  may  cause  localized,  interstitial  pneumonia  of  great  sever- 
ity. The  organisms  associated  with  chronic  pneumonia  may  be  t"he 
pneumococcus  or  the  staphylococcus,  but  more  frequently  we  believe  it 
is  the. influenza  bacillus  either"  alone  or  in  combination.  It  is  hard  to 
say  why  in  one  case  complete  resolution  takes  place  in  a  diseased  lung 
and  in  another  there  follows  a  chronic  progressive  lesion.  It  is  probably 
dependent  upon  a  balance  between  the  individual  resistance  and  the  sever- 
ity of  the  infecting  organism. 

-Lesions. — The  part  of  the  lung  affected  may  be  an  entire  lobe,  but 
usually  it  is  a  portion  of  one  lobe,  or  there  are  areas  in  more  than  one 
lobe.  There  are  dense  connective-tissue  adhesions  binding  the  diseased 
part  to  the  chest  wall,  to  the  diaphragm  and  to  the  pericardium,  often 
so  firmly  that  the  lung  is  torn  on  removal.  The  affected  lung  is  smaller 
than  in  health;  it  is  hard,  tough,  and  fibrous.  Surrounding  the  fibrous 
portions  are  emphysematous  areas.  On  section,  the  process  is  seen  to 
be  somewhat  irregularly  distributed  through  the  lung,  the  lesion  being 
usually  most  marked  in  the  vicinity  of  the  smaller  bronchi,  and  some- 
times seen  only  there,  the  intervening  lung  being  nearly  normal  (Plate 
X).  In  some  portions,  where  the  process  is  most  advanced,  almost 
all  trace  of  lung  tissue  may  have  disappeared,  the  part  resembling  a  solid 
fibrous  tumor,  through  which  run  the.  bronchial  tubes,  usually  much 
dilated.  In  places  this  dilatation  may  be  sufficient  to  form'  cavities  of 
considerable  size.  The  bronchial  glands  are  often  enlarged  to  the  size 
of -a  hazelnut,  and  they  may  be  tuberculous. 

Upon  examination  with  the  mic'roscope,  the  pleura  is  found  greatly 
thickened,  .with  bands  of  new  fibrous  tissue  passing  from  it  into  the  lungi 
The  walls  of  the  small  bronchi  a're  in  most  places  thicker  than  normal, 
but  elsewhere  they  have  undergone  cylindrical  dilatation;  and  are  filled 
with,  pus.  The  wails  of  the  alveoli  show  a  ma'i'ked  proliferation  of  the 
connective-tissue  elements,  and  the  alveoli  are  filled  with  organized  in- 
flammatory products,  so  that  they  are  nearly  or  quite  obliterated.  The 
stroma  is  much  increased  in  amount  throughout  the  affected  lung. 

Symptoms. — In  most  cases  there  is  a  history  of  repeated  attacks  of 
acute  bronchopneumonia,  from  which  the  child  made  a  slow  convales- 


PLATE  X 


Chronic  Bronchopneumonia 
In  the  greater  part  of  the  specimen  the  disease  is  limited  to  the  -vicinity  of  the  small 
bronchi,  AAA,  each  of  which  is  surrounded  by  a  zone  of  new  connective  tissue,  the  result 
of  the  inflammatory  process,  the  intervening  lung  tissue,  B  B,  being  normal.  In  the 
lower  left-hand  portion,  the  disease  is  more  diffuse-  the  air  vesicles,  C,  between  the  areas 
of  new  connective  tissue  are  greatly  compressed,  and  in  some  places  entirely  obliterated. 

(After  Delafield.) 


CHRONIC  BRONCHOPNEUMONIA  549 

cence,  remaining  pale,  anemic,  and  sometimes  wasted  for  several  months. 
ImproTement  then  took  place  in  the  general  symptoms,  the  appetite  and 
strength  returned,  and  in  many  cases  the  lost  weight  was  nearly  or  quite 
regained.  However,  neither  the  pulmonary  symptoms  nor  the  physical 
signs  entirely  disappeared.  There  remained  a  dry,  hard  cough,  which  at 
times  was  severe.  Pains  in  the  chest  were  occasionally  complained  of, 
and  perhaps  shortness  of  breath  on  exertion  was  noticed. 

Examination  shows  a  persistence  of  the  dulness  on  percussion,  with 
a  rude  or  bronchovesicular  respiratory  murmur  of  very  feeble  intensity. 
Little  change  may  take  place  in  these  signs  for  months;  then  an  acute 
attack  of  bronchitis  or  bronchopneumonia  may  occur.  If  the  latter,  the 
same  lung  is  affected,  and  a  fresh  consolidation  is  added  to  the  previous 
disiease.  This  attack  may  not  be  very  severe,  but  it  drags  on  for  several 
weeks,  with  slight  fever  and  little  or  no  change  in  the  physical  signs. 
Partial  resolution  may  then  take  place,  but  the  lung  is  left  much  more 
seriously  crippled  than  before.  Often  there  is  a  history  of  several  such 
attacks,  each  one  leaving  the  lung  a  little  worse  than  it  found  it. 

The  characteristic  physical  signs  of  chronic  bronchopneumonia  are 
not  usually  present  until  the  process  has  continued  for  many  months. 
They  may  be  found  over  part  of  a  lobe,  or  over  an  entire  lobe,  or  even  the 
greater  part  of  one  lung.  On  inspection,  there  may  be  seen,  in  a  well- 
marked  case,  retraction  of  the  chest,  which  is  especially  noticeable  when 
the  disease  is  situated  at  the  apex  of  the  lung.  The  vocal  fremitus  is 
usually  increased,  but  it  may  not  be  abnormal.  There  is  marked  dulness, 
often  flatness,  over  the  affected  area,  with  exaggerated  resonance  over 
the  rest  of  the  lung.  The  area  of  flatness  shades  off  gradually.  The  most 
striking  thing  on  auscultation  is  the  very  feeble  respiratory  murmur ;  in 
many  eases  the  lung  is  almost  silent.  More  rarely  there  is  marked  bron- 
chial voice  and  breathing.  Pales  and  friction  sounds  are  usually  absent 
except  during  an  acute  exacerbation  of  the  symptoms,  when  they  may 
be  heard  as  in  any  attack  of  bronchopneumonia.  In  recent  cases  there 
is  no  displacement  of  the  heart;  in  those  of  long  standing  it  may  be 
drawn  far  to  the  affected  side  by  contraction  of  the  adhesions.  There 
may  be  clubbing  of  the  fingers  in  cases  of  long  standing. 

When  these  lesions  are  once  present  complete  recovery  is  impossible, 
and  there  is  always  a  tendency  for  them  to  increase  rapidly  or  slowly, 
according  to  the  child's  vigor  of  constitution,  his  surroundings,  and  the 
frequency  with  which  exacerbations  occur.  If  the  process  is  extensive 
the  patient  often  succumbs  to  some  intercurrent  disease  or  to  an  acute 
attack  of  pneumonia;  if  limited  in  area,  the  process  may  be  arrested  and 
the  patient  recover,  always,  however,  to  be  more  or  less  embarrassed 
because  of  the  crippling  of  a  part  of  one  lung.  Not  a  small  number  of 
these  children  ultimately  die  of  tuberculosis,  and  in  such  cases  it  is  al- 


550  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

ways  a  difficult  matter  to  decide  whether  tuberculosis  was  present  from 
the  beginning,  or  whether  it  was  due  to  subsequent  infection. 

The  cases  in  which  bronchiectasis  is  the  most  important  condition 
are  not  common.  The  only  characteristic  additional  symptom  is  a 
copious  mucopurulent  expectoration,  which  is  usually  very  fetid.  It 
may  amount  to  several  ounces  a  day,  and  is  expelled  after  paroxysms  of 
coughing,  which  usually  occur  in  the  morning.  This  may  continue  for 
months,  or  even  years,  and  yet  these  patients  are  generally  without  fever, 
seldom  lose  weight,  and  may  have  the  appearance  of  being  in  very  good 
health.    It  is  rare  that  the  physical  signs  of  a  cavity  are  present. 

Prognosis. — This  depends  on  the  extent  of  the  disease,  the  patient's 
age  and  constitution,  and  on  our  ability  to  prevent  by  treatment,  climatic 
and  otherwise,  the  occurrence  of  acute  exacerbations.  Under  the  most 
favorable  conditions,  a  few  patients  may  recover  completely  so  far  as 
symptoms  are  concerned ;  but  the  majority  remain  at  best  delicate  during 
childhood,  or  even  throughout  life. 

Diagnosis. — The  most  important  thing  is  to  distinguish  between  the 
simple  and  the  tuberculous  cases,  and  this,  by  symptoms  and  physical 
signs,  is  in  the  majority  impossible.  If  the  family  history  is  good,  if 
the  patient  lives  in  the  country,  if  his  symptoms  begin  with  a  well- 
defined  acute  attack  of  pneumonia,  if  the  seat  of  disease  is  the  base  pos- 
teriorly, and  if  the  examination  of  the  sputum  is  negative  for  tubercle 
bacilli  the  process  is  proliably  simple.  If  the  family  history  is  doubtful 
or  is  positively  tuberculous,  if  the  patient  lives  in  the  city,  and  especially 
if  he  is  an  inmate  of  an  institution  or  if  his  home  is  in  the  tenements, 
if  the  initial  symptoms  are  indefinite,  if  the  disease  is  situated  anteriorly, 
the  process  is  probably  tuberculous.  The  cutaneous  tuberculin  test  aids 
much  in  diagnosis.  With  a  negative  reaction  tuberculosis  can  be  ex- 
cluded almost  with  certainty ;  but  a  positive  reaction  does  not  prove  that 
the  pulmonary  process  is  tuberculous,  although  it  is  strongly  sugges- 
tive. The  discovery  of  tubercle  bacilli  in  the  sputum  is,  of  course,  con- 
clusive. 

Foreign  bodies  in  the  lung  may  give  symptoms  of  chronic  broncho- 
pneumonia; metallic  and  many  solid  substances  may  be  detected  by  the 
X-ray. 

Treatment. — Nothing  has  any  essential  influence  upon  the  disease 
except  change  of  climate.  This  should  be  the  same  as  for  tuberculous 
cases.  The  treatment  of  the  patient  has  for  its  object  the  maintenance 
of  the  general  nutrition  at  its  highest  point,  by  careful  feeding,  judicious 
exercise,  and  by  most  of  the  measures  enumerated  in  the  chapter  on  Mal- 
nutrition. Cod-liver  oil  may  often  be  given  with  advantage  especially 
during  the  winter.  The  cough  may  be  treated  as  in  cases  oi  chronic 
bronchitis. 


ABSCESS  OF  THE  LUNG  551 

Cases  of  bronchiectasis  may  obtain  considerable  relief  from  inhala- 
tions of  creosote.     Operation  is  not  to  be  recommended. 


ABSCESS  OF  THE  LUNG 

Multiple  small  abscesses  are  not  uncommon  as  a  termination  of  acute 
bronchopneumonia,  in  which  connection  they  have  already  been  consid- 
ered. Larger  non-tuberculous  abscesses  of  the  lung  are  rare,  very  obscure 
in  their  symptoms,  and  apt  to  be  mistaken  for  localized  empyema,  some- 
times for  interstitial  pneumonia  with  bronchiectasis.  Four  such  cases 
have  come  under  our  observation.  One  was  discovered  at  autopsy,  the 
other  three  were  recognized  during  life  and  successfully  treated  by  opera- 
tion. Other  examples  in  young  children  have  been  reported  by  Huber 
and  by  Hedges.  The  cause  of  these  single  al)scesses  is  usually  a  previous 
attack  of  acute  primary  pneumonia,  less  frequently  an  inflammation  ex- 
cited by  a  foreign  body  in  the  lung. 

An  abscess  due  to  a  foreign  body  is  usually  accompanied  by  wasting, 
and  a  widely  fluctuating  temperature  of  a  hectic  type — symptoms  sug- 
gestive of  a  rapidly  advancing  tuberculous  process.  If  the  abscess  fol- 
lows an  ordinary  pneumonia  the  course  is  generally  less  intense.  The 
constitutional  symptoms  difEer  little  from  those  of  empyema.  There  is 
an,  irregular  type  of  fever,  sometimes  quite  high,  but  more  often  only 
from  99°  to  101°  or  102°  F.,  a  moderate  cough,  not  much  wasting,  and 
generally  not  very  marked  prostration.  A  leucocytosis  of  30,000  to 
50,000  is  usually  present.  The  physical  signs  are  somewhat  confusing 
and  are  a  combination  of  those  present  in  effusion  and  consolidation. 
There  is  an  area  of  flatness  shading  off  into  dulness.  The  vocal  fremitus 
may  be  increased  or  it  may  be  diminished.  The  respiratory  murmur  is 
very  feeble  or  absent  over  the  abscess,  often  it  is  bronchovesicular  in  char- 
acter. Friction  sounds  and  rales  are  usually  present.  The  heart  is 
slightly  or  not  at  all  displaced.  If  an  exploratory  needle  is  introduced, 
pus  may  not  be  found  even  by  Tepeated  punctures ;  or  it  may  be  obtained 
at  one  time  and  not  at  another,  although  introduced  in  the  same 
intercostal  space,  the  difference  in  result  being  due  to  the  direction  in 
which  the  needle  is  passed  into  the  lung.  When  pus  is  found,  the 
diagnosis  of  a  localized  empyema  is  generally  regarded  as  established, 
and  it  is  not  until  the  chest  is  opened  that  the  mistake  is  discovered. 
The  operator  then  comes  upon  the  lung,  -which  may  or  may  not  be 
adherent.  If  the  abscess  follows  an  acute  pneumonia  the  pus  may 
show  a  pure  culture  of  the  pneumococcus.  If  it  is  due  to  a  foreign  body, 
there  is  invariably  a  mixed  infection,  and  the  pus  is  apt  to  be  fetid. 

When  not  treated  surgically,  abscess  of  the  lung  may  rupture  into 


552  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

the  pleural  cavity,  producing  a  secondary  empyema,  or  spontaneous 
evacuation  may  take  place  through  a  bronchus  and  recovery  follow. 
When  the  cause  is  a  foreign  body,  rapid  recovery  often  follows  its  ex- 
pulsion by  coughing.  If  the  diagnosis  is  made  and  proper  surgical 
treatment  is  instituted,  recovery  occurs  in  probably  the  majority  of 
cases. 

The  general  plan  of  treatment  should  be  the  same  as  in  empyema. 
In  a  small  proportion  of  cases  aspiration  may  suffice  for  a  cure.  How- 
ever, incision  is  usually  necessary.  If  the  pleura  is  not  adherent,  adhe- 
sions should  be  excited  by  packing  the  thoracic  wound  with  gauze,  and 
after  a  few  days  a  second  operation  may  be  done.  The  lung  should  be 
opened  with  a  lilunt  instrument,  following  the  line  of  the  exploring 
needle,  and  a  drainage-tube  inserted  as  in  empyema,  the  subsequent 
treatment  being  the  same  as  for  that  disease. 


GANGRENE  OF  THE  LUNG 

Pulmonary  gangrene  is  rare  in  children,  although  probably  more  com- 
mon than  in  adults.  It  is  most  frequently  associated  with  pneumonia. 
It  is  usually  circumscribed,  and  seldom  diagnosticated  during  life. 

Etiology. — All  but  one  of  our  cases  have  been  in  children  under 
three  years  old,  the  youngest  an  infant  of  four  months.  Gangrene  occurs 
for  the  most  part  in  children  who  are  ill-conditioned,  feeble,  or  cachectic, 
and  often  follows  one  of  the  infectious  diseases,  particularly  measles. 
Of  twelve  cases  which  have  come  under  our  personal  observation,  eight 
complicated  acute  bronchopneumonia.  Pulmonary  gangrene  has  been 
present  in  about  three  per  cent  of  our  autopsies  upon  cases  of  pneu- 
monia. The  immediate  cause  of  the  necrotic  process  is  interference 
with  the  circulation  in  a  part  of  the  lung,  which  is  usually  due  to  throm- 
bosis or  embolism  of  some  of  the  branches  of  the  pulmonary  artery.  To 
this  there  is  added  the  entrance  of  putrefactive  bacteria.  In  some  cases 
pulmonary  gangrene  may  begin  as  a  septic  thrombosis,  this  infection 
originating  in  some  process  in  a  distant  part  of  the  body. 

Lesions. — The  lower  lobes  are  more  frequently  affected  than  the 
upper,  and  the  surface  of  the  lung  rather  than  the  central  portions. 

Two  forms  of  gangrene  may  be  seen :  the  diffuse  form,  which  affects 
a  whole  lobe,  or  even  a  whole  lung;  and  the  circumscribed  form,  which 
occurs  in  a  number  of  small  scattered  areas.  The  latter  is  the  variety 
usually  seen  in  children.  In  the  diffuse  form  the  lung  is  of  a  dirty- 
green  or  brown  color,  moist,  and  emits  a  gangrenous  odor.  In  the 
circumscriljed  form,  when  occurring  in  pneumonia,  the  parts  affected  arc 
of  a  gray  or  green  color,  usually  wedge-shaped,  with  the  base  at  the 


ACQUIRED  ATELECTASIS— PULMONARY  COLLAPSE  553 

surface  of  the  lung.  In  the  earl}'  stage  they  are  not  softened^  and  have 
no  gangrenous  odor;  later,  both  these  conditions  may  be  present,  and 
masses  of  necrotic  lung  tissue  may  be  found  in  a  cavity  with  ragged  walls, 
partly  filled  with  fetid  pus.  Careful  dissection  will  reveal,  in  many 
cases,  the  presence  of  thrombi  in  the  vessels  leading  to  the  gangrenous 
parts. 

Symptoms. — There  are  but  two  distinctive  symptoms  of  pulmonary 
gangrene :  the  fetid  odor  of  the  breath,  and  the  expectoration  of  masses 
of  necrotic  lung  tissue.  In  the  cases  associated  with  acute  pneumonia, 
which  include  the  majority  of  those  seen,  death  nearly  always  takes 
place  before  there  is  any  separation  of  the  sloughs,  and  even  before 
very  active  decomposition  in  the  necrotic  areas  has  occurred.  Both  the 
peculiar  symptoms  are  therefore  wanting,  and  the  diagnosis  is  made 
only  at  the  autopsy.  This  has  been  true  of  nearly  all  the  cases  which 
have  come  under  our  observation.  But  these  patients,  with  two  ex- 
ceptions, were  infants.  In  older  children,  particularly  in  eases  secondary 
to  the  entrance  of  a  foreign  body,  the  characteristic  symptoms  are  more 
frequently  seen,  and  there  may  be  a  third  symptom — hemorrhage.  This 
is  present  in  about  one-fourth  of  the  cases  (Rilliet  and  Barthez),  and 
may  be  fatal.  The  general  symptoms  associated  with  gangrene  are  those 
of  profound  asthenia,  resembling  the  typhoid  condition. 

From  what  has  been  said,  it  will  be  evident  that  the  diagnosis  is  very 
difficult  If  the  characteristic  odor  of  the  breath  is  present,  conditions 
in  the  mouth  from  wliich  it  might  arise  must  be  excluded.  Cavity  forma- 
tion in  tubercidosis  may  also  be  a  cause  of  a  very  foul  breath.  The 
cutaneous  tuberculin  test  will  aid  greatly  in  the  diagnosis.  The  physical 
signs  differ  in  no  respect  from  those  of  ordinary  cases  of  pneumonia. 
The  termination  is  almost  always  in  death.  This  is  due  not  only  to  the 
condition  itself,  but  to  the  circumstances  in  which  it  is  seen. 

Treatment. — The  general  treatment  should  be  supporting  and  stimu- 
lating, as  in  all  severe  cases  of  pneumonia.  For  the  local  process  but 
little  can  be  done,  except  the  inhalation  of  antiseptics,  of  which  creosote 
and  turpentine  are  undoubtedly  the  best. 


ACQUIRED  ATELECTASIS— PULMONARY  COLLAPSE 

These  terms  are  applied  to  a  state  of  the  lung  resembling  the  fetal 
condition,  but  occurring  in  a  lung  which  has  once  been  expanded.  It 
may  be  due  to  compression  or  to  obstruction. 

Collapse  from  Compression. — The  principal  cause  of  this  form  is 
pleuritic  effusion.  It  may  also  be  produced  by  pneumothorax,  enlarge- 
ment of  the  heart,  pericardial  effusion,  deformities  of  the  chest  from 


554  DISEASES  OF  THE  EESPIEATORY  SYSTEM 

rickets  or  Pott's  disease,  and  tumors  of  the  mediastinum  or  the  thoracic 
wall.  In  these  conditions,  on  account  of  the  external  pressure,  the  air 
vesicles  are  not  filled,  although  the  bronchi  are  pervious.  After  collapse 
has  existed  for  a  considerable  time,  changes  may  take  place  in  the  lung 
which  render  expansion  difficult  or  impossible.  Unless,  however,  there 
are  pleuritic  adhesions,  expansion  often  takes  place  readily  after  many 
weeks  or  even  months.  The  symptoms  and  signs  are  those  of  the 
original  disease. 

Treatment  is  available  chiefly  in  that  form  which  follows  pleuritic 
effusion,  and  will  be  considered  in  the  chapter  on  Empyema. 

Collapse  from  Obstruction. — This  is  due  to  two  factors:  blocking  of 
either  the  large  or  small  bronchial  tubes,  and  feeble  inspiratory  force. 
The  importance  of  collapse  from  obstruction  in  the  acute  diseases  of 
the  lung  in  infancy  has  undoubtedly  been  exaggerated.  Whenever  a  large 
or  small  bronchus  is  completely  obstructed  by  a  foreign  body,  the  portion 
of  the  lung  to  which  the  bronchus  is  distributed  gradually  becomes 
collapsed.  If  it  is  one  of  the  primary  bronchi  which  is  occluded, 
a  whole  lung  may  be  collapsed;  if  one  of  the  lobar  divisions,  an  entire 
lobe;  if  one  of  the  smaller  divisions,  only  a  small  area.  The  collapse 
does  not  take  place  immediately,  but  the  contents  of  the  air  vesicles  are 
gradually  absorbed.  The  collapsed  portion  is  slightly  depressed  below 
the  surface  of  the  lung.  It  is  of  a  dark-red  color,  very  vascular,  and  to 
the  naked  eye  resembles  a  pneumonic  area,  which  it  may  subsequently 
become. 

Many  writers  exj^lain  the  development  of  bronchopneumonia  from 
bronchitis  of  the  smaller  tubes,  through  the  intervention  of  pulmonary 
collapse,  assuming  that  the  obstruction  of  the  small  bronchi,  from  swell- 
ing of  their  walls  and  the  accumulation  of  secretion,  produces  the  same 
result  as  the  plugging  of  a  bronchus  by  a  foreign  body.  In  our  own 
autopsies  we  have  found  little  support  for  this  theory.  In  acute  bron- 
chitis of  the  smaller  tubes  the  lumen  is  narrowed,  but  seldom  enough 
to  prevent  the  entrance  of  air.  The  result  is  usually  emphysema,  not 
atelectasis.  Such,  at  least,  has  been  the  condition  we  have  most  fre- 
quently found  in  autopsies  in  the  earliest  stage  of  bronchopneumonia  fol- 
lowing bronchitis  of  the  fine  tubes.  There  are  very  often  groups  of 
collapsed  air  vesicles  surrounding  pneumonic  areas,  but  these  are  neither 
an  essential  nor  a  very  important  part  of  the  lesion.  Collapse  of  a 
large  part  of  the  lung,  or  even  of  a  lobe,  we  have  never  seen,  either 
in  pertussis  or  in  acute  bronchitis. 

There  is  seen  in  delicate  or  rachitic  infants  a  form  of  collapse 
which  comes  on  very  gradually.  It  is  accompanied  by  bronchitis  affect- 
ing the  tubes  in  the  dependent  part  of  the  lung.  It  may  resemble 
the  congenital  form  of  atelectasis.    Under  the  microscope  there  is  almost 


EMPHYSEMA  555 

invariably  found,  accompanying  the  collapse,  lobular  pneumonia  and 
bronchitis  of  the  tubes  in  the  affected  regions. 

The  symptoms  of  acquired  atelectasis  are  much  the  same  as  in  the 
persistent  congenital  form.  The  respiration  is  rapid,  and  there  may  be 
inspiratory  dyspnea  with  deep  recession  of  the  chest  walls,  especially  if 
there  is  rickets.  There  is  also  at  times  cyanosis  of  variable  intensity. 
The  temperature  is  not  elevated,  but  frequently  is  subnormal.  The  phys- 
ical signs  are  very  uncertain.  There  is  usually  feeble  respiratory  murmur 
over  the  affected  areas,  occasionally  accompanied  by  moist  rales.  The 
essential  point  of  difference  between  these  cases  and  those  of  congenital 
atelectasis  is  that  in  the  former  the  patients  are  often  strong  at  birth, 
crying  and  breathing  well,  giving  no  signs  of  anything  wrong  in  the  lungs 
until  the  general  nutrition  has  suffered  from  some  other  cause. 

The  following  is  a  fairly  typical  case:  A  female  infant  thirteen 
months  old  had  been  under  observation  for  several  months  before  death. 
During  this  period  she  suffered  a,  great  part  of  the  time  from  mild 
bronchitis.  The  chest  was  extremely  rachitic.  The  resjoiration  was 
always  accelerated,  and  on  inspiration  the  lateral  recession  of  the  chest 
was  at  times  extreme.  There  was  occasionally  seen  slight  cyanosis,  and 
during  the  last  few  weeks  it  was  constant.  Death  occurred  quite  sud- 
denly. At  autopsy  there  was  found  very  marked  vesicular  emphysema 
of  both  lungs  in  front.  Nearly  the  whole  of  both  lower  lobes  were  in 
a  condition  of  collaj^se,  and  of  a  uniform  grayish-purple  color.  The  pos- 
terior portion  of  the  upper  lobes  was  similarly  affected,  but  to  a  less 
degree.  With  moderate  force  all  of  the  collapsed  areas  could  be  com- 
pletely inflated.    Bronchitis  was  present,  but  the  pleura  was  normal. 

The  treatment  of  these  cases  is  the  same  as  that  outlined  in  the 
chapter  upon  Congenital  Atelectasis. 


EMPHYSEMA 

Pulmonary  emphysema  consists  [jrimarily  in  overdistention  of  the  air 
vesicles.  It  may  result  in  their  rupture  and  the  escape  of  air  into  the 
interlo])ular  connective  tissue  of  tlie  lung.  In  infancy  and  childhood 
emphysema  is  usually  associated  with  acute  processes. 

Etiology. — Cases  of  emphysema  are  divided  into  two  groups  Avhich 
are  due  to  quite  different  causes.  In  one  group  it  is  compensatory, 
and  consists  in  overdistention  of  the  air  vesicles  in  certain  parts  of  the 
lungs  because  the  full  expansion  of  other  parts  is  prevented  either 
because  they  are  consolidated,  as  in  pneumonia  or  tuberculosis,  bound 
down  by  adhesions  from  old  pleurisy,  or  subjected  to  external  pressure, 
as  from  chest  deformities  due  to  Pott's  disease  or  rickets.     In  these 


556  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

conditions  it  is  probable  that  the  emphysema  is  produced  during  inspira- 
tion. It  may  also  be  produced  by  the  artificial  inflation  of  the  lungs  of 
the  newly  born. 

In  the  second  group  of  cases  emphysema  is  produced  by  obstructive 
expiratory  dyspnea  or  cough.  It  is  seen  in  all  forms  of  laryngeal  stenosis^ 
in  acute  bronchitis  and  bronchopneumonia,  in  asthma,  pertussis,  and 
occasionally  it  is  produced  by  any  condition  which  requires  deep  inspira- 
tion and  holding  the  breath.  In  bronchitis  the  obstruction  may  be  caused 
by  a  swelling  of  the  mucous  membrane  or  by  an  accumulation  of  secre- 
tion. In  this  group  of  cases  air  enters  the  lung,  but  as  it  can  not  readily 
escape,  the  air  vesicles  are  distended,  sometimes  to  such  a  degree  that 
their  resiliency  is  almost  entirely  lost. 

Lesions.- — The  riiost  common  form  in  early  life  is  acute  vesicular 
emphysema,  which  occurs  when  the  force  distending  the  air  cells  is  only 
moderate.  In  this  form  there  is  dilatation  of-  the  vesicles  with  very 
slight  structural  changes,  there  being  usually  rupture  of  a  few  alveolar 
septa  only  (Fig.  49).  Although  the  dilatation  may  be  quite  marked, 
the  emphysema  is  not  permanent.  The  parts  most  affected  are  the 
upper  lobes,  particularly  the  anterior  borders.  In  appearance  the  emphy^ 
sematous  lung  is  pale,  sometimes  almost  white.  The  affected  areas  are 
]3rominent,  and  do  not  collapse  upon  opening  the  chest.  With  a  lens,  or 
even  with  the  naked  eye,  the  individual  air  vesicles  can  often  be  dis- 
tinguished as  minute  pearly  bodies,  at  times  resembling  miliary  tubercles. 
When  the  disease  is  secondary  to  acute  bronchitis  or  laryngeal  stenosis 
it  may  affect  nearly  the  whole  of  both  lungs. 

With  a  greater  distending  force  rupture  of  many  of  the  air  vesicles 
results,  and  this  may  give  rise  to  interstitial  or  interlobular  emphysema. 
At  times  blebs  are  formed,  varying  in  size  from  a  pin's  head  to  a  cherry 
or  even  larger  ones.  These  are  usually  seen  at  the  anterior  border  or  at 
the  root  of  the  lung  on  its  inner  surface.  Again,  the  air  finds  its  way  be- 
tween the  lobules,  dissecting  them  apart  in  all  directions  throughout  the 
lung.  Sometimes  a  large  part  of  the  surface  of  both  lungs  is  seamed  with 
irregular  deep  crevasses  containing  air,  the  largest  being  an  inch  or  more 
in  length  and  nearly  one-fourth  of  an  inch  wide.  The  most  severe  cases 
occur  in  pertussis.  On  two  or  three  occasions  we  have  seen  this  form 
of  emphysema,  once  to  an  extreme  degree,  when  children  had  died  from 
diseases  unconnected  with  the  respiratory  tract,  and  when  no  history 
could  be  obtained  which  threw  any  liglit  upon  the  etiology  of  the  em- 
physema. 

Localized  emphysema  not  infrequently  occurs  in  the  subcutaneous 
tissue  of  the  thoracic  wall  folloAving  exploratory  puncture  of  the  chest. 
This  is  seldom  extensive  and  the  air  usually  disappears  in  a  few  days  by 
absorption  without  causing  any  symptoms.     Sometimes  from  a  rupture 


EMPHYSEMA 


557 


of  an  emphysematous  vesicle  at  the  hiliis  of  the  lung  there  occurs  em- 
physema of  the  mediastinum  which  may  spread  to  the  tissues  of  the  neck 
and  ultimately  to  almost  the  entire  body.  The  patient  gives  the  impres- 
sion of  having  been  artificially  inflated  (Fig.  72).  Such  widespread 
emphysema  is  usually  as- 
sociated with  conditions 
which  prove  fatal,  the  em- 
physema adding  much  to 
the  patient's  discomfort  but 
not  increasing  the  danger  of 
the  original  disease. 

Symptoms. — E  m  p  h  y- 
sema  occurring  in  acute 
pulmonary  diseases  gives 
rise  to  no  peculiar  symp- 
toms and  to  no  physical 
signs  except  exaggerated 
resonance  upon  percussion. 
This  masks  dulness  from 
consolidation  and  also  that 
from  the  liver  and  spleen. 
If  the  patients  recover  from 
the  original  disease,  the  em- 
physema greatly  diminishes 
or  disappears  completely  in 
the  course  of  a  few  weeks  or 
months.    Acute  interlobular 

emphysema  can  not  be  diagnosticated  during  life,  unless,  as  is  sometimes 
the  case,  general  subcutaneous  emphysema  is  seen,  which  may  come  on 
quickly,  last  for  several  hours  or  days  and  then  gradually  disappear. 

The  treatment  of  emphysema  is  that  of  the  disease  with  which  it  is 
associated. 


Fig.  72. — General  Subcutaneous  Emphysema, 
Child  14  Months  Old.  Following  perfora- 
tion of  a  caseous  nodule  at  the  root  of  the 
lung;  pulmonary  tuberculosis. 


CHAPTEK  VI 
PLEURISY 


All  the  common  forms  of  inflammation  of  the  pleura  are  seen  in 
childhood.  In  the  great  majority  of  cases  they  are  secondary  to  disease 
of  the  lung  itself.  Serous  effusions  are  much  less  frequent  than  in  adults, 
and  under  three  years  large  ones  are  rare.    Purulent  effusion  (empyema) 


558  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

is,  however,  much  more  often  seen  than  in  adult  life,  and  it  is  the  most 
important  variety  of  pleurisy  with  which  the  physician  has  to  deal. 

Whether  inflammation  of  the  pleura  ever  occurs  as  a  strictly  primary 
disease  is  still  a  mooted  point.  Cases  are  occasionally  observed  clinically 
in  which  both  the  serous  and  purulent  forms  of  the  disease  appear  to  be 
primary,  but  these  are  extremely  rare.  Acute  pleurisy  may,  however, 
follow  inflammation  of  the  lung  so  rapidly  that  it  is  not  easy  to  de- 
termine that  the  lung  was  first  affected.  In  infants,  extension  from  the 
lung  is  almost  the  sole  cause.  It  occurs  both  with  lobar  and  broncho- 
pneumonia, existing  to  some  degree  in  nearly  every  case  in  which  there 
is  consolidation  of  the  lung.  Xext  in  frequency  to  simple  pneumonia  as 
a  cause  of  pleurisy  are  the  tuberculous  processes  of  the  lung.  Tuberculous 
pleurisy  without  tuberculosis  of  the  lungs  or  the  bronchial  glands  is 
of  doubtful  occurrence.  Acute  pleurisy  is  an  occasional  complication 
of  the  infectious  diseases,  particularly  scarlet  and  typhoid  fevers,  measles, 
and  influenza.  In  most  of  these  cases  also  it  is  secondary  to 
disease  of  the  lung.  Pleurisy  in  older  children  occasionally  follows 
cold  and  exposure,  although  it  is  doubtful  whether  in  any  case  this 
is  the  only  cause.  In  them  also  it  may  occur  as  a  complication  of 
rheumatism. 

The  most  important  cause  of  acute  pleurisy  being  extension  from 
pneumonia,  it  follows  that  it  is  most  frequent  in  the  cold  season,  that  it 
occurs  more  often  in  males  than  in  females,  and  between  the  ages  of  one 
and  five  years.  It  may,  however,  be  seen  at  all  ages,  and  may  even  occur 
in  intra-uterine  life.  The  youngest  case  in  which  we  have  found  ex- 
tensive pleuritic  adhesions  as  an  evidence  of  previous  inflammation  was 
in  an  infant  of  three  months.  In  this  case  firm  connective  tissue  ad- 
hesions were  found  over  the  whole  of  both  lunffs. 


DRY  PLEURISY 

In  infants  and  young  children  this  usually  accompanies  pneumonia 
or  tuberculous  processes  in  the  lung.  In  older  children  it  may  be  pri- 
mary. 

Lesions. — On  account  of  the  frequency  with  which  this  occurs  in 
pneumonia  we  have  an  opportunity  of  observing  it  in  all  stages.  In  the 
mildest  varieties  it  affects  only  the  pulmonary  pleura,  and  occurs  over  the 
pneumonic  areas.  The  pleura  is  injected,  has  lost  its  luster,  and  appears 
dull  or  roughened.  This  is  due  to  an  exudation  of  fibrin  upon  its  sur- 
face. If  the  process  continues,  more  fibrin  is  poured  out,  and  there  are 
in  addition  swelling  and  a  proliferation  of  the  connective-tissue  cells,  and 
an  exudation  of  leucocytes  from  the  blood-vessels.     The  pleura  is  then 


DRY  PLEURISY  559 

coated  with  a  layer  of  fibrin  of  variable  thickness,  in  which  are  entangled 
pus  cells  and  new  connective-tissue  cells.  The  layer  of  fibrin  varies  from 
the  thickness  of  tissue  paper  to  that  of  an  ordinary  book  cover.  In  re- 
cent cases  it  may  easily  be  stripped  off,  while  in  older  ones  it  becomes 
organized  and  is  firmly  adherent.  The  color  of  the  exudate  varies  with 
the  number  of  pus  cells.  It  is  gray,  grayish-yellow,  or  yellowish-green, 
according  as  these  cells  are  few  or  numerous.  As  a  rule,  dry  pleurisy 
is  localized,  but  the  two  opposing  surfaces  are  affected.  Part  of  the 
exudate  is  usually  absorbed,  but  it  is  doubtful  if  complete  recovery  oc- 
curs, there  being  left  behind  some  adhesions  between  the  visceral  and 
parietal  layers. 

In  the  dry  form  of  tuberculous  pleurisy  there  may  l)e  only  an  ex- 
udation of  fibrin,  or  the  pleura  may  be  covered  with  gray  tubercles  and 
yellow  tuberculous  nodules.  These  are  not  only  seen  upon  the  surface 
of  the  pleura,  but  develop  in  the  exudation.  In  this  form,  which  is 
usually  chronic,  great  thickening  of  the  pleura  may  take  place.  Both 
the  serous  and  purulent  effusions  occurring  in  conjunction  with  tuber- 
culosis are  likely  to  be  sacculated  because  of  the  previous  existence  of 
adhesions. 

After  nearly  every  case  of  dry  pleurisy  there  probably  remains  some 
slight  thickening  of  the  pleura.  In  certain  cases  there  follows  a  chronic 
inflammation  of  the  pleura  with  the  production  of  new  connective  tissue, 
which  results  in  thickening  and  adhesions  which  may  be  so  extensive  as 
to  entirely  obliterate  the  pleural  cavity.  Either  one  or  both  sides  may 
be  affected.  It  is  usually  accompanied  by  external  pericarditis.  This 
form  is  rare  in  childhood. 

Symptoms. — As  an  independent  clinical  disease,  acute  dry  pleurisy 
has  no  existence  in  infancy  or  early  childhood.  The  cases  which  are  occa- 
sionally so  diagnosticated  have  in  our  experience  invariably  proved  to  be 
bronchopneumonia.  In  older  children  dry  pleurisy  may  occur  under  the 
same  conditions  as  in  adults. 

The  symptoms  are  sharp,  localized  pain,  increased  by  full  inspiration, 
sometimes  tenderness  upon  pressure,  and  a  short,  teasing  cough.  The 
pain  is  not  always  felt  upon  the  affected  side,  and  it  may  be  referred  to 
the  abdomen.  Upon  physical  examination,  dry  pleurisy  is  recognized  by 
the  presence  of  a  pleuritic  friction  sound.  This  is  usually  of  a  dry 
rubbing  character,  generally  localized,  and  heard  both  on  inspiration 
and  expiration.  It  is  quite  superficial,  and  not  changed  by  coughing. 
This  form  of  pleurisy,  as  a  rule,  runs  a  course  of  a  few  days  or  a  week 
without  constitutional  symptoms.  When  dry  pleurisy  occurs  as  a  com- 
plication of  pneumonia  it  is  recognized  by  the  signs  just  mentioned;  but 
it  usually  causes  no  new  symptoms  except  pain. 

Treatment. — The  treatment  consists  in  counter-irritation  bv  mus- 


560  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

tard  or  iodin,  according  to  the  severity  of  the  inflammation,  and  in  the 
use  of  opium.  Severe  pain  can  sometimes  be  relieved  by  firmly  encircling 
the  chest  with  a  broad  band  of  adhesive  plaster. 


PLEURISY  WITH  SEROUS  EFFUSION 

This  form  of  pleurisy  is  not  common  in  young  children,  and  in 
infants  except  with  acute  pneumonia  it  is  rare.  In  those  somewhat 
older  it  is  usually  tuberculous  in  origin  in  which  case  it  frequently  acts 
like  a  primary  disease.  It  occurs  as  a  complication  of  pneumonia 
and  may  be  seen  in  nephritis,  acute  rheumatism,  scarlet  fever,  or  any 
of  the  other  acute  infectious  diseases.  Bacteria  are  occasionally  present 
in  the  exudation,  even  in  cases  which  do  not  become  purulent,  but  their 
number  is  usually  small.  The  tubercle  bacillus,  the  streptococcus  and 
the  pneumococcus  are  the  forms  most  often  seen. 

Lesions. — The  early  changes  are  much  the  same  as  in  dry  pleurisy, 
but  in  addition  serum  is  poured  out  from  the  blood-vessels,  in  some 
cases  almost  from  the  beginning  of  the  inflammation.  This  may  be 
small  in  amount,  or  it  may  fill  the  pleural  cavity.  The  lesions  are 
similar  to  those  seen  in  adults,  except  that  in  children  there  is  apt 
to  be  more  fibrin.  The  process  usually  terminates  in  absorption  of  the 
serum,  but,  as  in  dry  pleurisy,  more  or  less  extensive  adhesions  are  left 
behind  from  the  fibrinous  exudation.  In  other  cases  there  is  at  first  a 
clear  serum,  often  containing  pneumocqcci,  then  it  becomes  somewhat 
turbid,  and  finally  purulent.     This  is  especially  common  in  infants. 

Symptoms. — The  very  small  serous  effusions  which  occur  so  fre- 
quently as  a  complication  of  pneumonia  rarely  cause  new  symptoms  or 
a  change  in  the  physical  signs.  In  the  present  connection  only  those 
cases  will  be  discussed  in  which  the  amount  of  effusion  is  considerable. 
This  form  of  pleurisy  sometimes  follows  a  well-defined  attack  of  pneu- 
monia. Other  cases  come  on  with  acute  febrile  symptoms  somewhat 
resembling  those  of  pneumonia,  but  with  all  the  symptoms  less  severe, 
except  the  pain.  After  an  illness  of  only  two  or  three  days  the  chest 
may  be  found  full  of  fluid.  In  a  third  group  the  disease  comes  on  in- 
sidiously, with  little  or  no  fever,  and  often  with  no  distinct  pulmonary 
symptoms  except  shortness  of  breath.  There  is  general  weakness,  some- 
times loss  of  flesh,  anemia,  and  moderate  prostration;  but  usually  the 
patients  are  not  sick  enough  to  go  to  bed.  The  symptoms  of  pleurisy 
with  effusion  vary  greatly.  When  it  occurs  as  a  complication  of  some 
acute  infectious  disease,  it  is  often  latent,  and  the  diagnosis  is  to  be 
made  only  by  the  physical  examination  of  the  chest. 

In  cases  in  which  the  fluid  does  not  become  purulent,  the  usual  course 


PLEURISY  WITH  SEROUS  EFFUSION  561 

of  the  disease  is  for  the  fluid  to  disappear  gradually  by  absorption,  the 
case  going  on  to  spontaneous  recovery.  Serious  symptoms  resulting 
from  pressure  upon  the  heart  and  lungs  are  not  common,  but  may  occur 
when  the  fluid  accumulates  rapidly;  hence  they  are  most  likely  to  be 
seen  early  in  the  attack.  There  may  be  great  dyspnea,  sometimes 
orthopnea,  cyanosis,  weak  pulse,  and  even  attacks  of  syncope.  Death 
may  occur  with  these  symptoms.  In  certain  cases  there  is  seen  no 
tendency  to  spontaneous  absorption,  and  the  exudation  may  remain  sta- 
tionary for  months.  There  may  then  be  fever,  usually  slight  but  some- 
times quite  regular,  with  a  decline  in  the  general  health,  pallor  and 
anemia,  which  may  strongly  suggest  the  existence  of  pus,  although  this 
is  not  present.     Others  are  regarded  as  cases  of  tuberculosis. 

Physical  Signs. — The  signs  in  the  chest  are  essentially  the  same 
whether  the  fluid  is  serous  or  purulent.  On  inspection,  there  is  dimin- 
ished movement  of  the  afi^ected  side,  sometimes  bulging  of  the  intercostal 
spaces,  and  if  the  efl^usion  is  large,  an  increase  in  the  measurement  of 
the  affected  side  of  the  chest.  The  apex  beat  of  the  heart  will  usually 
be  considerably  displaced  if  the  effusion  is  upon  the  left  side.  It  may 
be  found  at  the  epigastrium,  at  the  right  border  of  the  sternum,  or  even 
in  the  right  mammary  line.  In  disease  of  the  right  side  the  displacement 
is  less,  and  occurs  only  with  a  large  effusion.  It  may  then  be  found  in 
or  near  the  left  axillary  line.  On  palpation,  the  vocal  fremitus  is  usually 
diminished  or  absent,  but  it  may  be  but  little  changed.  Percussion  gives 
marked  dulness  or  flatness.  In  a  large  effusion  this  is  over  the  entire 
lung.  There  is  also  a  sensation  of  increased  resistance  appreciable  by  the 
percussing  finger.  With  a  smaller  effusion  there  is  usually  flatness  over 
the  lower  part  of  the  chest  and  dulness  or  tympanitic  resonance  above ; 
sometimes  dulness  is  found  behind  and  tympanitic  resonance  at  the  apex 
in  front.  The  line  of  flatness  may  change  with  the  position  of  the  patient. 
Grocco's  sign  is  found  in  the  majority  of  cases.  This  is  a  small  tri- 
angular area  of  dulness  posteriorly,  with  its  base  to  the  spine,  on  the  side 
opposite  to  the  eff'usion.  The  signs  on  auscultation  are  variable,  and 
probably  lead  to  more  frequent  mistakes  in  diagnosis  than  in  any  other 
pulmonary  affection.  Bronchial  breathing  and  bronchial  voice  over  the 
fluid  are  common  in  children.  Absence  of  both  voice  and  breathing  is 
sometimes  met  with,  but  it  is  exceptional.  The  bronchial  breathing 
over  fluid  usually  differs  from  that  over  consolidation,  in  that  it  is  feebler 
and  distant;  in  some  cases,  however,  it  is  indistinguishable  from  that 
heard  over  consolidation.  Friction  sounds  may  be  heard  above  the  level 
of  the  fluid,  or  when  the  fluid  is  subsiding,  and  there  may  be  bronchial 
rales. 

Diagnosis. — The  most  reliable  signs  for  diagnosis  are  displacement 
of  the  heart,  flatness  on  percussion,  absence  of  rales  and  friction  sounds. 


562  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

and  (usually  distant)  bronchial  breathing.  In  an  infant,  flatness  should 
always  lead  one  to  suspect  fluid.  If  there  is  flatness  over  one  entire 
lung,  the  existence  of  fluid  is  almost  certain.  Between  serous  and 
purulent  effusions  a  positive  diagnosis  is  possible  only  by  the  use  of  the 
exploring  needle.  This  should  be  employed  in  every  case,  as  it  is  im- 
portant to  know  early  whether  or  not  we  have  a  purulent  effusion  to  deal 
with.  The  amount  of  fluid  in  serous  pleurisy  is  generally  less  than  in 
the  purulent  variety. 

Pleurisy  is  further  to  be  differentiated  from  pneumonia,  and  from 
tuberculosis.  From  pneumonia,  the  acute  cases  are  distinguished  by  the 
lower  temperature,  the  less  severe  prostration,  lower  leucocyte  count  and 
the  fact  that  all  the  general  symptoms  are  milder ;  but  especially  by  the 
physical  signs.  The  differential  diagnosis  by  the  physical  signs  between 
effusion  and  the  various  forms  of  consolidation  is  considered  under  the 
head  of  Empyema. 

Prognosis. — In  the  acute  cases  complicating  pneumonia,  a  serous 
pleurisy  is  very  apt  to  become  purulent.  Other  forms  of  pleurisy  with 
effusion,  as  a  rule,  terminate  in  recovery  by  absorption.  In  cases  com- 
ing on  without  definite  cause  there  should  always  exist  a  suspicion  of 
tuberculosis,  and  hence  every  patient  should  be  closely  watched  for  the 
development  of  the  other  signs  of  that  disease. 

Treatment. — In  the  great  majority  of  cases,  only  symptomatic  treat- 
ment is  required  during  the  acute  period.  The  patient  should  be  kept 
in  bed,  and  pain  relieved  by  opium,  counter-irritation,  or  dry  cups.  After 
the  fever  has  ceased  the  patient  may  be  allowed  to  sit  up,  but  all  exer- 
tion should  be  carefully  avoided  if  the  effusion  is  large.  Sudden  death 
has  occurred  when  this  rule  has  been  violated.  The  patient  should  in 
suitable  Aveather  be  kept  in  the  open  air  as  much  as  possible.  In  the 
course  of  a  few  weeks  the  effusion  usually  subsides  under  simple  tonic 
treatment.  Absorption  may  sometimes  be  hastened  by  counter-irritation 
and  diuretics ;  but  convalescence  is  apt  to  be  slow,  and  it  may  be  several 
months  before  the  health  is  entirely  restored. 

The  removal  of  the  fluid  by  operation  is  indicated  in  the  acute  form 
when  it  is  accumulating  so  rapidly  as  to  endanger  life  from  the  pressure 
upon  the  heart  and  lungs;  also  when  there  is  no  tendency  to  absorption 
after  from  two  to  three  weeks  of  constitutional  treatment.  In  such  cases 
nothing  is  to  be  gained  by  waiting,  and  harm  may  be  done  to  the  lung 
by  the  delay.  The  usual  method  is  by  aspiration.  In  the  acute  stage 
enough  should  be  removed  to  relieve  the  patient's  s^anptoms,  aspiration 
being  repeated  if  necessary  in  twelve  or  twenty-four  hours.  In  infants, 
particularly,  there  is  great  danger  of  Avounding  the  lung  when  aspiration 
is  repeated  several  times.  This  usually  results  in  the  production  of 
pneumothorax  which  may  mask  the  re-accumulation  of  the  fluid.     In 


EMPYEMA  563 

the  subacute  stage  the  removal  of  a  portion  of  the  fluid  may  be  all  that 
is  required,  spontaneous  absorption  of  the  remainder  often  taking  place 
quite  promptly. 

EMPYEMA 

Fully  nine-tenths  of  the  cases  of  empyema  in  children  under  five  years 
either  occur  with  or  follow  pneumonia,  being  usually  the  sequel  of  the 
form  described  as  pleuropneumonia.  In  some  of  these  cases,  however, 
the  pleurisy  masks  the  pneumonia,  so  that  the  former  appears  to  be  the 
primary  disease.  Tuberculosis  is  a  rare  cause  in  early  childhood,  but 
becomes  more  frequent  after  the  seventh  year.  Empyema  may  com- 
plicate scarlet  fever,  measles,  or  any  of  the  other  acute  infectious  dis- 
eases. It  is  met  with  in  pyemia  from  all  causes.  It  may  occur  in  the 
newly  born  as  the  result  of  infection  through  the  umbilical  wound  or 
the  skin.  It  is  seen  with  suppurative  inflammations  of  the  joints  and 
with  osteomyelitis.  It  may  complicate  suppurative  processes  in  the  ab- 
domen, such  as  appendicitis  or  purulent  peritonitis.  Among  the  local 
causes  may  be  mentioned  traumatism,  necrosis  of  a  rib,  and  the  rupture 
into  the  pleural  cavity  of  abscesses  originating  in  the  mediastinum,  in 
the  thoracic  wall,  or  below  the  diaphragm. 

Since  empyema  is  generally  secondary  to  pneumonia,  its  causes  are 
mainly  those  of  that  disease.  Of  180  cases  observed  at  the  Babies'  Hos- 
pital in  which  the  nature  of  the  organism  was  determined  it  was  as  fol- 
lows, 83  per  cent  of  these  patients  being  under  two  years  of  age : 

Pneumococcus 115 

Streptococcus 26 

Staphylococcus 14 

B.  Influenzae 1 

B.  Tuberculosis 1 

Mixed  infections 23 

Two-thirds  of  the  mixed  infections  showed  the  pneumococcus.  The 
predominance  of  the  male  sex  is  even  more  striking  than  in  pneumonia. 
Of  204  consecutive  cases  in  the  same  institution  the  proportion  of  males 
was  68.6  per  cent. 

Lesions. — Empyema  is  an  inflammation  with  the  production  of 
serum,  fibrin,  and  pus.  In  most  of  the  cases — and  the  younger  the 
child  the  more  frequent  its  occurrence — it  succeeds  pleuropneumonia. 
There  is  first  an  exudation  of  fibrin  with  an  excess  of  pus  cells.  As  the 
process  continues,  more  and  more  pus  is  poured  out,  with  serum.  At 
first  the  fiuid  collects  in  small  pockets  formed  by  the  slight  adhesions. 
As  it  accumulates  these  are  broken  down,  and  the  pleural  cavity  may  be 
filled  with  pus.     If  the  original  inflammation  involved  but  a  portion  of 


64.0 

per  cent. 

14.4 

7.8 

0.5 

0.5 

12.8 

564 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


the  pleura  the  empyema  may  be  sacculated.  This  is  often  seen  even  in 
infants.  Much  has  been  written  regarding  inter-lobar  empyema.  This 
we  have  never  seen  either  at  autopsy  or  operation  and  we  believe  it  to 
be  a  very  rare  condition  in  children.  Localized  empyema  is,  however, 
seen  very  often.  It  is  usually  posterior  and  over  one  lower  lobe,  but 
may  be  in  any  part  of  the  chest.  In  very  rare  cases  there  may  be 
several  sacs  containing  pus,  separated  by  septa.    Such  a  condition  we  have 

never  seen  in  empyema 
following  pneumonia. 
The  cases  just  described 
are  those  in  which,  in  in- 
fants and  young  children, 
the  pneumococccus  is 
regularly  found.  The 
amount  of  fibrin  is  large, 
covers  both  surfaces  of 
the  pleura,  and  many 
large  masses  float  in  the 
fluid.  The  pus  is  usually 
thick,  creamy,  and  odor- 
less. In  another  group 
of  cases  the  evidences  of 
inflammation  of  the 
pleura  are  much  less 
marked,  and  in  some  they 
may  be  slight.  There  is 
but  little  fibrin  in  the 
exudate,  and  adhesions 
are  rare.  In  this  form 
the  streptococcus  or  the 
staphylococcus  is  the  or- 
ganism usually  found. 
In  these  cases  the  inflam- 
mation may  be  purulent  from  the  outset,  and  the  pus  is  thinner  than 
in  the  preceding  variety.  Empyema  following  pneumonia  is  occasion- 
ally preceded  by  a  serious  effusion  which,  although  almost  clear,  is 
usually  found  to  contain  great  numbers  of  bacteria,  usually  pneumococci. 
Even  when  the  fluid  is  moderate  in  quantity  it  is  not  all  at  the  bottom 
of  the  chest,  but  is  generally  distributed  over  a  considerable  part  of  its 
surface,  and  its  depth  at  the  middle  and  upper  part  of  the  chest  may 
be  only  half  an  inch,  or  even  less.  When  the  accumulation  is  larger, 
the  lung  does  not  float  on  the  surface  of  the  fluid,  but  the  fluid  sur- 
rounds the  lung,  which  is  compressed  on  all  sides  (Figs.  73,  74,  75).    The 


Fig.  73. — Section  of  a  Lung.  To  illustrate  the  dis- 
tribution of  the  fluid  in  the  chest  with  a  moderate 
effusion  (diagrammatic) . 


EMPYEMA 


565 


Fig.  74. 


Empyema,  Right  Side;  Moderate 
Effusion. 


heart  is  displaced;  the  diaphragm  and  the  abdominal  viscera  are  some- 
what depressed,  and  there  may  be  bulging  of  the  chest  on  the  affected 
side.  The  amount  of  fluid  in  ordinary  cases  is  from  four  to  twenty 
ounces,  although  in  neglected  cases  it  may  accumulate  until  it  amounts 
to  four  or  five  pints.  The  effect 
upon  the  lung  will  depend  upon 
the  amount  of  fluid  and  the 
duration  of  tlie  compression. 
When  the  quantity  is  small,  or 
when  the  pressure  is  removed 
early,  the  lung  in  most  cases 
readily  expands,  air  being  forced 
into  it  from  the  opposite  lung, 
especially  during  the  act  of 
coughing.  With  the  exception 
of  adhesions,  recovery  may  be 
complete.  Although  wide  in  ex- 
tent, the  adhesions  are  not 
usually  strong  enough  to  inter- 
fere seriously  with  the  function 
of  the  lung.  If  the  pressure  is  great  and  has  been  long  continued,  the 
adhesions  over  the  lung  may  become  so  dense  and  firm  that  expansion  is 
difficult,  and  can  at  best  be  only  partial.  In  such  cases  recession  of  the 
chest  wall  occurs.    In  old  cases  expansion  is  still  further  interfered  with 

by  the  changes  taking  place  in 
the   lung  itself,  usually   a  low 
grade  of  interstitial  pneumonia. 
In  cases  receiving  no  treat- 
ment, absorption  of  the  pus  is 
possible,    but   is   not   to   be   ex- 
pected.    It  generally   seeks  an 
external  outlet ;  the  lung  may  be 
perforated  and  the  pus  be  evac- 
uated  through  the    bronchi,   or 
external     rupture     may     occur, 
generally  in  the  neighborhood  of 
the  nipple.     In  still  other  cases 
the  pus  may  burrow  along  the 
spine,  or  through  the  diaphragm 
reaching  the  peritoneum. 
Empyema  is  more  often  of  the  left  than  of  the  right  side,  the  propor- 
tion being  about  three  to  two.     It  is  double   in  about  three  per  cent 
of  all  cases,  but  much  oftener  in  infants.    The  most  serious  complication 


P^iG.  75. — Empyema  with  Large  Effusion. 


566 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


ill  young  children  is  pericarditis,  nsnalty  ^vitli  empyema  of  the  left  side; 
in  older  children  a  frequent  complication  is  pulmonary  tuberculosis. 

Symptoms. — "When  it  occurs  as  a  sequel  of  pneumonia,  the  S5^mptoms 
of  empyema  may  follow  those  of  the  original  disease  without  any  inter- 
mission ;  or  after  the  temperature  has  been  normal  or  nearly  so  for  sev- 


DAY 

1         2 

3 

i 

5 

6 

7 

8 

9 

10      11    1  12 

13 

11 

15 

IG 

17 

IS 

19 

20 

21 

22 

23 

106 
105 
101 
103 
102 
101 
100 
99 

M    E 

M    E 

M   E 

M   E 

M   E 

M   E 

M   E 

M    E 

M   E 

M    E 

W    E 

M    E 

M    E 

M    E 

M    E 

M    E 

M    E 

M    E   M    E 

M    E 

M    E 

M    E 

M   1 

A 

A 

A/ 

\A 

^/\ 

v/' 

Jl 

/w 

Y 

\l 

V 

\a 

A 

A 

h 

^ 

\/l 

A 

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V'^' 

\V\ 

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/Vi^ 

i       \ 

r-ir- 

i 

y 

v'^ 

y' 

sT 

\/\ 

A 

A 

V 

V\ 

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^\ 

/ 

r 

Fig.  76. — Empyema  followixg  Pneumonia.  Private  patient,  girl,  eight  years  old;  se- 
vere pneumonia  terminating  by  lysis;  development  of  empyema  indicated  by  second- 
ary temperature;   operation  on  seventeenth  day;   recovery. 

eral  davs  it  may  rise  again,  sometimes  quite  suddenly,  but  more  often 
gradually.  With  this  accession  of  fever  there  are  other  sj'mptoms  point- 
ing to  an  increase  in  the  thoracic  disease.  (See  Figs.  76  and  77.) 
After  scarlet  fever  or  other  infectious  diseases,  the  onset  of  empyema  is 

often  signalized  by 
cough,  rapid  breath- 
ing, and  the  other 
usual  symptoms  of 
pulmonary  disease.  In 
the  cases  where  em- 
pyema ajDpears  to  be 
primary,  the  onset  is 
acute,  with  high  tem- 
perature and  general 
and  local  symptoms 
resembling  those  of 
pneumonia.  After  such 
a  beginning,  the  chest 
may  be  found  full  of 
pus  bv  the  third  or  fourth  day.  In  older  children  empyema  may  come  on 
with  gradual,  and  even  insidious  symptoms,  there  being  only  slight  fever, 
dyspnea,  and  cachexia.  Marked  leucocytosis,  25,000  to  -iO.OOO,  is  almost 
invariably  j)resent.  The  proportion  of  polymorphonuclear  cells  is  usually 
from  seventy-five  to  eighty-five  per  cent. 


DAY 

5         G    1    7 

8 

9    j   10 

11      12  1  13 

14 

15 

IG   1   IT 

18   1   19 

iog" 
ids" 

IM 
103 
102 
101 
100 
99 

M    E 

M    E 

M  E 

M    E 

M   E 

M    E 

M    E 

M    E 

M    E 

M    E 

M    E 

M    EiM    E 

M  e!m  e 

A 

A 

A 

\ 

\l\  A 

/     /I 

nl\  \i\ 

~li 

V 

A 

i 

A 

l\  1 

» 

A 

A 

71  /\  / 

V^ 

1  \ 

ll 

/N 

/ 

U         iV_ 

V 

V     V 

IK/ 

/ 

v 

T — 

8 

Fig.  77. — Empyema  following  Pneumonia.  Hospital 
patient,  two  years  old;  single-lobe  pneumonia  with 
crisis  on  ninth  day;  no  resolution,  but  instead  gradual 
development  of  signs  of  empyema  closely  following 
the  temperature  curve. 


EMPYEMA  5G7 

Of  88  patients  with  empyema  in  the  Babies'  Hospital,  nearly  all  under 
three  years  old,  positive  blood  cultures  were  obtained  in  -il  per  cent.  The 
pneumococcus  was  the  organism  usually  found. 

Whatever  may  have  been  the  mode  of  onset,  when  tlie  pus  has  been 
in  the  chest  for  some  time  the  symptoms  are  fairly  miiform.  During 
the  acute  stage  there  are  present  pallor,  anemia,  and  prostration.  The 
respirations  are  always  accelerated,  being  usually  from  forty  to  seventy 
a  minute.  Cough  is  present;  there  is  dyspnea,  sometimes  marked,  but 
more  often  it  is  scarcely  noticeable.  The  temperature  is  exceedingly 
variable;  usually  it  ranges  from  101°  to  103°  F.  A  typical  hectic  tem- 
perature with  sweating  is  in  our  experience  very  Tare.  The  pulse  is 
rapid  but  of  fair  strength.  There  is  loss  of  flesh,  sometimes  even  emacia- 
tion and  anorexia;  occasionally  there  is  diarrhea.  The  stage  of  acute 
symptoms  may  last  from  two  to  four  weeks.  This  may  be  succeeded  by 
a  subacute  stage  which  may  last  for  months.  In  this  there  is  little  or  no 
fever;  the  patient  seems  convalescent  so  far  as  regaining  strength  and 
color  are  concerned;  but  cough,  dyspnea,  and  rapid  respiration  con- 
tinue. The  chest  shows  no  change  in  signs  from  those  of  the  acute  stage. 
In  chronic  cases  the  general  symptoms  closely  resemble  those  of  tubercu- 
losis. There  may  be  clubbing  of  the  Angers,  albuminuria,  swelling  of  the 
feet,  and  often  marked  lateral  curvature  of  the  spine. 

Diagnosis. — The  physical  signs  do  not  differ  essentially  from  those 
present  in  serous  effusion.  If  there  are  signs  of  fluid  in  the  chest  and 
the  patient  is  under  three  years  of  age,  the  fluid  is  likely  to  be  purulent; 
and  from  the  third  to  the  seventh  year,  pus  is  much  more  often  found 
than  serum.  A  marked  leucocytosis  always  makes  pus  more  probable.  In 
every  case  in  which  fluid  is  suspected  the  exploring  needle  should  be 
used,  because  of  the  great  importance  of  an  early  diagnosis.  The  skin 
should  be  surgically  clean  and  the  needle  sterilized.  Pus  may  not  be 
found  because  the  needle  is  too  small,  too  short,  or  because  it  is  intro- 
duced too  far  into  the  chest;  for  when  the  layer  of  pus  is  thin,  the 
needle  may  be  pushed  through  this  into  the  lung. 

The  i)hysical  signs  upon  which  most  reliance  is  to  be  placed  are, 
marked  dulness  or  flatness  on  percussion,  feeble  breathing,  and  displace- 
ment of  the  heart.  When  in  a  young  child  these  signs  are  present, 
whether  general  or  localized,  a  needle  should  be  inserted,  and  if  pus  is 
not  found  at  the  first  trial,  repeated  punctures  should  be  made  until 
the  presence  or  absence  of  fluid  is  deflnitely  settled. 

Empyema  is  most  frequently  confounded  with  unresolved  pneumonia. 
The  differentia!  points  are  that  in  unresolved  pneumonia  the  dulness  is 
usually  over  a  single  lobe,  rales  or  friction  sounds  are  heard,  and  there  is 
no  displacement  of  the  heart ;  empyema  may  give  flatness  over  the  whole 
lung,  or  over  the  lower  half  of  the  chest  in  front  and  behind,  rales  and 


568  DISEASES  OF  THE  RESPIBATORY  SYSTEIM 

friction  sounds  are  absent  over  this  area,  and  the  heart  is  usually  dis- 
placed. In  both  conditions  we  may  get  bronchial  breathing  and  voice. 
The  confusion  of  acute  pneumonia  or  tuberculosis  with  empyema,  gen- 
erally arises  from  placing  too  much  reliance  upon  auscultation.  In 
pleuropneumonia,  with  an  excessive  exudation  of  fibrin,  the  signs  may 
be  identical  with  those  of  empyema,  except  that  the  heart  is  not  dis- 
placed. We  have  several  times  seen  pulmonary  tuberculosis,  with  casea- 
tion of  an  entire  lobe,  which  gave  signs  that  were  identical  with  those 
of  a  sacculated  empyema.  It  is  by  the  exploring  needle,  and  by  that 
alone,  that  empyema  is  positively  differentiated  from  these  pulmonary 
conditions. 

There  are  some  other  thoracic  diseases  from  which  the  diagnosis  may 
be  even  more  difficult.  A  large  pericardial  effusion  gives  signs  which 
are  in  some  cases  identical  with  those  of  empyema  of  the  left  side. 
Marked  displacement  of  the  heart  to  the  right  is  always  a  strong  point 
in  favor  of  empyema;  besides,  such  pericardial  effusions  are  extremely 
rare  in  young  children.  A  pulmonary  abscess  of  considerable  size — also 
a  rare  condition — gives  signs  identical  with  those  of  localized  empyema, 
and  is  only  distinguished  from  it  by  autopsy  or  operation.  Abscesses 
from  broken-down  tuberculous  glands  may  give  signs  resembling  those 
of.  localized  empyema,  and  like  an  empyema  may  point  between  the  ribs 
in  the  upper  part  of  the  chest.  The  constitutional  symptoms  of  empyema 
may  at  times  resemble  typhoid  fever  or  malaria;  but  it  is  distin- 
guished from  them  by  the  physical  signs  and  by  the  examination  of 
the  blood. 

Prognosis,. — The  outcome  of  a  case  of  empyema  depends  chiefly  upon 
the  age  and  general  condition  of  the  patient,  the  exciting  cause,  the 
duration  of  the  symptoms,  the  presence  or  absence  of  serious  complica- 
tions, and  the  treatment.  The  mortality  in  young  children  is  high, 
particularly  in  the  first  year.  Of  204  consecutive  cases  admitted  to  the 
Babies'  Hospital,  the  death  rate  was  as  follows : 

First  year  74  cases ;     mortality  74  per    cent 

Second  "    93      "  "  59     "        " 

Over  two  years 37      "  "  13     "        '' 

It  is  often  difficult  to  understand  why  the  cases  in  infancy  do  so 
badly;  many  of  these  children  on  admission  are  in  excellent  condition 
and  do  well  for  a  week  or  more  after  operation.  Then  the  temperature 
rises,  the  patients  lose  ground  rapidly  and  die  of  exhaustion  during  the 
third  or  fourth  week.  Their  inability  to  expand  the  compressed  lung 
properly  seems  an  important  factor,  as  this  condition  is  almost  invariably 
found  at  autopsy.     Very  seldom  is  there  trouble  with  drainage.     Em- 


EMPYEMA  569 

pyema  in  children  over  three  years  old  seen  reasonably  early  and  receiving 
proper  treatment,  almost  invariably  terminates  in  recovery,  unless  the 
disease  is  double  or  serious  complications  exist.  The  best  results  are 
seen  in  the  cases  that  follow  pneumonia.  Pneumococcus  and  staphylo- 
coccus cases  have  a  better  outlook  tban  those  due  to  the  streptococcus 
or  to  mixed  infections.  Tuberculosis  before  the  seventh  year  is  an  ex- 
ceedingly infrequent  cause,  and  gangrene  of  the  lung  and  general  pyemia 
are  both  rare  causes  in  early  life.  It  is  these  three  conditions  that  make 
the  prognosis  of  the  disease  in  adults  so  serious.  Clreat  delay  in  opera- 
tion makes  the  prognosis  worse,  because  the  more  difficult  the  expansion 
of  the  lung  the  more  tedious  is  the  disease,  and  the  greater  the  likelihood 
of  a  sinus  remaining.  With  proper  early  treatment  these  patients  not 
only  recover,  but  in  most  cases  the  recovery  is  surprisingly  complete. 
Eetraction  of  the  chest  and  its  resulting  lateral  curvature  of  the  spine 
are  rare,  and  seen  only  in  neglected  cases.  In  very  many  patients,  in 
which  a  reasonably  early  operation  was  done,  it  is  impossible,  after  the 
lapse  of  two  or  three  years,  to  detect  any  difference  whatever  in  the 
physical  signs  of  the  two  sides  of  the  chest.  There  are  few  serious 
diseases  the  treatment  of  which  is  more  satisfactory  than  that  of  acute 
empyema  in  older  children. 

Spontaneous  recovery  in  empyema  may  take  place  by  absorption ;  but 
this  is  so  rare  that  it  is  not  to  be  expected.  The  pus  may  be  evacuated 
spontaneously  through  a  bronchus,  rupture  having  taken  place  through 
the  visceral  pleura.  When  this  occurs,  a  large  amount  of  pus  may  be 
coughed  up  in  a  few  hours,  usually  followed  by  immediate,  but  not 
always  lasting,  improvement.  This  is  the  most  favorable  of  the  natural 
terminations.  External  opening  may  take  place,  usually  in  the  region  of 
the  nipple.  There  is  an  area  of  redness,  then  a  fluctuating  tumor,  and 
finally  the  pointing  of  an  abscess.  The  discharge  may  continue  for 
months,  or  even  for  years.  External  opening  rarely  occurs  until  the  dis- 
ease has  lasted  several  months.  Of  19  cases  of  empyema  in  children 
collected  by  Schmidt,  in  which  a  spontaneous  discharge  of  pus  occurred 
either  externally  or  through  a  bronchus,  there  were  17  deaths  and  3 
recoveries.  Empyema  may  burrow  behind  the  diaphragm  into  the  ab- 
dominal cavity,  appearing  as  a  psoas  abscess;  it  may  burrow  posteriorly 
into  the  lumbar  region;  it  may  rupture  into  the  esophagus,  or  through 
the  diaphragm  into  the  peritoneal  cavity.  All  these  conditions,  how- 
ever, are  very  rare.  The  chances  of  spontaneous  cure  in  empyema  are 
small.  Of  32  cases,  reported  l)y  Eillict  and  Bartbcz,  Avliich  received 
no  surgical  treatment,  21  proved  fatal.  ^J'he  statistics  of  empyema  be- 
fore the  general  adoption  of  surgical  treatment  are  appalling.  Patients 
were  either  worn  out  by  the  protracted  suppuration,  or  died  from  amyloid 
degeneration,  pneumonia,  or  tuberculosis. 


570  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

Treatment. — The  medical  treatment  relates  to  the  jjatieut  onlj;  the 
disease  is  always  to  be  treated  surgically.  Like  any  other  acute  abscess^ 
empyema  requires  free  incision  and  drainage  with  proper  aseptic  pre- 
cautions. 

Aspiration  as  a  means  of  cure  is  now  seldom  used.  L^nquestionably 
it  sometimes  suffices  to  cure  empyema,  most  frequently  when  it  is  local- 
ized, and  when  the  cause  is  the  staphylococcus.  How  often  this  occurs 
is  shown  by  the  following  statistics:  Of  139  cases  Avhich  we  collected 
that  were  treated  by  aspiration,  25  were  cured,  8  of  these  by  a  single 
aspiration;  13  died,  and  the  remaining  101  were  afterward  subjected  to 
other  treatment.  The  objections  to  aspiration  are,  that  it  is  not  possible 
to  remove  all  the  pus;  that  it  affords  no  opportunity  for  the  removal  of 
the  large  filjrinous  masses;  besides,  there  is  the  danger,  especially  with 
repeated  aspirations,  of  puncturing  the  lung  and  producing  pneu- 
mothorax. Simple  aspiration,  therefore,  is  to  be  advised  in  children 
only  for  temporary  relief  when  the  amount  of  fluid  is  large  and  the 
jjatient's  condition  such  as  to  make  it  desirable  to  defer  any  more  seriaus 
operation.  It  is  to  be  advised  also  in  the  case  of  double  empyema  until 
sufficient  adhesions  have  formed  uj^on  the  first  side  operated  upon  to 
make  opening  of  the  other  j^leural  cavity  safe.  Aspiration,  followed  by 
the  injection  of  formalin  and  glycerin,  is  not,  from  our  experience,  to 
be  recommended. 

Incision  mid  Drainage. — In  most  cases  it  is  preferable  to  delay 
incision  until  the  period  of  most  acute  inflammation  has  subsided,  as 
shown  by  lower  temperature  and  stationary  physical  signs.  This  is 
usually  seen  two  or  three  weeks  after  the  pleural  invasion.  Such  delay 
is  not  admissil^le  if  either  the  local  condition  or  the  temperature  points 
to  a  steady  increase  in  the  disease;  nor  wlien  the  general  symptoms' 
indicate  increasing  prostration  or  sepsis.  The  dangers  attendant  upon 
general  anesthesia  are  considerable,  and  in  most  cases  it  is  better  not  to 
employ  it.  We  have  known  of  six  deaths  on  the  taljle  during  operation, 
and  in  several  other  cases  have  seen  very  alarming  symptoms  occur. 
Chloroform  is  more  to  be  feared  than  ether.  It  is  well,  when  possible, 
to  employ  local  anesthesia.  The  most  favorable  point  for  incision  is  the 
posterior  axillary  line  in  the  seventh  intercostal  space  upon  the  right 
side,  the  eighth  upon  the  left.  In  a  case  of  localized  empyema,  the 
lowest  point  at  which  pus  can  be  obtained  by  puncture  should  be  chosen. 
The  incision  is  made  in  the  middle  of  the  intercostal  space.  No  matter 
Avhat  has  l)een  found  by  puncture  on  previous  occasions,  the  exploring 
needle  should  always  be  used  at  the  time  of  operation  and  at  the  site 
of  the  incision  before  the  latter  is  made.  The  incision  should  be  only 
large  enough  to  allow  the  introduction  of  two  tubes  side  by  side  into  the 
pleural  cavity.     The  hemorrhage  is  very  rarely  sufficient  to  require  a 


EMPYEMA  571 

ligature.  It  is  undesirable  to  attempt  to  empty  the  chest  at  the  time 
of  operation.  A  better  plan  is  to  insert  the  tubes  at  once  and  apply  the 
dressings,  allowing  the  pus  to  escape  slowly.  The  drainage  tubes  should 
be  of  rubber,  fenestrated,  one-fourth  to  tbree-eigbths  of  an  inch  in 
diameter  and  about  three  inclies  long.  To  secure  them  from  slipping 
into  the  cavity,  the  outer  end  should  be  transfixed  by  a  large  safety-pin 
before  introduction. 

Both  the  original  operation  and  the  subsequent  dressings  should  be 
done  with  strict  aseptic  precautions  on  account  of  the  danger  of  sec- 
ondary infection,  the  occurrence  of  which  adds  to  the  severity  and  pro- 
longs the  course  of  the  disease.  After  the  third  or  fourth  day  the  second 
tube  may  be  omitted  and  the  remaining  one  gradually  shortened.  Often, 
by  the  end  of  the  fourth  week,  and  sometimes  before,  the  tube  may  be 
dispensed  with  altogether.  The  time  of  redressing  and  the  removal  of 
the  tube  is  determined  by  the  amount  of  discharge  and  the  tem- 
perature. 

Simple  incision  with  drainage  is  in  infants  to  be  j^referred  to  rib 
resection.  It  requires  less  time,  no  general  anesthetic,  and  is  altogether 
a  much  less  severe  operation.  Our  experience  is  that  following  it  pul- 
monary expansion  takes  place  with  more  facility  than  when  a  large 
opening  is  made  in  the  chest,  and  that  in  the  great  majority  of  cases 
it  secures  all  the  room  required  for  drainage.  There  are,  however,  some 
disadvantages.  The  smaller  opening  may  not  give  adequate  room  for 
the  removal  of  large  masses  of  fibrin.  In  old  cases,  particularly,  it  not 
infrequently  happens  that  after  the  chest  has  been  emptied  the  ribs 
become  so  closely  approximated  that  but  little  space  is  left,  and  the 
drainage  tubes  are  pinched.  Furthermore,  the  contact  of  the  tubes  may 
lead  to  erosion  and  superficial  necrosis  of  the  adjacent  ribs,  sometimes 
to  exostoses. 

Incision  wiili  Elh  Besection. — This  is  the  operation  to  be  preferred 
with  children  over  three  or  four  years  of  age.  It  is  sometimes  needed 
as  a  secondary  operation  in  cases  which  cannot  be  jDroperly  drained  by 
the  simple  incision  owing  to  approximation  of  the  ribs.  The  removal  of 
an  inch  of  rib  is  usually  all  tbat  is  necessary.  This  allows  the  insertipn 
of  the  finger  into  the  chest,  the  removal  of  masses  of  fibrin  and  the 
breaking  down  of  adhesions  if  any  are  present,  and  it  secures  free 
drainage.  The  extensive  manipulation  which  is  sometimes  practiced  in 
these  cases  with  older  patients  is  not  admissible  with  young  children. 

Siphon  Drainage. — This  method  of  treatment  ijitroduced  many  years 
ago  by  Bulau  and  recently  revised  and  improved  by  Kenyon  has  much 
to  commend  it  for  young  infants.  The  opening  made  into  the  chest 
is  a  very  small  one  admitting  only  a  single  large  drainage  tube.  The 
wound  is  tightly  strapped  about  the  tube  so  as  to  exclude  air.     The 


572 


DISEASES  OF  THE  RESPIRATORY  SYSTEM 


/ 


thoracic  tube  is  connected  by  a  glass  tube  with  several  feet  of  rubber 
tubing  and  this  with  the  wash  bottle  which  contains  a  sterile  salt  solu- 
tion. This  bottle  is  suspended  beneath  the  patient's  bed  or  placed 
upon  the  floor.  The  character  and  the  amount  of  discharge  can  thus 
readily  be  seen.     As  the  tube  often  need  not  be  changed  for  several 

days  the  child  is  spared  the  fa- 
tigue and  distress  of  frequent 
dressings.  The  exclusion  of  air 
diminishes  the  danger  of  sec- 
ondary infection  and  favors  the 
expansion  of  the  lung.  The  bot- 
tle is  emptied  once  or  twice  a  day, 
the  air  being  meanwhile  excluded 
by  clamping  the  tube.  The  chief 
objection  to  this  method  of  treat- 
ment is  interference  with  drain- 
age by  the  blocking  of  the  tube. 
Such  an  occurrence  is  at  once 
recognized  by  inspection  of  the 
fluid  in  the  wash  bottle.  A  fibriil 
plug  can  sometimes  be  removed 
by  suction,  or  by  raising  the  bot- 
tle and  allowing  some  of  the  ster- 
ile solution  to  flow  into  the  chest, 
afterwards  siphoning  it  out;  but 
in  many  cases  .the  tube  must  be 
removed  to  clear  it.  Even  if  this 
is  carefully  done  by  keeping  a 
tight  pad  on  the  wound,  air  can- 
not be  excluded  from  the  chest 
nor  secondary  infection  of  the 
pleura  entirely  avoided.  When 
repeated  blocking  of  the  tube  oc- 
curs the  treatment  may  have  to 
be  discontinued.  The  tube  can 
usually  be  worn  for  ten  or  twelve 
days,  after  which  it  loosens  owing 
to  ulceration  about  it  and  an  air- 
tight wound  can  no  longer  be 
maintained.  The  short  tube  with  the  dressing  of  gauze  and  cotton  is 
substituted.  An  extensive  trial  of  siphon  drainage  leads  us  to  recommend 
its  use  in  many  cases  of  empyema  in  infants. 

Washing   out    the   pleural    cavity   is    indicated   in    cases    in   which 


Fig.  78. — Deformity  after  an  Old  Em- 
pyema OF  THE  Left  Side  for  which 
Estlander's  Operation  was  Per- 
formed. Portions  of  five  ribs  were 
removed.  (From  a  photograph  seven 
years  after  operation.) 


EMPYEMA 


573 


the  pus  is  foul.  A  single  washing  for  the  purpose  of  removing  fibrin 
is  the  routine  practice  of  some  surgeons.  For  this  a  warm,  sterilized  salt 
solution  should  be  used.  Personally,  we  have  seldom  found  this  neces- 
sary. Repeated  irrigations  should  not  be  employed.  The  usual  dura- 
tion of  the  discharge  in  cases  treated  by  simple  incision  is  from  three 
to  six  weeks,  the  average  being  about  five  weeks. 

A  persistence  of  temperature  or  a  fresh  rise  after  operation  most 
frequently  indicates  defective  drainage,  generally  due  to  blocking  of 
the  tube;  but  this  is  not  always  the  case.  It  may  be  due  to  pneumonia, 
either  a  continuance  of  the  old  process  or  the  lighting  up  of  a  new  one, 
to  abscess  of  the  lung,  to 
empyema  of  the  opposite 
side,  to  pericarditis,  or  to 
some  cause  outside  the 
chest,  very  frequently  oti- 
tis. The  mistake  is  often 
made  of  allowing  the  tube 
to  remain  for  too  long  a 
time,  so  that  a  sinus  is 
kept  open  which  would 
otherwise  close. 

In  chronic  cases,  or 
those  which  have  been  long 
neglected,  some  further 
operative  treatment  is 
often  necessary.  The  lung 
is  so  bound  down  by  firm 
adhesions  that  further  ex- 
pansion is  impossible,  and 
even  after  the  chest  has  re- 
ceded to  its  utmost,  so  that  the  ribs  are  in  contact,  there  still  remains  a 
cavity  which  cannot  close.  For  such  cases  the  only  hope  is  an  operation 
by  which  portions  of  several  ribs  are  removed,  thus  allowing  a  greater 
collapse  of  the  chest  wall.  This  is  known  as  "thoraplasty,"  or  "Estland- 
er's  operation."  The  operation  is  of  itself  a  serious  one,  and  only  to  be 
advised  as  a  last  resort  in  inveterate  cases.  Such  an  operation  is,  of 
course,  always  followed  by  very  great  deformity  (Fig.  78). 

Methods  of  Inducing  Expansion  of  the  Lung. — In  most  of  the  cases, 
particularly  the  recent  ones,  complete  expansion  of  the  lung  takes  place 
without  any  difficulty,  the  chief  agent  being^the  cough.  In  some  cases 
this  may  be  insufficient.  The  apparatus,  devised  by  James,  shown  in 
the  accompanying  cut  (Fig.  79),  serves  at  the  same  time  as  a  toy  for 
the  child's  amusement  and  as  a  most  efficient  means  of  inducing  forced 
30 


Fig.  79.- 


-James's  Appaeatus  for  Expanding  the 
Lung  after  Empyema. 


574  -       DISEASES  OF  THE  RESPIRATORY  SYSTEM 

expiration.  One  bottle  is  placed  a  few  inches  higher  than  the  other,  and 
the  child  blows  a  colored  fluid  from  the  lower  into  the  higher  bottle, 
allowing  it  to  siphon  back.  Blowing  soap  bubbles  often  answers  the 
same  purpose. 


SECTION  V 
DISEASES   OF   THE   CIRCULATORY   SYSTEM 

CHAPTEE  I 
PECULIARITIES  OF  THE  HEART  AND  CIRCULATION  IN  EARLY  LIFE 

The  Fetal  Circulation. — During  the  latter  part  of  fetal  life  the  cir- 
culation may  he  hriefiy  described  as  follows :  The  purified  blood  comes 
from  the  placenta  through  the  umbilical  vein.  Entering  the  body,  it 
divides  at  the  under  surface  of  the  liver  into  two  branches,  the  smaller 
one,  the  ductus  venosus,  communicating  directly  with  the  inferior  vena 
cava;  the  larger  branch  joining  the  portal  vein,  so  that  its  blood  traverses 
the  liver,  and  then  enters  the  inferior  vena  cava  through  the  hepatic 
vein.  From  the  inferior  vena  cava  the  blood,  enters  the  right  auricle,  like 
that  returned  from  the  head  and  upper  extremities  by  the  superior  vena 
cava.  A  part  of  the  blood  now  passes  directly  into  the  left  auricle 
through  the  foramen  ovale;  the  remainder,  through  the  tricuspid  orifice 
into  the  right  ventricle.  As  the  requirements  of  the  pulmonary  circula- 
tion are  not  great,  only  a  small  part  of  the  blood  is  sent  through  the 
pulmonary  artery  to  the  lungs;  the  greater  portion  passes  from  the 
pulmonary  artery  through  the  ductus  arteriosus  into  the  aorta,  joining 
here  the  blood  fiiom  the  left  ventricle.  The  blood  thus  finds  its  way 
from  the  right  heart  to  the  left,  only  in  small  part  Ijy  Avay  of  the  lungs, 
the  greater  part  passing  directly  from  the  right  auricle  to  the  left,  or 
from  the  right  ventricle  into  the  aorta  through  the  ductus  arteriosus. 
From  the  aorta,  the  blood  reaches  the  placenta  through  the  umbilical 
arteries,  which  are  a  continuation  of  the  hypogastric  arteries,  which 
in  turn  are  given  otf  from  the  internal  iliacs. 

Changes  in  the  Circulation  at  Birth. — AVith  the  ligation  of  the 
umbilical  cord,  the  circulation  through  the  umbilical  vein  and  arteries 
and  the  ductus  venosus  ceases.  With  the  establishment  of  respiration 
and  the  consequent  increased  demands  made  by  the  pulmonary  circula- 
tion, the  blood  ceases  almost  at  once  to  pass  through  the  ductus  arterio- 
sus, and  very  soon  through  the  foramen  ovale.  The  umbilical  vessels 
during  the  first  few  days  of  life  are  filled  with  small  thrombi,  which  be- 
jcome  organized.    By  the  end  of  the  first  week,  these  vessels,  as  well  as  the 

57.'5 


576  DISEASES  OF  THE  CIECULATORY  SYSTEM 

ductus  venosus,  are  usually  closed  at  their  extremities,  although  they  may 
remain  patulous  throughout  the  greater  part  of  their  extent  for  several 
weeks.  They  subsequently  atroiDhy  to  the  condition  of  small  fibrous 
cords.  For  some  weeks  before  birth  the  circulation  through  the  foramen 
ovale  is  slight,  it  being  gradually  obstructed  by  the  growth  of  a  septum 
which  nearly  fills  the  space  at  birth.  After  the  first  week  of  extra-uterine 
life  very  little,  if  any,  blood  passes  through  it,  although  complete  closure 
of  the  foramen  often  does  not  take  place  until  the  middle  of  the  first  year. 
In  fully  one-fourth  of  the  autopsies  we  have  made  upon  infants  under  six 
months  old,  there  have  been  found  minute  openings  at  the  margin  of  the 
foramen  ovale,  but  they  are  usually  oblique,  and  closed  by  the  valvular 
curtain  so  as  effectually  to  obstruct  the  current  of  blood.  The  ductus 
arteriosus  is  first  closed  by  a  clot,  which  becomes  organized  and  blends 
with  the  products  of  a  proliferating  arteritis.  It  is  rarely  found  open  after 
the  tenth  day,  and  by  the  twentieth  it  is  almost  invariably  obliterated.  . 
Size  and  Growth  of  the  Heart. — The  relative  size  of  the  heart  is 
slightly  greater  in  infancy  than  in  later  life,  it  being  smallest  at  about 
the  seventh  year.  The^  average  weight  at  the  different  periods  of  life  is 
as  follows: 

The  growth  of  the  heart  is  rapid  during  the  first  three  years,  and 
nearly  proportionate  to  that  of  the  body.  It  is  slowest  from  the  third 
to  the  tenth  year,  and  most  rapid  from  the  eleventh  to  the  fifteenth 
year.  At  birth,  the  thickness  of  the  right  ventricle  is  very  nearly  the 
same  as  that  of  the  left,  the  ratio  being  6:  7.  The  left  ventricle,  how- 
ever, grows  very  much  more  rapidly  than  the  right,  so  that  at  the  end 
of  the  second  year  the  ratio  is  1:2,  which  is  nearly  that  of  the  rest  of 
childhood. 

The  Pulse. — The  pulse  in  early  life  is  not  only  more  frequent,  but  it 
is  very  much  more  variable  than  in  adults.  The  following  is  the  average 
pulse-rate  in  healthy  children  during  sleep  or  perfect  quiet : 

Six  to  twelve  months 105  to  115  per  minute. 

Two  to  six  years 90  "    105    "         " 

Seven  to  ten  years 80"     90    " 

Eleven  to  fourteen  years 75  "     85    "         " 

The  pulse  is  a  little  more  frequent  in  females  than  in  males,  and  more 
frequent  when  sitting  than  when  lying  down.  Muscular  exercise  or  ex- 
citement increases  the  pulse-rate  by  from  twenty  to  fifty  beats.  Very 
trivial  causes  disturb  not  only  the  frequency  but  the  force  of  the  pulse. 
The  pulse  in  young  infants  may  be  irregular  even  in  health  and  during 
sleep.  When  rapid,  it  is  frequently  irregular  without  special  significance. 
No  dicrotism  is  seen  in  the  pulse  wave  of  early  infancy. 

The  circulation  is  much  more  active  in  infancy  than  in  later  child- 
hood; thus,  according  to  Vierordt,  the  entire  round  of  the  circulation  is 


EXAMINATION  OF  THE  HEART 


5.77 


accomplished  in  the  newly  born  in  twelve  seconds;  at  three  years,  in 
fifteen  seconds;  in  the  adult,  in  twenty-two  seconds. 


Age. 

Ounces. 

Grams. 

Ratio  to  Body 
Weight. 

Birth 

0.50 
1.25 

1.87 
2.25 
2.80 
5.84 
8.50 

14] 
351 
531 
64  J 
80 

166 

241 

1  year 

1  to  225 

2  years 

3       « 

7       " 

1  to  280 

14     "    

1  to  222 

Adult 

1  to  226 

The  figures  in  infancy  are  from  one  hundred  and  fifty-five  observations  made 
in  the  New  York  Infant  Asyhmi;  the  others  are  taken  from  Sahh. 

Position  of  the  Apex  Beat. — In  the  infant  the  heart  is  placed  some- 
what higher,  and  occupies  a  position  a  little  nearer  the  horizontal  than 
in  the  adult.  This  is  partly  due  to  the  higher  position  of  the  dia- 
phragm. The  apex  beat  is  therefore  higher  and  farther  to  the  left  than 
in  adult  life.  According  to  the  observations  of  Wassilewski  and  Starck, 
whose  combined  examinations  with  reference  to  this  point  were  made 
upon  over  2,100  children,  the  apex'  beat  is,  as  a  rule,  outside  the  mam- 
mary line  until  the  fourth  year;  if  -it  is  less  than  one-third  of  an  inch 
beyond  the  nipple,  it  can  not  be  considered  abnormal.  From  the  fourth 
to  the  ninth  year,  the  apex  beat  is  in  or  near  the  mammary  line.  After 
the  thirteenth  year,  under  normal  conditions,  it  is  invariably  within 
that  line.  During  the  first  year  the  apex  beat  is  usually  found  in  the 
fourth  intercostal  space;  from  the  first  to  the  seventh  year,  it  is  found 
with  about  equal  frequency  in  the  fourth  and  the  fifth  spaces;  after  the 
seventh  it  is  usually,  and  after  the  thirteenth  year  it  is  always,  when 
normal,  in  the  fifth  space.  The  position  of  the  apex  beat  may  be  con- 
siderably modified  by  severe  deformities  of  the  chest  resulting  from 
rickets.  Pott's  disease,  or  lateral  curvature  of  the  spine. 

Examination  of  the  Heart. — Inspection. — Bulging  of  the  precordium 
is  a  frequent  and  important  sign  of  cardiac  disease  during  childhood. 
The  cardiac  impulse  is  generally  weaker  than  in  the  adult,  and  often  it  is 
ditlicult  to  locate  the  apex  beat  owing  to  the  thick  layer  of  adipose  tissue 
covering  the  chest. 

Palpation. — This  is  usually  a  much  more  satisfactory  method  than  is 
inspection  for  determining  the  position  of  the  apex  beat.  For  this  pur- 
pose the  child  should  be  in  the  sitting  posture,  with  the  body  inclined 
slightly  forward.  Great  displacement  of  the  apex  beat  is  always  signifi- 
cant, and  should  lead  one  to  suspect  pleuritic  effusion;  lesser  degrees  of 
displacement  to  the  left  indicate  hypertrophy,  especially  of  the  left  ven- 
tricle; epigastric  pulsation  indicates  hypertrophy  of  the  right  ventricle. 


578  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Percussion. — This  may  be  done  either  by  the  finger  or  the  percussion 
hammer.  A  light  blow  should  be  used,  on  account  of  the  thinness  and 
elasticity  of  the  chest  walls.  In  percussing  the  heart,  changes  in  the 
percussion  note  are  generally  better  appreciated  if  one  proceeds  from  the 
lung  toward  the  heart  rather  than  in  the  opposite  direction.  The  outline 
of  the  area  of  "relative"'  or  deep  cardiac  dulness,  especially  in  small 
children,  is  proportionately  larger  than  in  the  adult.  This  may  lead  to 
the  mistaken  opinion  that  the  heart  is  enlarged,  when  it  is  really  of  nor- 
mal size.  The  upper  boundary  of  this  area  is  at  the  second  interspace  or 
the  upper  border  of  the  third  costal  cartilage,  at  the  left  margin  of  the 
sternum;  from  this  point  the  line  of  dulness  extends  in  a  curved  direc- 
tion outward  and  downward,  the  extreme  left  limit  being  at  or  slightly 
beyond  the  mammary  line  at  the  fourth  interspace.  On  the  right  side 
the  line  of  dulness  extends  downward  from  the  second  interspace  in  a 
slightly  curved  direction  along  the  parasternal  line.  The  lower  border 
is  indeterminable  on  account  of  the  liver. 

The  area  of  "absolute"  or  superficial  cardiac  dulness,  or  that  part 
of  the  heart  uncovered  by  the  lung,  resembles  in  shape  the  same  area  in 
the  adult,  but  it  is  relatively  larger. 

Auscultation. — This  is  of  little  value  unless  the  child  is  quiet.  For 
an  accurate  diagnosis  the  stethoscope  is  indispensable,  but  auscultation 
should  always  be  practiced  with  the  naked  ear  as  well.  The  rhythm  and 
rapidity  of  the  child's  heart  action  are  much  more  easily  disturbed  than 
are  the  adult's,  and  such  disturbances  are  consequently  much  less  sig- 
nificant. The  rapidity  of  the  heart  in  infancy  is  ordinarily  so  great  as 
to  make  it  dilficult  to  determine  the  exact  period  in  the  cardiac  cycle  at 
which  a  murmur  occurs.  Normally,  the  loudest  sound  is  the  first  sound 
at  the  apex;  the  weakest  sound  is  the  second  sound  at  the  aortic  orifice. 
The  pulmonary  second  sound  is  regularly  louder  than  the  second  aortic 
up  to  the  fourteenth  year  and  in  some  children  almost  to  adult  life. 

In  consequence  of  the  small  size  and  the  thin  walls  of  the  chest,  all 
sounds,  both  normal  and  pathological,  appear  relatively  louder  than  in 
the  adult,  and  the  area  of  diffusion  is  therefore  much  greater.  Thus  it  is 
a  frequent  occurrence  for  murmurs  to  be  heard  all  over  the  chest  both  in 
front  and  behind. 

Eeduplication  of  the  heart  sounds,  in  consequence  of  the  valves  of 
the  two  sides  not  closing  exactly  together,  is  not  uncommon  in  children, 
and  may  be  due  simply  to  excitement.  During  the  first  four  years  of 
life  nearly  all  the  abnormal  murmurs  heard  are  systolic.  Accidental 
murmurs  are  very  common.  They  may  be  due  to  anemia  and  to  many 
other  conditions;  although  not  so  common  as  in  older  patients,  they  are 
by  no  means  rare  in  infants. 

In  older  children,   especially  when  lying  on  the  left  side,   there  is 


CONGENITAL  ANOMALIES  579 

often  heard  a  sound  in  the  early  part  of  diastole,  the  so-called  "third 
heart  sound."  This  is  only  heard  in  the  region  of  the  apex  and  always 
follows  the  second  sound  by  an  interval  longer  than  occurs  in  true  re- 
duplication. The  sound  has  the  character  of  a  dull,  distant  thud.  It 
is  never  blowing.  The  sound  probably  results  from  the  sudden  tension 
of  the  auriculoventricular  valves  produced  by  the  rapid  entrance  of  blood 
into  the  ventricle.  It  should  be  recognized  that  tbis  sound  is  not  an 
abnormality.    Failure  to  do  so  may  cause  errors  in  diagnosis. 


CHAPTEE    II 

CONGENITAL  ANOMALIES  OF  THE  HEART 

Etiology. — Of  the  causes  of  congenital  cardiac  disease  little  is  defi- 
nitely known.  It  occurs  more  often  in  first-born  children  than  later 
ones;  16  of  50  cases  being  in  first  children  (Still).  It  is  often  associated 
with  other  forms  of  imperfect  development,  notably  of  the  brain,  as 
in  Mongolian  idiocy.  An  attempt  has  been  made  to  connect  cardiac 
malformations  with  syphilis.  A  syphilitic  family  history  is  very  sel- 
dom found;  but  Warthin  has  brought  forward  additional  reason  for 
suspecting  syphilis  since  he  has  found  that  a  positive  Wassermann  test 
is  given  by  some  of  the  children  with  congenital  cardiac  disease,  but  in 
our  experience  this  has  not  been  found  with  sufficient  frequency  to 
establish  a  causal  relation.  There  has  not  been  adduced  any  evidence  to 
show  that  rheumatism  plays  a  part. 

Lesions. — The  congenital  anomalies  of  the  heart  may  be  grouped 
under  three  general  heads : 

1.  Malformations  resulting  from  imperfect  development  of  certain 
parts  of  the  heart,  most  frequently  one  of  the  septa.  Either  the  ven- 
tricular or  the  auricular  septum  may  be  affected,  or  tbat  dividing  the 
pulmonary  artery  from  the  aorta.  Such  failure  in  development  per- 
petuates conditions  which  are  normal  in  the  early  mojiths  of  fetal  life. 
There  may  also  be  atresia  of  any  one  of  the  orifices,  absence  of  one  or 
more  of  the  valvular  leaflets,  or  of  any  one  of  tbe  large  vessels. 

3.  The  results  of  fetal  endocarditis.  The  effects  of  this  condition 
vary  according  to  the  time  of  its  occurrence.  It  is  almost  invariably  of 
the  right  side,  most  frequently  affecting  the  pulmonic  valves.  Valvular 
disease  in  fetal  life  leads  not  only  to  hypertrophy  and  dilatation,  but 
also  interferes  with  the  normal  development  of  the  heart  by  preventing 
the  closure  of  the  auricular  or  ventricular  septum  or  the  ductus  arterio- 
sus, these  being  kept  o|)en  by  way  of  compensation.     It  is  not  clear  how 


580  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

important  a  part  fetal  endocarditis  plays  in  the  production  of  con- 
genital lesions,  certainly  not  so  important  a  one  as  it  was  formerly 
believed. 

3.  Persistence  of  fetal  conditions,  snch  as  the  foramen  ovale  or  duc- 
tus arteriosus.  This  is  usually  by  way  of  compensating  for  some  mal- 
formation the  result  of"  imperfect  development  or  of  fetal  endocarditis. 
Very  rarely  a  fetal  condition  may  persist  when  no  sufficient  reason  for  it 
can  be  found. 

In  the  following  table  are  given  the  lesions  found  iu  two  hundred  and 
forty-two  cases  collected  from  medical  literature : 

Frequency  c[  the  different  lesions  in  2Ji.2  autopsies  upon  cases  of  congen- 
ital cardiac  anomaly 

Defect  in  the  ventricular  septum 149  cases;  the  only  lesion  in  5  cases. 

Defect  in  the  auricular  septum,  or  patent  fora- 
men ovale.... 126  "  "  "  "  "9  " 

Pulmonic  stenosis  or  atresia 108  "  "  "  "  "  6  " 

Patent  ductus  arteriosus 68  "  "  "  "  "  3 '     " 

Abnormalities  in  the  origin  of  the  great  vessels .  45  "  "  "  "  "  0  " 

Pulmonic  insufficiency 17  "  "  "  "  "0  " 

Tricuspid  insufficiency 6  "  "  "  "  "0  " 

Tricuspid  stenosis  or  atresia 3  "  "  "  "  "0  " 

Mitral  insufficiency. 1  "  "  "  "  "0  " 

Mitral  stenosis  or  atresia 6  "  "  "  "  "0  " 

Aortic  insufficiency 1  "  "  "  "  "0  " 

Aortic  stenosis  or  atresia 6  "  "  "  "  "0  " 

Transposition  of  the  heart t 2  "  "  "  "  "0  " 

Ectocardia 1  "  "  «  "  "0  " 

The  most  frequent  associated  lesions 

Pulmonic  stenosis  with  defect  in  the  ventricu- 
lar septum 92  cases,  the  only  lesions  in  20  cases. 

Pulmonic  stenosis,  with  defect  in  the  auricular 

septum .52      "         "        "  "        "     8      " 

Defects  in  both  septa 82      "         "        "  "        "17      " 

Pulmonic  stenosis  with  defects  in  both  septa .  .   36      "        "        "         "        "  21      " 

From  this  tal)le  it  will  be  seen  that,  in  the  great  majority  of  cases, 
several  lesions  are  present,  the  most  frequent  combinations  being  pul- 
monic stenosis  with  defective  ventricular  septum;  pulmonic  stenosis 
with  defective  auricular  sej^tum;  the  three  lesions  associated;  or  the  first 
two  witli  a  patent  ductus  arteriosus.  Stenosis  of  the  isthmus  of  the 
aorta,  although  not  noted  in  this  series,  is  not  a  very  unconnnon  lesion; 
the  obstruction  is  iu  the  arch  of  the  aorta  beyond  the  point  where  the 
large  vessels  are  given  off. 

Defect  in  the  Ventricular  Septum. — This  is  the  most  frequent  lesion 
in  congenital  cardiac  disease,  and  in  half  the  cases  is  associated  with 
pulmonic  stenosis.      The  defect  is   generally  at  tlie  upper  part  of  the 


CONGEXITAL  ANOMALIES 


581 


septum  (Fig.  80).  It  is  usually  from  one-fourth  to  one-half  an  inch 
in  diameter,  but  not  infrequently  there  is  a  large  defect;  or  the  septum 
may  be  entirely  absent,  the  heart  then  consisting  of  but  three  cavities — 
two  auricles  and  one  ventricle.  If  the  auricular  septum  also  is  wanting, 
as  may  be  the  case,  the  heart  has  but  tM^o  cavities.  Frequently  there  are 
also  abnormalities  in  the  origin  of  the  great  vessels.  The  pulmonary 
artery  and  the  aorta  may  be  given  off  from  a  common  ventricle,  or 
the  aorta  may  arise  partly  from  one  ventricle  and  partly  from  the  other. 
If  pulmonic  stenosis  or  atresia  is 
present,  the  opening  in  the  ven- 
tricular septum  is  conservative, 
affording  a  channel  for  the  pas- 
sage of  blood  from  the  right  to  the 
left  side  of  the  heart. 

Patent  Foramen  Ovale,  or  De- 
fect in  the  Auricular  Septum. — 
Although  this  is  one  of  the  most 
common  congenital  malforma- 
tions, it  is  not  one  of  the  most  im- 
portant. It  rarely  occurs  alone, 
but  is  frequently  found  with  pul- 
monic stenosis  or  a  defect  in  the 
ventricular  septum.  Small  oblique 
openings  in  the  auricular  septum 
— usually  at  the  foramen  ovale — 
are  not  infrequently  met  with  in 
autopsies  upon  young  infants,  but 
they  are  of  no  importance.  In 
pathological  conditions  the' open- 
ing is  from  one-fourth  to  one  inch 

in  diameter,  and  there  may  be  more  than  one  opening.    A  defect  in  this 
septum  is  frequently  secondary  to  pulmonic  stenosis. 

Patent  Ductus  Arteriosus. — As  a  solitary  lesion  this  is  rare,  bilt  it  is 
frequently  associated  with  pulmonic  stenosis,  usually  with  a  defect  in  one 
oy  both  septa.  It  is  then  one  of  the  channels  by  which  the  blood  may 
find  its  way  to  the  lungs  when  the  pulmonary  orifice  is  obstructed.  It 
is  not  a  malformation,  but  simply  the  persistence  of  a  fetal  condi- 
tion usually  necessitated  by  other  changes  in  the  heart.  But  the  direc- 
tion of  the  blood  current  is  the  opposite  of  that  which  exists  in  fetal 
life. 

Pulmonic  Stenosis. — -This  is  one  of  the  most  frequent  and  most  im- 
portant lesions.  It  was  formerly  looked  upon  as  being  often  due  to 
fetal  endocarditis,  but  is  now  believed  in  most  cases  to  be  due  to  a  failure 


Fig.  80. — Congenital  Cardiac  Disease. 
The  left  ventricle  is  shown  with  a  defect 
in  the  ventricular  septum,  the  opening 
being  just  beneath  the  aortic  valve. 
(From  a  patient  dying  in  the  Babies' 
Hospital.) 


582  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

of  development  of  the  infiincliljulum  of  the  right  ventricle.  It  is  often 
a  primary  lesion,  and  when  marked  it  is  ahvays  accompanied  by  other 
changes,  most  frequently  by  a  defect  in  one  or  both  septa  or  by  a  patent 
ductus  arteriosus.  This  is  important,  as  being  more  constantly  asso- 
ciated with  cyanosis  than  is  any  other  congenital  lesion.  ^Most  of  the 
children  who  live  beyond  six  or  seven  years  with  cyanosis  have  this 
lesion,  always  accompanied  by  others  of  a  compensatory  character.  The 
amount  of  obstruction  varies  from  a  slight  narrowing  of  the  orifice  to 
complete  atresia.  The  seat  of  obstruction  may  be  at  the  pulmonic  orifice, 
in  the  conus  arteriosus,  or  in  the  pulmonary  artery  just  beyond  the 
valves.  If  there  is  atresia,  the  pulmonary  artery  is  very  small,  and  may 
be  rudimentary. 

Pulmonic  Insufficiency. — This  lesion  is  relatively  rare.  It  is  usually 
the  result  of  fetal  endocarditis,  but  there  may  be  absence  of  the  pid- 
monary  valve.  It  is  most  frequently  associated  with  a  defect  in  the  ven- 
tricular septum. 

Tricuspid,  mitral,  and  aortic  disease  are  very  infrequent  and  usually 
seen  in  cases  with  multiple  defects.  Atresia  or  stenosis  is  much  more 
common  than  insufficiency. 

Abnormalities  in  the  Origin  of  the  Large  Vessels. — These  are  quite 
frequent;  but,  as  will  be  seen  from  the  table,  they  are  always  associated 
with  other  lesions.  Three  forms  are  seen :  (1)  Transposition  of  the  large 
vessels — the  pulmonary  artery  is  given  off  from  the  left,  and  the  aorta 
from  the  right  ventricle.  (2)  Both  arteries  arise  from  a  common 
trunk.  This  is  usually  due  to  an  incomplete  development  of  the  lower 
part  of  the  septum  dividing  the  two  arteries.  Usually  the  pulmonary 
artery  appears  to  be  a  branch  of  the  aorta.  This  condition  is  fre- 
quently associated  with  other  abnormalities,  often  with  so  large  a  defect 
in  the  ventricular  septum  that  there  is  really  but  one  ventricle.  (3)  The 
aorta  has  an  abnormal  origin,  arising  from  the  right  ventricle,  or  partly 
from  both  ventricles.  This  also  is  associated  with  a  large  defect  in  the 
ventricular  septum.  When  described  as  arising  from  both  ventricles,  the 
aorta  is  usually  given  off  directly  above  the  line  of  the  septum. 

An  abnormality  in  the  number  of  valvular  segments  is  quite  fre- 
quent, but  seldom  impairs  the  valve's  function.  In  rare  cases  a  valve  is 
rudimentary,  and  it  may  be  absent,  generally  at  the  pulmonic  or  tri- 
cuspid orifice.  Absence  of  the  right  auricle  and  absence  of  the  pericar- 
dium have  been  recorded ;  also  opening  of  the  pulmonary  veins  into  the 
right  auricle,  and  a  single  pulmonary  artery.  In  one  case  in  the  series 
there  was  ectocardia,  this  being  associated  with  a  congenital  fissure  of 
the  sternum.  We  have  seen  two  very  remarkable  instances  of  congenital 
cardiac  displacement;  the  heart  was  in  both  situated  in  the  abdominal 
cavity.     The  pulsations  could  be  plainly  seen  and  felt  just  above  the 


CONGENITAL  ANOMALIES  583 

umbilicus.  lu  each  case  there  was  a  congenital  defect  of  the  abdominal 
walls  and  also  an  opening  in  the  diaphragm. 

Transposition  of  the  heart,  or  true  dextrocardia,  was  recorded  but 
twice  in  this  series  of  cases.  The  transposition  of  the  heart  alone  is  a 
very  rare  condition.  It  is  not  so  unusual  to  find  transposition  of  all  of 
the  thoracic  and  abdominal  viscera.  In  the  last  two  years  we  have  seen 
three  such  cases. 

Secondary  Lesions. — In  congenital  malformations  the  right  heart  is 
usually  found  hypertrophied,  since  there  are  present  one  or  more  of  the 
fetal  conditions  in  which  the  greater  part  of  the  work  is  thrown  upon 
the  right  ventricle.  Such  hypertrophy  is  in  most  cases  accompanied  by 
some  dilatation.  Changes  in  the  muscular  wall  of  the  left  heart  alone 
are  exceedingly  rare.  In  four  cases  there  was  evidence  of  malignant 
endocarditis  which  was  the  cause  of  death,  all  but  one  of  these  patients 
being  adults. 

Symptoms. — The  symptoms  of  congenital  cardiac  disease  are  usually 
manifested  soon  after  birth.  Of  128  cases  in  which  the  time  of  the  first 
symptoms  was  noted,  they  were  congenital,  or  appeared  during  the 
first  month,  in  85 ;  after  one  month  and  during  the  first  year,  in  18 ; 
from  one  to  sixteen  years,  in  15;  while  in  10  no  symptoms  were  observed 
until  after  puberty.  Congenital  cardiac  disease  is  one  of  the  causes,  but 
not  a  frequent  one,  of  death  during  the  first  days  of  life. 

The  most  striking  objective  symptom  is  cyanosis.  This  is  present 
in  most  of  the  severe  cases;  but,  considering  all  varieties,  cyanosis  is 
more  often  absent  than  present,  and  it  may  be  absent  even  with  serious 
lesions.  It  may  be  slight  and  noticed  only  upon  exertion,  as  upon 
coughing  or  crying,  or  it  may  be  intense  and  constant,  giving  the  skin 
a  dark,  leaden  color,  and  the  mucous  membrane  of  the  moutb  a  rasp- 
berry hue.  The  view  that  cyanosis  depends  upon  an  admixture  of 
arterial  and  venous  blood  is  generally  discredited.  In  the  great  ma- 
jority of  the  cases  at  least,  the  explanation  is  a  deficient  oxygenation  of 
the  blood  in  the  lungs,  owing  to  some  interference  with  the  pulmonary 
circulation.  In  sixty-three  j^er  cent  of  the  cases  with  cyanosis  in  the 
series,  there  was  found  pulmonic  stenosis  or  atresia,  or  a  small  pulmonary 
artery.  Cyanosis  is  of  much  value  in  diagnosis,  as  in  acquired  cardiac 
disease  it  is  rarely  persistent.  The  degree  of  cyanosis  and  its  con- 
stancy are  of  some  importance  in  determining  tbe  gravity  of  the  lesion, 
although  cyanosis  alone  is  not  to  be  depended  upon. 

Another  frequent  symptom  is  the  enlargement  of  the  terminal 
phalanges  known  as  clubbed  or  "drum-stick"  fingers  (Fig.  81)  and  toes. 
This  almost  invariably  accompanies  cyanosis,  and  is  generally  propor- 
tionate to  it.  The  enlargement,  wliich  usually  involves  all  the  phalanges, 
is  probably  due  to  venous  obstruction.     Occasionally  tbere  are  seen  dysp- 


584  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Ilea,  edema  of  the  face  or  lower  extremities,  dropsy  of  the  serous  cavities, 
and  hemorrhages,  particularly  hemoptysis  and  epistaxis. 

There  is  generally  marked  dyspnea  on  exertion  in  the  cases  in  which 
cyanosis  is  present;  but  in  most  of  those  without  cyanosis  there  is  no 
dyspnea,  and,  in  fact,  no  objective  or  siibjective  symptoms,  even  though 
the  murmur  may  be  very  loud.  The  majority  of  the  cyanotic  children 
are  undersized  and  develop  slowly;  in  them  the  problem  of  nutrition  is  a 
difficult  one. 

In  cases  accompanied  by  cyanosis,  or  with  obstruction  to  the  pulmo- 


FiG.  81. — Clubbing  Of  the  Fingers  in  Congenital  Heabt  Disease.     (From  a  boy  five 

years  old.) 

nary  circulation,  a  polycythemia  is  present.  The  increase  in  the  number 
of  red  cells  is  generally  proportionate  to  the. cyanosis;  the  average  of  fif- 
teen cases  studied  in  the  Yanderbilt  Clinic  by  Wile  was  7,495,000;  the 
highest  Avas  12,480,000.  The  hemoglobin  is  usually  correspondingly 
increased.  In  the  series  mentioned  the  average  was  107  per  cent,  the 
highest  being  130.  The  number  of  white  cells  is  changed  very  slightly, 
if  at  all ;  the  average  in  these  cases  was  10,200,  which  disproves  the  theory 
of  blood  concentration.  The  best  explanation  of  the  polycythemia  seems 
to  be  that  it  is  compensatory,  and  that  the  blood  hypertrophies  like 
other  tissues.  The  blood-forming  organs  are  stimulated  to  greater 
activity  by  the  demands  of  the  tissues  for  oxygen.  The  quantity  of  blood 
remains  the  same,  but  the  number  of  red  cells  and  the  hemoglobin,  and 


CONGENITAL  ANOMALIES  585 

consequently  the  oxygen-carr3dng  power,  are  very  greatly  increased.  This 
in  part  compensates  for  the  smaller  amount  of  blood  that  can  traverse 
the  lungs  and  there  become  oxygenated. 

Diagnosis. — The  most  important  diagnostic  features  are  cyanosis,  the 
presence  of  a  loud  murmur,  and  signs  of  enlargement  of  the  right  heart. 

Murmurs  are  present  in  fully  nine-tenths  of  the  cases.  They  are 
almost  always  systolic  in  time,  are  heard  loudest  to  the  left  of  the 
sternum,  usually  at  the  base  or  over  the  body  of  the  heart,  rarely  at  the 
apex.  They  are  in  most  cases  widely  diffused,  often  being  audible  all 
over  the  chest.  The  point  of  maximum  intensity  is  important  for  diag- 
•  nosis.  In  the  great  majority  of  cases  only  a  single  murmur  is  hearcl. 
A  systolic  murmur  is  usually  due  to  pulmonic  stenosis,  deficient  ventricu- 
lar septum  or  aortic  stenosis,  very  rarely  to  mitral  or  tricuspid  regurgita- 
tion. Since  these  conditions  are  very  often  associated,  it  may  be  difficult 
to  tell  upon  which  one  the  murmur  depends. 

A  patent  ductus  arteriosus  usually  gives  a  prolonged,  continuous 
murmur  with  systolic  intensification,  which  is  loudest  in  the  second  or 
third  left  interspace.  From  the  presence  of  a  continuous  murmur  in  a 
child,  a  diagnosis  of  patent  ductus  arteriosus  can  be  made.  The  asso- 
ciated lesion  is  almost  always  pulmonary  stenosis.  In  a  young  child,  a 
loud  murmur  at  the  base  of  the  heart  with  cyanosis  almost  always  means 
congenital  disease.  A  thrill  is  often  present  but  it  is  not  important  for 
a  diagnosis. 

Enlargement  of  the  right  heart,  chiefly  from  ventricular  hypertrophy, 
is  present  in  most  of  the  car-es. 

A  diagnosis  of  the  precise  nature  of  the  malformation  is  very  difficult, 
and  in  the  great  majority  of  cases  only  a  probable  diagnosis  is  possible. 
Nearly  all  the  cases  are  complex,  and  the  variety  of  combinations  is  very 
great.  A  study  of  the  histories  and  autopsies  of  the  cases  in  this  series 
reveals  many  apparently  contradictory  facts.  Loud  murmurs  are  some- 
times heard  which  are  difficult  to  explain  by  the  lesions,  and  murmurs 
may  be  absent  when  there  is  every  reason  from  the  post-mortem  findings 
for  expecting  their  presence.  With  reference  to  the  other  conditions, 
we  can  not  do  better  than  give  the  more  frequent  clinical  symptoms  with 
the  results  of  the  autopsies  in  the  series  of  cases  which  have  been  pre- 
sented. 

A  Systolic  Murmur  at  the  Base  ivith  Cyanosis. — This  was  the  most 
common  combination  met  with,  and  was  present  in  about  one-third  of 
the  entire  number.  In  over  eighty  per  cent  of  the  cases  with  these 
symptoms,  pulmonic  stenosis  was  found.  The  remainder  were  compli- 
cated cases  of  quite  a  wide  variety.  Pulmonic  stenosis  was  usually 
associated  with  a  defect  in  one  of  the  cardiac  septa,  or  a  patent  ductus 
arteriosus. 


586  -  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

A  Systolic  Murmur  without  Cyanosis. — In  this  series  of  autopsies 
this  was  not  a  frequent  combination,  being  noted  but  six  times.  It  is 
usually  dependent  upon  a  defect  in  the  ventricular  septum  without  pul- 
monic stenosis.  Clinically,  however,  this  is  more  often  seen,  in  fact  it 
is  one  of  the  most  common  types.  The  murmur  is  generally  loudest 
at  the  left  margin  of  the  sternum  at  the  third  space.  There  is  a  striking 
absence  of  all  other  symptoms.  We  have  watched  a  number  of  such  pa- 
tients grow  to  maturity  and  go  through  serious  attacks  of  illness  without 
showing  any  symptoms  referable  to  the  heart. 

A  Systolic  Murmur  at  the  Apex  vnth  Cyanosis. — Of  the  six  cases  with 
this  combination,  all  were  examples  of  complex  malformation,  the  most 
frequent  lesions  being  a  defect  in  the  auricular  septum,  transposition  of 
the  great  vessels,  and  patent  ductus  arteriosus. 

Cyanosis  without  murmurs  was  noted  fourteen  times.  It  usually  in- 
dicates either  pulmonic  atresia  or  the  transposition  or  irregular  origin 
of  the  great  vessels,  but  is  sometimes  seen  when  lesions  such  as  usually 
give  murmurs  are  found  at  autopsy. 

Diastolic  murmurs  were  heard  in  but  two  cases,  and  depended  upon 
pulmonic  insufficiency.  Diastolic  murmurs  are  also  heard  when  an 
acute  endocarditis  causing  aortic  or  pulmonary  insufficiency  supervenes 
upon  a  congenital  lesion.  We  have  seen  one  such  case  and  several  have 
been  reported. 

Ahsence  of  both  cyanosis  and  murmurs  was  recorded  in  five  cases. 
The  lesions  found  were :  atresia  of  the  aorta,  both  arteries  arising  from 
the  right  ventricle,  or  defective  septa. 

The  only  cases,  therefore,  in  which  a  fairly  certain  anatomical  diag- 
nosis can  be  made  are  those  of  pulmonic  stenosis,  deficient  ventricular 
septum,  and  patent  ductus  arteriosus. 

Diagnosis  of  Congenital  from  Acquired  Disease. — Congenital  dis- 
ease may  be  suspected  if  the  patient  is  under  two  years  of  age ;  if  there 
is  no  history  of  previous  rheumatism;  if  the  murmur  is  atypical  in  its 
location,  character,  or  transmission;  if  there  is  a  very  loud  murmur  at 
the  base  or  over  the  body  of  the  heart,  and  if  there  is  evidence  of  enlarge- 
ment of  the  right  heart.  If  cyanosis  and  clubbing  of  the  fingers  are 
present  the  diagnosis  is  almost  certain. 

Especially  difficult  are  the  cases  without  cyanosis  seen  in  older  chil- 
dren. But  absence  of  hypertrophy  of  the  left  ventricle,  continued  absence 
of  subjective  symptoms,  even  with  a  very  loud  murmur,  and  a  lesion 
which  does  not  increase — all  point  strongly  to  a  congenital  malforma- 
tion. 

Diagnosis  of  Congenital  from  Accidental  Murmurs. — This  is  often  a 
more  difficult  matter  than  to  decide  between  congenital  and  acquired  dis- 
ease.    From  a  murmur  alone  one  s'hould  be  verv  cautious  in  makiuo-  a 


CONGENITAL  ANOMALIES  587 

diagnosis  of  cardiac  malformation  in  a  very  anemic  infant.  Anemic 
murmurs  are  systolic,  usually  basic,  unaccompanied  by  enlargement  of  the 
heart,  usually  heard  in  the  carotids,  often  in  the  subclavian  arteries,  but 
are  seldom  so  loud  as  those  due  to  malformations.  In  some  cases  it 
may  be  necessary  to  watch  the  progress  of  the  case  before  deciding  the 
question. 

It  is  not  uncommon  in  children  to  find  at  about  the  level  of  the  nipple 
at  the  left  border  of  the  sternum  a  soft  systolic  murmur  best  heard 
in  the  recumbent  position,  which,  as  it  usually  disappears,  must  be 
considered  functional.  It  may  be  mistaken  for  a  congenital  murmur, 
but  is  not  so  loud. 

Prognosis. — Of  325  cases,  60  per  cent  were  fatal  before  the  end  of 
the  fifth  year,  and  nearly  one-half  of  these  during  the  first  two  months ; 
while  sixteen  per  cent  of  the  patients  lived  over  sixteen  years,  and  eight 
per  cent  over  thirty  years.  The  prognosis  in  cases  without  cyanosis  is 
good;  in  many  children  the  lesion  has  apparently  little  effect  on  the 
health  or  development.  The  prognosis  is  much  worse  in  cases  with 
cyanosis,  and  generally  it  is  bad  in  proportion  to  the  degree  of  cyanosis. 
The  loudness  of  the  murmur  has  no  prognostic  importance. 

In  the  cases  fatal  soon  after  bitth  the  usual  lesions  are  large  defects 
in  the  septa,  transposition  of  the  great  vessels,  or  pulmonic  atresia.  In 
five  of  twenty-three  cases  dying  thus  early,  the  heart  had  but  two  cavities. 
Lesions  which  are  compatible  with  the  longest  life  are  minor  septum 
defects,  and  pulmonic  stenosis  which  can  be  compensated  for  by  patency 
of  the  ductus  arteriosus  and  in  other  ways.  Many  exceptional  instances 
are  recorded  in  which  patients  have  lived  a  long  time  in  spite  of  ex- 
treme deformities.  One  child  with  transposition  of  the  pulmonary 
artery  and  aorta  lived  two  and  a  half  years.  Tiedemann's  patient  lived 
eleven  years  with  a  heart  consisting  of  three  cavities — two  auricles  and 
one  ventricle — and  with  constant  cyanosis.  In  three  cases  reported  by 
Eokitansky,  the.  patients  lived  over  forty  years  with  rudimentary  auric- 
ular septa ;  cyanosis  is  not  mentioned  as  being  i:)resent.  Gelpke's  patient 
had  cyanosis,  and  lived  twenty-seven  years  with  rudimentary  auricular 
and  ventricular  septa,  and  with  no  tricuspid  opening.  Patients  with 
serious  congenital  cardiac  lesions  are  especially  susceptible  to  pulmonary 
disease  of  all  kinds  and  occasionally  develop  malignant  endocarditis. 
Almost  any  acute  illness  may  prove  fatal. 

Treatment. — These  patients  are  prone  to  develop  at  times  attacks 
resembling  angina  pectoris,  which  are  best  relieved  by  nitroglycerin  or 
by  the  use  of  morphin  hypodermically.  No  treatment  is  of  the  slightest 
avail  in  diminishing  the  amount  of  deformity  or  promoting  the  closure 
of  any  of  the  abnormal  openings.  x411  cases  are  to  be  treated  sympto- 
matically. 


588  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

CHAPTEE    III 
PERICARDITIS 

Inflammation  of  the  pericardium  is  uncommon  in  infancy  and 
early  childhood,  only  two  cases  being  seen  in  726  consecutive  autopsies 
at  the  New  York  Infant  Asylum.  But  in  later  childhood  pericarditis 
is  more  frequent  and  more  serious  than  the  same  disease  in  adults. 

Pericarditis  is  almost  invariably  a  secondary  disease,  following  (1) 
empyema  or  pleuropneumonia;  (2)  acute  rheumatism;  (3)  acute  in- 
fectious diseases,  especially  scarlet  fever;  (4)  pyemia;  (5)  tuberculosis; 
(6)  local  conditions.  The  relative  importance  of  these  causes  differs 
with  the  age  of  the  child.  In  infancy  and  early  childhood  nearly  all  the 
cases  complicate  disease  of  the  lung  or  pleura,  more  frequently  of  the 
left  side.  After  the  fourth  year  rheumatism  takes  the  first  place  as  an 
etiological  factor.  Pericarditis  is  then  generally  associated  with  endo- 
carditis, and  may  precede  or  follow  the  articular  manifestations  of  rheu- 
matism. Following  scarlet  fever,  pericarditis  often  occurs  in  connection 
with  nephritis  or  multiple  joint  inflammations.  In  typhoid  fever  also 
it  is  usually  associated  with  pneumonia  or  joint  lesions.  Pyemia  may 
be  a  cause  in  the  newly  born,  or  it  may  occur  in  connection  with  disease 
of  the  bones  or  joints  in  older  children;  in  both  it  is  usually  associated 
with  similar  lesions  of  other  serous  membranes.  Tuberculous  pericarditis 
is  more  frequent  after  the  third  year,  and  is  generally  secondary  to  pul- 
monary tuberculosis.  Among  the  local  causes  may  be  mentioned  trau- 
matism, ulceration  of  a  foreign  body  from  the  esophagus  into  the  peri- 
cardium, disease  of  the  sternum,  ribs,  or  vertebrae,  and  abscesses  resulting 
from  cheesy  bronchial  lymph  nodes. 

Lesions. — Pericardial  transudations,  or  an  increase  in  the  normal 
pericardial  fluid,  are  met  Avith  in  many  conditions  in  which  there  is  a 
very  marked  degree  of  anemia,  general  dropsy,  or  a  weak  heart,  partic- 
ularly of  the  right  side.  Generally  from  one  to  two  ounces  of  clear 
serum  are  found  in  the  pericardial  sac. 

Pneumococcus  pericarditis  is  ahvays  acute  and  closely  resembles  in 
its  lesions  the  inflammation  of  the  pleura  due  to  the  same  cause.  In 
the  milder  cases  there  is  seen  only  a  fibrinous  exudate.  In  the  more 
common  and  more  severe  forms  the  visceral  and  parietal  pericardium  is 
covered  with  a  thick  coating  of  fibrin  and  pus  (compare  pleuropneu- 
monia), or  more  pus  cells  and  serum  may  be  poured  out  and  the  sac 
contain  fluid  pus.  The  amount  is  usually  small,  one-half  to  one  ounce, 
but  it  may  be  as  much  as  a  pint.  AVhen  the  inflammation  is  excited  by 
other  pyogenic  organisms,  the  staphylococcus  or  the  streptococcus,  the 
lesions  are  similar  to  those  just  described. 


PERICARDITIS  589 

In  rheumatic  pericarditis  the  inflammation  may  be  a  plastic  one  with 
a  fibrino-cellnlar  exudate  (dry  pericarditis)  or  sero-fibrinous  (pericar- 
ditis with  effusion).  The  inflammation  generally  begins  at  the  base  of 
the  heart  and  affects  both  the  visceral  and  parietal  layers.  The  quantity 
of  fluid  present  is  usually  small,  not  exceeding  two  or  three  ounces;  ex- 
ceptionally as  much  as  a  pint  may  be  present.  It  may  be  clear  or 
slightly  turbid.  More  important  than  the  pericarditis  are  the  associated 
changes  in  the  heart  muscle.  These  are  present  in  every  severe  case. 
To  the  myocarditis  and  consequent  dilatation  the  most  serious  symptoms 
of  pericarditis  are  due. 

Purulent  pericarditis  may  be  set  up  by  a  foreign  body  ulcerating  into 
the  sac,  by  the  rupture  of  a  mediastinal  abscess,  or  by  general  pyemia. 
In  these  circumstances  the  process  may  be  purulent  from  the  outset. 
Any  of  the  pyogenic  bacteria  may  be  found. 

External  or  mediastinal  pericarditis  is  always  associated  with  medi- 
astinal pleurisy,  and  results  in  more  or  less  extensive  adhesions  of  the 
pericardial  and  pleural  surfaces,  with  an  increase  in  the  connective  tissue 
of  the  mediastinum.  This  is  often  a  tuberculous  process.  When  severe., 
it  may  cause  compression  of  the  large  blood-vessels,  but  seldom  in  any 
other  way  produces  symptoms.  With,  this  form  there  is  usually  inflam- 
mation of  the  internal  layer  of  the  pericardium  as  well.  Only  inflamma- 
tion of  the  internal  layer  is  ordinarily  considered  as  pericarditis,  the 
other  form  being  preferably  classed  as  mediastinitis. 

Pericarditis  with  an  efl^usion  of  blood  is  very  rare  in  children.  It  may 
occur  from  the  rupture  of  organized  adhesions  or  in  certain  blood  states 
such  as  purpura,  and  very  rarely  in  tuberculosis. 

With  acute  tuberculosis  there  is  usually  only  a  dejDosit  of  miliary 
tubercles,  or  there  may  be  a  small  serous  or  sero-sanguinolent  effusion. 
In  chronic  cases  there  may  be  a  tuberculous  inflammation  with  the  for- 
mation of  caseous  nodules,  new  connective  tissue,  and  extensive  adhesions. 
This  generally  occurs  in  connection  with  pulmonary  tuberculosis — some- 
times with  tuberculous  peritonitis. 

In  any  form  of  pericarditis  complete  recovery,  so  far  as  pathological 
conditions  are  concerned,  is  rare — if,  indeed,  it  ever  occurs.  After  a 
rheumatic  pericarditis  adhesions  remain,  which  may  be  slight,  but  are 
often  complete,  causing  entire  obliteration  of  the  pericardial  sac.  Such 
adhesions  are  followed  by  secondary  changes.  The  growth  and  devel- 
opment of  the  heart  are  interfered  with,  and  there  may  be  sufficient 
pressure  upon  the  coronary  vessels  to  lead  to  degeneration  of  the  mus- 
cular walls  and  chronic  dilatation  of  the  heart. 

Symptoms. — A  pericardial  transudation,  or  dropsy  of  the  pericar- 
dium, is  very  rarely  large  enough  to  make  a  diagnosis  possible. 

External  pericarditis  is  seldom  recognized  during  life,  there  being  no 


590  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

symptoms  except  those  of  the  pleurisy  with  which  it  is  associated.  Occa- 
sionally there  may  be  heard,  particularly  if  the  inflammation  is  anterior, 
a  pleuritic  friction  sound  which  is  increased  with  the  systole  of  the 
heart.  The  pulse  may  be  weak  during  inspiration,  and  there  may  be  an 
increased  area  of  cardiac  dulness.  If  the  inflammation  is  chiefly  poste- 
rior, it  causes  only  the  symptoms  of  mediastiuitis,  which  is  recognized 
principally  by  its  pressure  effects  upon  the  great  vessels.  It  may  produce 
edema  of  the  face  or  of  the  lower  extremities,  ascites,  enlargement  of  ihe 
liver  and  spleen,  but  rarely  albuminuria.  It  is  usually  progressive,  .and 
lasts  from  a  few  months  to  two  or  three  years,  according  to  its  cause. 

Pericarditis  in  infancy  is  usually  overlooked,  not  only  on  account  of 
its  rarity,  but  also  from  the  obscurity  of  its  symptoms.  When  pericarditis 
develops  at  the  height  of  an  attack  of  pneumonia,  as  it  usually  does, 
there  may  be  no  new  symptoms,  or  at  most  only  increased  prostration 
with  perhaps  a  more  rapid  or  slightly  irregular  pulse.  On  auscultation, 
if  practiced  early,  one  may  hear  pericardial  friction  sounds ;  but  these  are 
masked  by  the  pulmonary  signs  and  in  infants  seldom  made  out.  The 
most  striking  sign  is  that  the  cardiac  sounds  formerly  distinct  are  now 
feeble  and  distant,  at  times  almost  inaudible.  Later  there  may  be  in- 
creased dulness  from  pericardial  effusion,  or  from  dilatation.  The  phy- 
sician should  be  on  the  watch  for  it  in  infants  with  pleuropneumonia, 
especially  of  the  left  side. 

Eheumatic  pericarditis  affecting  as  it  generally  does  older  children 
is  easier  of  recognition.  Localized  pain  and  tenderness  are  usually  pres- 
ent and  also  a  certain  amount  of  embarrassment  of  the  heart's  action, 
manifested  by  precordial  distress,  palpitation,  or  a  tumultuous  heart 
action  with  a  rapid  and  at  times  an  irregular  pulse.  There  is  often  vom- 
iting, dyspnea,  and  a  teasing,  dry  cough;  there  may  be  orthopnea  and 
some  cyanosis.     Sometimes  there  is  delirium. 

The  earliest  physical  sign  of  ]3ericarditis  is  a  friction  sound  which 
can  generally  be  heard  all  over  the  precordium,  though  sometimes  only 
over  a  small  area  at  the  base.  The  sound  is  usually  a  double,  to-and-fro 
sound,  synchronous  with  the  movement  of  the  heart.  In  character,  the 
sound  is  rough,  scratching  or  grating,  not  at  all  blowing  in  character, 
and,  while  it  may  be  heard  widely  over  the  heart,  is  not  transmitted. 
With  the  accumulation  of  the  fluid,  the  friction  sound  may  only  be 
heard  over  a  restricted  area,  Init  almost  always  persists  at  the  base  even 
though  fluid  may  be  present  in  large  amount.  It  differs  thus  radically 
from  the  friction  sound  in  pleurisy  with  effusion.  Very  early  there 
is  an  increase  in  cardiac  dulness  which  is  often  considerable.  This 
may  be  due  to  effusion  or  to  cardiac  dilatation,  which  is  apt  to  occur 
in  all  severe  cases  of  pericarditis.  With  early  and  rapidly  developing 
dulness  it  is  safe  to  assume  that  some  dilatation  is  present.     The  dulness 


PEEICARDITIS 


591 


can  be  made  out  both  to  the  left  and  to  the  right  of  the  heart.  On  the 
right  side  it  is  usually  first  noted  in  the  fifth  right  intercostal  space 
with  an  obliteration  of  the  normal  acute  cardiohepatic  angle,  an  obtuse 
angle  resulting.  The  dulness  usually  does  not  extend  more  than  an  inch 
or  two  beyond  the  right  border  of  the  sternum  and  a  similar  distance 
beyond  the  left  mammary  line,  but  with  very  extensive  effusion  there 
may  be  dulness  to  the  right  of  the  right  mammary  line,  and  as  far  as  the 
left  anterior  axillary  line.     (Figs.  82,  83.) 

The  area  of  dulness  with  small  effusions  is  triangular  or  pear-shaped 
■with  the  base  below.    With  large  effusions  it  is  almost  circular,  in  which 


Fig.  82. — Pericarditis  with  Effusion. 
Anterior  view,  showing  moderate  dis- 
tention of  the  pericardium,  especially 
to  the  left  of  the  middle  line;  right 
tjorder  at  A.     Boy  eight  years  old. 


Fig.  83. — Pericarditis    with    Effusion. 
Same  patient   as   Fig.   82,   but   taken 
four  days  later.     Great  distention  of 
the  pericardium;    right   border  at  B.- 
Complete  recovery  by  absorption. 


case  the  cardiohepatic  angle  again  becomes  acute.  There  also  may  be 
dulness  to  tlie  left  of  the  vertebral  column  behind.  When  there  is 
considerable  effusion,  the  apex  beat  is  feeble  and  may  be  displaced 
upAvard.  It  may  be  impossible  to  locate  it.  The  cardiac  sounds  are 
diminished  in  intensity  and  may  be  almost  inaudible.  Of  assistance  in 
diagnosis  is  sometimes  the  disproportion  between  the  cardiac  sounds  and 
the  force  of  the  pulse — the  latter  may  be  nearly  normal  when  the  cardiac 
sounds  can  barely  be  heard.  As  the  result  of  pressure  upon  the  lung  from 
large  accumulations  of  fluid,  bronchial  breathing  may  be  heard  poste- 
riorly, at  and  inside  the  spine  of  the  scapula. 

In  cases  terminating  fatally  the  progress  of  the  disease  is  quite  rapid, 
the  entire  duration  being  seldom  longer  than  three  or  four  weeks,  and 
it  may  be  much  less.  Pneumonia  often  develops  toward  the  close.  When 
ending  in  recovery  improvement  is  very  slow  and  it  may  be  two  or  three 
months  before  the  patient  is  out  of  bed,  and  a  much  longer  time  before 
even  a  moderate  degree  of  health  is  established. 

Prognosis.— Acute  pericarditis  due  to  the  pneumoeoccus  in  infancy 


592  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

almost  invariably  ends  fatally  and  in  older  children  this  is  the  usual 
termination.  Occasionally  at  the  later  age  resolution  may  take  place 
before  pus  forms,  or  the  pyopericardium  which  ensues  is  successfully 
opened  and  drained.  Purulent  pericarditis  from  other  causes  is  usually 
fatal.  In  rheumatic  pericarditis  the  outlook  for  life  is  better,  but  this 
with  its  associated  myocarditis  is  without  doubt  the  gravest  manifesta- 
tion of  rheumatism  in  early  life.  Xo  complication  is  more  to  be  dreaded, 
both  on  account  of  immediate  and  remote  dangers.  Of  forty-eight  cases 
of  acute  pericarditis  reported  by  Still  in  which  this  supervened  during 
endocarditis,  forty  proved  fatal  in  the  course  of  a  few  weeks.  In  patients 
who  do  not  die  from  the  disease  the  remote  consequences  by  reason  of 
adhesions  and  subsequent  dilatation  are  very  serious. 

Diagnosis. — ^Pericarditis  is  recognized  by  knowing  when  to  look  for 
it — in  infants  with  pneumonia,  in  older  children  with  rheumatism.  The 
difficulties  of  diagnosis  of  dry  pericarditis  are  very  much  greater  in  young 
children  owing  to  the  very  rapid  action  of  the  heart.  Dry  pericarditis 
is  recognized  by  the  friction  sounds,  which  are  best  heard  over  the  base 
and  are  to  be  differentiated  from  endocardial  murmurs.  Pericarditis 
with  effusion  is  to  be  differentiated  from  dilatation  of  the  heart  and 
from  pleuritic  effusion.  From  dilatation,  the  diagnosis  is  ver}^  difficult  in 
childhood,  but  the  recognition  of  small  effusions  is  not  essential,  since  the 
important  condition  is  the  accompanying  dilatation.  Large  effusions  may 
be  mistaken  for  a  sacculated  empyema  of  the  left  side;  in  the  latter, 
however,  the  heart  is  generally  crowded  to  the  right.  When  empyema  and 
pericarditis  coexist,  it  may  be  impossible  to  recognize  the  condition. 
The  diagnosis  between  serous  and  pnrulent  effusions  can  be  made  only 
by  aspiration. 

Treatment.- — In  an  attack  of  acute  pericarditis  the  patient  should  be 
kept  in  bed,  absolutely  quiet,  and  an  ice-bag  used  over  the  heart.  A 
layer  of  thin  flannel  should  be  placed  beneath  the  bag.  During  the 
acute  stage  it  should  be  applied  constantly  with  perhaps  a  few  hours' 
omission  during  the  night.  To  be  effectiye  much  attention  to  detail  is 
necessary.  Some  children  will  not  tolerate  ice  and  for  them  dry  heat 
may  be  substituted.  It  often  mitigates  the  pain.  Counter-irritation  by 
mustard  from  time  to  time  is  useful,  but  blisters  should  not  be  employed 
in  children.  Leeching  is  much  used  in  England,  not  so  much  in  this 
country  as  its  merits  warrant.  Four  or  five  leeches  are  applied  over 
the  sternum  or  liver.  The  especial  indications  for  the  use  of  leeches 
are  cyanosis,  marked  dyspnea,  and  dilatation  as  shown  by  increase  in 
the  cardiac  dulness.  A  rapid  increase  in  dulness  is  to  be  regarded  as 
mainly  due  to  dilatation  rather  than  effusion.  Opium  is,  in  our  opinion, 
of  more  value  than  any  other  drug.  It  has  a  steadying  influence  upon  the 
excited  heart,  it  relieves  pain  and  also  quiets  the  distressing- cough.    Tlie 


CHRONIC  PEFdCARDITIS  WITH  ADHESIONS  593 

form  of  administration  is  immaterial.  The  patient  should  be  kept 
moderately  under  its  influence  throughout  the  active  stage  of  the  attack. 
Digitalis  is  sometimes  useful,  but  must  be  used  with  caution.  Alcohol 
is  not  indicated.  Strychnin  and  caffein  may  be  used  when  symptoms  of 
heart  failure  are  present ;  but  very  little  is  to  be  expected  from  any  drug. 
For  the  concurrent  rheumatism  anti-rheumatic  remedies  should  usually 
be  continued.  Serous  efi'usions  usually  subside  under  general  treatment. 
With  very  large  serous  effusions  aspiration  may  relieve  distressing  symp- 
toms, after  which  the  rest  of  the  fltiid  may  undergo  absorption.  If  the 
exploring  needle  shows  the  fluid  to  be  purulent,  incisi(Hi  and  drainage 
should  be  practiced  as  in  empyema.  The  results  of  aspiration  for  pyo- 
pericardium  are  exceedingly  unfavorable.  Of  eighteen  cases  collected  ))y 
Keating,  only  four-  recovered.  In  puncturing  the  pericardium  the  point 
usually  selected  is  a  little  to  the  left  of  the  border  of  the  stermmi  in  the 
fifth  intercostal  space,  the  needle  being  directed  upward  and  outward.  In 
eases  which  do  not  end  fatally  a  prolonged  period  of  rest  in  bed  is  impera- 
tive on  account  of  the  dilatation. 


CHRONIC   PERICARDITIS   WITH   ADHESIONS 

This  is  not  a  very  uncommon  condition.  It  is  usually  general,  but 
may  be  localized.  The  youngest  case  which  has  come  under  our  observa- 
tion was  in  a  child  sixteen  months  old,  who  died  from  acute  broncho- 
pneumonia. The  adhesions  were  old  and  general,  the  pericardial  sac 
being  completely  obliterated.  Chronic  adhesive  pericarditis  may  follow 
single  or  repeated  attacks  of  acute  rheumatic  pericarditis ;  it  may  be 
tuberculous.  The  pericardium  may  become  very  greatly  thickened  and  its 
cavity  obliterated;  it  may  be  adherent  externally  to  the  pleura,  dia- 
phragm, and  chest  Avail.  Other  changes  are  usually  present  in  the  heart. 
It  is  often  the  seat  of  chronic  myocarditis;  the  cavities  are  usually  greatly 
dilated,  and  the  heart  Avails  much  hypertrophied.  Valvular  lesions  may 
be  present. 

Partial  adhesions  cause  no  symptoms  by  Avhich  they  can  be  recognized, 
and  even  general  adhesions  sufficient  to  obliterate  the  pericardial  sac 
may  be  found  at  autopsy  Avhen  not  suspected  during  life.  This  is  one  of 
the  conditions  in  which,  after  it  has  led  to  considerable  dilatation  of  the 
heart,  sudden  death  sometimes  occurs.  Usually  there  is  pallor,  slight 
cyanosis,  localized  edema  of  the  chest  .and  abdominal  walls,  and  dyspnea 
upon  slight  exertion.  The  liver  and  spleen' are  often  enlarged  and  there 
may  be  ascites.     These  symptoms  often  lead  to  errors  in  diagnosis. 

The  heart  is  almost  invariably  much  enlarged,  chiefly  from  dilatation. 


594 


DISEASES  OF  THE  CTRCULATORY  SYSTEM 


On  iuspection,  there  may  be  bulging  of  the  chest  Avail,  with  a  diffused 
and  often  feeble  or  absent  apex  beat.  The  characteristic  signs  are  a 
systolic  retraction  of  the  chest  at  or  near  the  apex  of  the  heart,  some- 
times at  the  tip  of  the  sternum.  This  is  due  to  the  external  pericardial 
adhesions,  and  is  often  better  appreciated  by  palpation  than  by  inspec- 
tion. It  is  followed  by  a  rapid  rebound,  associated  with  diastolic  collapse 
of  the  jugular  veins.  A  pulsus  paradoxicus  may  also  be  present.  Percus- 
sion shows  an  increase  in  the  cardiac  dulness  in  all  directions.  The 
position  of  the  apex  and  the  percussion  outline  of  the  heart  do  not 
change  with  the  posture  of  the  patient,  and  the  cardiac  dulness  is  but 
little  affected  by  full  inspiration.  A  systolic  murmur  is"  often  present. 
The  diagnosis  of  adherent  pericardium  always  presents  difficulties,  but 
it  can  be  made  with  tolerable  certainty  in  a  considerable  proportion  of 
cases.  On  account  of  the  enlargement  of  the  heart  and  the  frequency  of 
murmurs,  it  is  usuall}''  mistaken  for  valvular  disease.  The  prognosis  is 
very  bad.  The  lesion  is  a  permanent  one,  and  tends  to  increase.  The 
treatment  is  symptomatic. 


CHAPTER   lY 


ENDOCARDITIS  AND   VALVULAR   DISEASE   OF   THE  HEART 

ExDOCAEDiTis  may  occur  even  in  fetal  life.  At  this  period  it  usu- 
ally affects  the  right  side  of  the  heart,  and  is  one  of  the  important  causes 
of  congenital  malformations.  In  infancy,  acute  endocarditis  is  exceed- 
ingly rare,  but  a  single  instance  being  found  in  over  two  thousand  autop- 
sies upon  children  under  three  years  of  age  of  which  we  have  records. 
From  the  third  to  the  fifth  year  it  is  less  rare,  and  after  five  years  is 
quite  common. 

The  following  table  gives  the  age  and  sex  in  a  series  of  cases  of 
valvular  disease: 


Age. 

I 

jeai. 

yfHTE. 

jearB. 

4 
years. 

yeis. 

0 
years. 

years. 

jears. 

yea:,. 

in 

n 

].! 

,4 
years. 

Totals. 

Males           

1 
1 

2 
3 

2 
5 

4 

7 

6 
9 

4 
10 

9 
3 

8 
11 

6 
12 

5 

14 

7 
4 

6 
2 

1 
3 

55  or  38% 

Females 

90,  "62% 

Total 

2 

5 

7 

11 

15 

14 

12 

19 

18 

19 

11 

8 

4 

145 

The  proportion  as  to  sex  is  very  nearly  the  same  as  in  our  cases  of 
rheumatism.  Sturges,  in  100  cases  of  chronic  endocarditis,  gives  fifty- 
six  per  cent  females  and  forty-four  per  cent  males. 


ENDOCARDITIS  595 

Endocarditis  is  usually  spoken  of  as  secondary  to  rheumatism;  it  is 
rather  to  be  regarded  as  a  manifestation,  often  the  first,  of  that  disease. 
Of  117  cases  in  our  series,  ninety-three,  or  eighty  per  cent,  gave  a 
history  of  previous  rheumatism.  Of  the  31  cases  which  at  the  first 
examination  gave  no  history  of  rheumatism,  8  subsequently  developed 
articular  symptoms,  and  2  chorea;  so  that  nearly  ninety  per  cent  of  this 
series  of  cases  presented  conclusive  evidence  of  a  rheumatic  diathesis. 
Thirty  per  cent  had  chorea  previously,  or  developed  it  while  under  ob- 
servation. The  proportion  of  rheumatic  eases  corresponds  very  closel}'' 
with  Cheadle's  observations.  In  a  series  of  150  cases  of  valvular  dis- 
ease, Still  found  distinct  evidences  of  rheumatism  in  142. 

Endocarditis  may  occur  alone  or  with  other  manifestations  of  rheu- 
matism. ATliile  frequently  associated  with  acute  articular  rheumatism, 
in  a  much  larger  number  it  is  seen  with  articular  symptoms  which  are 
so  slight  as  to  be  overlooked  entirely  or  passed  over  as  unimportant.  It 
may  occur  with  or  follow  chorea,  tonsillitis,  or  torticollis,  with  or  without 
articular  symptoms.  The  proportion  of  rheumatic  cases  in  which  endo- 
carditis occurs  is  much  larger  in  children  than  in  adults.  In  rare  in- 
stances endocarditis  is  seen  in  the  course  of  almost  any  of  the  infectious 
diseases,  most  frequently  with  scarlet  fever,  being  often  associated  with 
pericarditis;  but  even  in  these  conditions  it  is  possible  that  it  is  some- 
times rheumatic.  The  bacteriology  of  rheumatic  endocarditis  has  not  yet 
been  determined  with  certainty. 

Lesions. — In  the  great  majority  of  cases  endocarditis  affects  the 
mitral  valve,  and  often  only  this.  In  150  autopsies  upon  children  dying 
of  cardiac  disease,  Poynton  found  the  mitral  valve  involved  in  149,  but 
in  76  of  these  the  changes  were  not  marked;  in  only  9  was  there  marked 
mitral  stenosis.  The  aortic  valve  was  affected  in  51,  but  in  only  9  was 
it  seriously  involved.  Yery  striking  was  the  frequency  of  pericarditis. 
Pericardial  adhesions  were  present  in  113  cases,  and  in  77  the  adhesions 
were  complete,  i.  e.,  the  pericardial  cavity  was  obliterated.  These  find- 
ings agree  substantially  with  the  observations  of  other  English  author- 
ities, but  in  America  the  pericardial  lesions  are  certainly  not  so  prom- 
inent. 

The  pathological  changes  of  acute  endocarditis  do  not  differ  essen- 
tially in  early  life  from  those  seen  in  adults.  There  is  first  an  accumula- 
tion of  bacteria  upon  the  endocardium  of  the  valves.  These  produce 
necrosis,  which  is  followed  by  a  clot  formation,  consisting  chiefly  of  blood 
platelets  and  fibrin,  in  the  meshes  of  which  are  leukocytes  and  a  few  red 
cells.  The  next  change  is  a  growth  of  new  connective  tissue  cells  and 
blood-vessels,  which  may  be  slight  and  superficial,  but  the  rheumatic 
lesion  usually  extends  deeply  with  an  extensive  proliferation  of  connective 
tissue  which  after  a  time  undergoes  contraction. 


596  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

In  the  mildest  forms  of  endocarditis  it  is  possible  for  complete  re- 
covery to  take  place.  In  other  cases  there  is  left  only  a  slight  valvular 
thickening,  not  enough  to  interfere  in  any  important  way  with  function. 
In  most  patients,  however^  more  marked  changes  are  left.  The  valvular 
segments  are  swollen,  adherent,  somewhat  shortened  and  consequently 
insufficient.  Other  changes  in  the  heart  usually  accompany  acute  endo- 
carditis. Dilatation  is  almost  invariably  present  and  is  an  important 
factor  in  producing  insufficiency.  In  cases  ending  fatally  there  is  very 
little  hypertrophy;  but  if  recovery  occurs,  hypertrophy  develops  and  the 
lesion  is  compensated  for  in  this  way.  A  certain  amount  of  myocarditis 
probably  occurs  in  every  severe  case.  It  is  most  marked  when  pericar- 
ditis is  also  present.  Emboli  in  children  are  rare.  Subsequent  attacks 
are  exceedingly  common  and  each  one  leaves  the  heart  more  seriously 
crippled. 

Chronic  inflammation  may  follow  the  first  attack  or  more  often  occur 
after  repeated  attacks.  The  changes  resulting  from  chronic  endocarditis 
are  practically  identical  with  those  seen  in  adult  life  and  need  not  be 
described  here.  Emphasis,  however,  should  be  laid  upon  the  fact  that 
the  younger  the  child  the  more  rapid  the  progress  of  the  disease. 

Symptoms, — When  endocarditis  occurs  as. a  primary  disease,  or  when 
it  is  the  only  manifestation  of  rheumatism,  it  may  begin  abruptly  with 
rather  severe  general  symptoms — a  temperature  of  101°  to  104°  F.,  pros- 
tration, exaggerated  heart  action,  restlessness,  and  sometimes  dyspnea. 
More  frequently,  however,  it  begins  much  less  acutely  with  only  general 
malaise  and  slight  fever,  which  often  is  not  recognized  without  the  ther- 
mometer. If  the  heart  is  not  watched  the  diagnosis  is  not  made  and  there 
may  be  no  suspicion  of  the  nature  of  the  primary  attack  until  some  time 
afterward,  when  the  existence  of  valvular  disease  is  discovered.  If,  how- 
ever, the  heart  is  carefully  and  frequently  examined  there  is  heard,  usu- 
ally on  the  third  or  fourth  day  of  the  illness,  a  soft,  blowing,  systolic 
murmur  at  the  apex. 

Endocarditis  occurring  with  rheumatism  is  by  no  means  limited  to 
those  attacks  with  well-defined  articular  symptoms.  It  is  very  common 
and  often  severe  when  the  articular  symptoms  are  no  more  than  stiffness, 
pain  on  motion,  and  slight  swelling  of  the  feet  or  ankles.  There  is  no 
relation  between  the  severity  of  these  symptoms  and  the  seriousness  of 
the  cardiac  lesion.  Occurring  during  chorea  or  after  tonsillitis  there  may- 
be nothing  to  call  attention  to  the  heart  except  sometimes  an  increased 
rapidity  or  irregularity  of  the  pulse  and  possibly  increased  prostration; 
but  frequently  the  cardiac  condition  is  not  suspected  until  the  heart  is 
examined. 

Most  of  the  cases  of  acute  endocarditis  seen  in  this  country  are  of  this 
mild  type.     Attacks  of  such  severity'  as  to  produce  death  in  the  acute 


CHRONIC  VALVULAR  DISEASE  597 

stage  are  relatively  rare  here,  in  marked  contrast  with  the  observations 
of  English  writers. 

The  usual  duration  of  acute  endocarditis  is  from  two  to  four  weeks, 
the  general  symptoms  slowly  subsiding  and,  if  the  case  progresses  favor- 
ably, the  cardiac  symptoms  improve,  but  there  is  usually  left  behind  a 
somewhat  damaged  heart  because  of  valvular  disease.  In  cases  progress- 
ing unfavorably  a  fatal  termination  may  come  in  the  course  of  from  two 
to  six  weeks  owing  usually  to  one  of  three  causes  or  a  combination  of 
these:  (1)  The  rapid  development  of  dilatation  accompanied  by  the 
usual  signs  of  cardiac  insufficiency;  (2)  pulmonary  complications,  gen- 
erally pneumonia;  (3)  the  supervention  of  acute  pericarditis. 

Course  of  Chronic  Valvular  Disease. — Chronic  valvular  disease  fol- 
lows one  or  more  attacks  of  acute  endocarditis,  and  may  exist  for  months 
and  sometimes  for  years,  before  it  is  recognized.  Its  course  is  usually 
divided  into  two  periods,  the  first  being  that  in  which  compensation  is 
present,  and  the  second  after  compensation  has  failed.  The  duration  of 
the  stage  of  compensation  is  indefinite.  The  only  subjective  symptom 
that  is  of  much  diagnostic  value  is  shortness  of  breath  on  exertion.  Occa- 
sionally other  symptoms  are  present,  such  as  precordial  pain,  attacks  of 
palpitation,  headache,  epistaxis,  aneiuia,  loss  of  weight,  and  cough. 
These  are  rarely  constant,  but  come  on  when  the  patient's  general  con- 
dition for  any  reason  is  below  normal.  As  a  rule,  there  is  in  young 
subjects  a  tendency  to  an  increase  in  the  disease,  although  this  is  often 
slow,  and  may  be  interrupted  by  long  periods  in  which  the  process  ap- 
pears to  be  stationary.  At  such  times  the  patients  either  have  no  symp- 
toms, or  suffer  only  from  a  slight  amount  of  inconvenience  on  marked 
exertion. 

Failure  in  compensation  is  generally  brought  about  by  one  of  the 
following  causes :  The  most  frequent  is  an  intercurrent  attack  of  rheu- 
matism with  a  fresh  endocarditis,  which  in  a  short  time  leads  to  a  very 
great  increase  in  the  heart's  disability.  It  may  be  due  to  additional  work 
thrown  upon  the  heart  from  excessive  muscular  exertion,  or  to  the  strain 
of  a  prolonged  attack  of  some  acute  illness,  especially  one  that  is  liable 
to  produce  changes  in  the  heart  muscle,  such  as  typhoid,  diphtheria,  or 
scarlet  fever.  It  is  sometimes  the  increased  work  which  is  thrown  upon 
the  heart  especially  at  the  time  of  puberty,  owing  to  the  rapid  growth 
of  the  body.  It  may  result  from  any  cause  which  seriously  affects  the 
])atient's  geiieral  nutrition,  particularly  when  this  is  associated  with 
marked  anemia. 

The  symptoms  indicating  failure  of  compensation  are  marked  dysp- 
nea or  orthopnea  and  cough,  sometimes  accompanied  by  profuse  ex- 
pectoration, which  may  be  bloody,  and  in  rare  cases  there  may  be  larger 
pulmonary  hemorrhages.     With  these  may  be  associated  other  signs  of 


598  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

pulmonary  congestion  and  even  pulmonary  edema.  The  obstruction  to 
the  systemic  venous  circulation  leads  to  dropsy,  which  usually  begins  in 
the  feet,  sometimes  in  the  face.  There  may  be  general  anasarca  and 
dropsy  of  the  serous  cavities,  especially  the  peritoneum  and  pleura;  also 
enlargement  and  functional  disturbances  of  the  liver,  enlargement  of  the 
spleen,  dyspeptic  symptoms,  and  chronic  congestion  of  the  kidney,  with 
scanty  urine  and  albuminuria.  There  may  be  dilatation  of  the  superficial 
veins  and  cyanosis;  and  there  may  be  cerebral  symptoms,  such  as  head- 
ache, dizziness,  and  fainting  attacks.  The  pulse  is  small  and  soft,  and 
the  heart's  action  rapid  and  irregular ;  the  cardiac  sounds  are  feeble  and 
often  indistinguishable,  and  it  may  be  impossible  to  decide  what  mur- 
murs, if  any,  are  present. 

It  is  rare  to  see  all  the  spiiptoms  of  chronic  progressive  cardiac  fail- 
ure in  children  under  seven  years,  but  toward  the  time  of  puberty  they 
are  common  enough.  The  symptoms  may  increase  in  severity  until 
death  occurs,  or  they  may  be  severe  for  a  time  and  then  nearly  disappear, 
to  return  again  after  a  longer  or  shorter  interval.^  Death  may  be  due  to 
sudden  cardiac  paralysis,  to  intercurrent  nephritis,  pneumonia,  embolism, 
inflammation  of  the  serous  membranes,  or  to  edema  of  the  lungs. 

Physical  Signs. — Mitral  murmurs  are  altogether  the  most  common 

^The  course  and  termination  of  these  cases  of  chronic  valvular  disease  is 
well  illustrated  by  the  following  history  of  a  little  girl  who  was  under  observa- 
tion for  nine  years :  When  first  seen  she  was  seven  years  old,  and  gave  a  his- 
tory of  cardiac  symptoms  for  one  year.  There  was  then  present  a  loud  mitral 
regurgitant  murmur,  with  considerable  hypertrophy.  There  was  general  dropsy, 
and  all  the  symptoms  pointed  toward  acute  dilatation.  Under  treatment,  the 
dropsy  and  other  sj-mptoms  disappeared,  and  she  went  on  comfortably  for  over 
a  year.  In  her  eighth  and  ninth  yesLVs  there  were  frequent  attacks  of  subacute 
rheumatism,  during  which  time  the  heart  lesion  steadily  increased  in  severity. 
At  twelve  years  there  was  an  eruption  of  subcutaneous  tendinous  nodules,  which 
remained  for  over  two  years.  During  this  year  there  was  heard  for  the  first 
time  a  presystolic  mitral  murmur,  accompanied  by  a  very  marked  thrill,  mitral 
stenosis  having  been  gradually  brought  about  by  the  slowly  progressing  endo- 
carditis. This  murmur  gradually  increased  in  intensity  from  that  time,  while 
the  mitral  regurgitant  murmur  became  less  distinct.  The  apex  beat  was  then  in 
the  sixth  space,  two  and  a  half  inches  to  the  left  of  the  nipple.  From  the 
twelfth  to  the  fifteenth  year  she  grew  very  little  in  height  or  weight,  and  showed 
no  signs  of  maturity,  the  cardiac  symptoms  being  nearly  stationary.  In  the 
fifteenth  year  she  developed  a  marked  enlargement  of  the  liver  and  spleen  with 
general  dropsy  and  all  the  symptoms  of  cardiac  insufficiency,  these  being  the 
first  symptoms  of  this  character  since  she  was  seven  years  old.  There  was  now 
heard  for  the  first  time  an  aortic  regurgitant  murmur  in  addition  to  the  others 
formerlj^  present.  The  symptoms  disappeared  under  treatment  in  the  course 
of  a  few  months,  but  six  months  later  returned  with  greater  severity  and  were 
accompanied  by  albuminuria,  the  patient  dying  from  heart  failure  in  a  few 
weeks.  During  the  last  exacerbation  there  was  heard  a  double  aortic  as  well  as 
a  double  mitral  murmur. 

At  autopsy  the  heart  weighed  fifteen  ounces.  There  was  a  very  great  hyper- 
trophy, especially  of  the  right  ventricle,  which  was  as  thick  as  the  left.  All  the 
cavities  were  much  dilated.  The  most  important  valvular  lesion  was  mitral 
stenosis,  the  orifice  not  admitting  the  end  of  the  little  finger.  The  valves  were 
the  seat  of  calcareous  deposits.  The  curtains  of  the  aortic  valve  were  thickened 
and  adherent;  there  was  also  thickening  of  the  pulmonic  and  tricuspid  valves. 


CHRONIC  VALVULAR  DISEASE  599 

both  in  acute  and  chronic  disease.  Of  141  cases  of  valvular  disease,  in 
children  under  fourteen  years,  observed  clinically,  mitral  murmurs  were 
present  in  135;  in  131  the  murmur  of  mitral  insufficiency  was  heard,  and 
in  99  this  alone.  In  mitral  insufficiency  there  is  regurgitation  of  blood 
from  the  left  ventricle  into  the  left  auricle  during  systole.  There  is 
heard  a  systolic  murmur,  synchronous  with  the  apex  impulse  and  with 
the  first  sound  of  the  heart,  which  may  wholly  or  in  part  replace  the  first 
sound.  It  is  loudest  at  the  apex,  transmitted  to  the  left,  and  is  usually 
heard  at  the  inferior  angle  of  the  left  scapula.  In  acute  endocarditis  the 
murmur  is  at  first  very  soft  and  usually  increases  in  intensity  for  sev- 
eral days.  It  may  be  represented  by  the  syllables  "whoo-ta"  pronounced 
in  a  whisper.  After  attaining  its  maximum  the  murmur  changes  but 
little  for  some  time.  It  may  then  diminish  and  eventually  disappear 
entirely;  but  usually  a  murmur  of  moderate  intensity  remains.  The 
only  other  important  sign  of  acute  endocarditis  is  enlargement  of  the 
heart  which  is  almost  entirely  from  dilatation.  If  the  acute  inflammation 
supervenes  upon  an  old  lesion,  the  previous  murmur  becomes  louder  and 
harsher.  In  chronic  endocarditis  the  murmur  is  similar  to  that  of  acute 
endocarditis  but  generally  louder  and  more  widely  diffused,  and  may  be 
audible  all  over  the  chest.  It  is  accompanied  by  an  accentuation  of  the 
pulmonic  second  sound  and  by  signs  of  hypertrophy,  especially  of  the 
right  heart.  When  both  these  signs  are  wanting,  the  existence  of  mitral 
insufficiency  is  somewhat  doubtful,  as  a  similar  murmur  may  be  func- 
tional or  accidental.  In  the  early  stages  of  the  disease  and  during  com- 
pensation, the  signs  of  hypertrophy  predominate;  in  the  later  stages  or 
with  broken  compensation,  those  of  dilatation. 

Mitral  stenosis  is  relatively  uncommon.  It  occurs  after  repeated  at- 
tacks of  rheumatism,  with  a  slowly  progressing  endocarditis.  It  is  usu- 
ally associated  with  mitral  regurgitation.  With  this  lesion  there  is  ob- 
struction to  the  flow  of  blood  from  the  left  auricle  into  the  left  ventricle. 
It  is  mainly  compensated  for  by  hypertrophy  of  the  right  ventricle,  but 
to  a  certain  degree  also  by  hypertrophy  of  the  left  auricle.  The  char- 
acteristic murmur  of  fully  developed  mitral  stenosis  is  presystolic,  pro- 
longed, rough  in  character,  and  terminates  abruptly  with  a  sharp  first 
sound  of  the  heart.  It  is  loudest  at  or  just  above  the  apex,  but  is  audible 
over  only  a  circumscribed  area.  Quite  as  constant  and  important  for 
diagnosis  is  the  presence  of  a  "purring  thrill,"  which  is  very  distinct 
upon  palpation,  and  terminates  sharply  as  the  apex  strikes  the  chest 
wall.  This  murmur  is  not  common  in  children  and  is  heard  only  in 
cases  in  which  cardiac  disease  has  lasted  several  years. 

With  milder  grades  of  mitral  stenosis,  or  earlier  in  the  course  of  the 
flisease,  there  may  be  heard,  shortly  after  the  second  sound,  a  murmur 
softer  in  quality  and  of  short  .duration.     It  is  usually  audible  aliove  and 


GOO  DISEASES  OF  TPIE  CIRCULATOEY  SYSTEM 

to  the  inner  side  of  the  apex  beat.  In  point  of  time  this  is  often  spoken 
of  as  the  early  diastolic  murninr  of  mitral  stenosis.  It  may  be  repre- 
sented by  the  whispered  syllables  "whoo-ta-whoo/'  in  which  the  first  syl- 
lable is  the  mitral  systolic  murmur,  which  is  somewhat  prolonged;  the 
second  syllable  is  the  second  cardiac  sound;  the  last  is  the  early  diastolic 
murmur,  which  is  much  shorter  than  the  systolic  murmur.  The  pulse  of 
mitral  stenosis  is  usually  small. 

Aortic  lesions  in  children  are  much  less  common  than  mitral  lesions, 
with  which  they  are  usually  associated;  they  are  seen  in  rather  older 
patients.  Aortic  insufficiency  is  much  more  frequent  than  aortic  stenosis. 
We  have  never  seen  it  as  the  only  lesion.  It  causes  a  regurgitation  of 
blood  from  the  aorta  into  the  left  ventricle  during  diastole.  It  is  com- 
pensated for  by  dilatation  and  hypertrophy  of  the  left  ventricle.  The 
signs  of  aortic  insufficiency  are  a  prolonged  diastolic  murmur,  with  or 
taking  the  place  of  the  second  sound  of  the  heart,  generally  loudest  at 
the  left  border  of  the  sternum  in  the  third  space,  and  transmitted 
downward  to  the  apex  of  the  heart  or  the  ensiform  cartilage.  This  is 
invariably  accompanied  by  signs  of  hypertrophy  and  dilatation  of  the 
left  ventricle,  which  are  usually  marked.  With  great  hypertrophy  there 
is  often  bulging  of  the  precordial  area  which  may  produce  striking 
thoracic  deformity.  A  characteristic  symptom  is  the  intense  throbbing 
of  the  carotids,  with  the  sudden  distention  followed  by  a  complete  col- 
lapse of  their  walls,  and  the  "water-hammer"  pulse  of  Corrigan.  A  capil- 
lary pulse  is  often  seen. 

Aortic  stenosis,  unless  congenital,  is  very  rare  in  early  life,  and  almost 
never  occurs  as  the  only  lesion.  Aortic  stenosis  is  compensated  for  by 
hypertrophy  of  the  left  ventricle.  It  causes  a  systolic  murmur,  which  is 
usually  loudest  at  the  right  border  of  the  sternum,  in  the  second  space, 
and  is  transmitted  upward,  being  distinct  in  the  carotids.  The  second 
sound  is  generally  weak  and  may  be  replaced  by  a  diastolic  murmur. 
A  systolic  thrill  over  the  aortic  area  is  usually  present.  Without  the 
signs  of  hypertrophy  of  the  left  ventricle,  a  positive  diagnosis  should 
not  be  made. 

Tricuspid  insufficiency  is  usually  secondary  to  disease  of  the  left  side 
of  the  heart,  occurring  in  its  late  stages.  It  most  frequently  follows 
mitral  insufficiency,  when  it  is  usually  due  to  dilatation  of  the  right 
ventricle  without  changes  in  the  valves.  It  may  be  secondary  to  certain 
diseases  of  the  lungs,  such  as  emphysema,  chronic  interstitial  pneumonia, 
or  chronic  pleurisy,  and  it  may  be  due  to  congenital  malformation.  Tri- 
cuspid insufficiency  gives  a  systolic  murmur,  loudest  over  the  lower  part 
of  the  sternum,  but  heard  usually  over  a  small  area.  It  is  associated  with 
signs  of  dilatation  of  the  right  ventricle.  The  jugular  veins  stand  out 
prominently,  and  often  show  systolic  pulsation,  especially  upon  the  right 


CHRONIC  VALVULAR  DISEASE  601 

side.  There  may  be  also  systolic  pulsation  of  the  liver.  The  symptoms 
associated  with  tricuspid  regurgitation  are  due  to  general  systemic 
venous  obstruction. 

Triscuspid  stenosis,  pulmonic  stenosis,  and  pulmonic  insufficiency  are 
practically  unknown  in  childhood  except  as  congenital  lesions. 

Prognosis. — The  danger  to  life  in  acute  endocarditis  is  not  great  un- 
less it  is  accompanied  by  pericarditis;  but  when  both  are  present  the 
outlook  is  serious.  Of  115  fatal  cases  reported  by  Poynton,  thirty-five 
proved  fatal  in  the  primary  attack.  It  is  difficult  during  the  active  stage 
to  foretell  how  serious  will  be  the  resulting  damage  to  the  heart.  It  is 
only  by  watching  the  progress  of  a  case  that  one  can  decide.  As  a  rule 
the  younger  the  child  the  worse  the  prognosis. 

Complete  recovery  from  valvular  disease  is  j^ossible  only  when  the 
lesions  are  very  slight.  Not  many  children  die  from  chronic  cardiac 
disease  before  reaching  the  age  of  eight  or  ten  years.  Up  to  about 
the  time  of  puberty  many  children  do  very  well ;  then  they  begin  to  lose 
ground,  and  may  fail  rajoidly.  But  more  often  it  is  a  fresh  endocarditis 
accompanying  an  intercurrent  attack  of  rheumatism  which  marks  the  be- 
ginning of  a  downward  course.  The  proportion  of  children  who  have 
serious  cardiac  lesions  before  the  age  of  six  years  and  reach  adult  life  in 
good  condition  is  very  small. 

There  are  several  features  of  cardiac  disease  in  children,  in  conse- 
quence of  which  serious  lesions  tend  to  progress  more  rapidly  than  in 
adults.  The  muscular  walls  are  less  resistant,  and  hence  dilatation  oc- 
curs much  more  readily  in  childhood  than  in  adult  life.  The  heart  must 
provide  not  only  for  constant  needs,  but  for  the  growth  of  the  body.  If 
the  patient's  general  nutrition  is  poor  during  the  period  of  most  rapid 
growth,  this  tells  quickly  and  seriously  upon  the  heart,  and  dilatation 
makes  rapid  progress.  The  demands  made  upon  the  heart  at  puberty 
are  especially  severe,  by  reason  of  the  rapid  growth  of  the  body  and 
the  frequency  with  which  anemia  and  malnutrition  are  seen  at  this  time. 
There  is  always  present  the  danger  of  rapid  advances  in  the  disease 
from  intercurrent  attacks  of  rheumatism,  from  which  children  are  more 
likely  to  suffer  than  are  older  subjects.  Extensive  pericardial  adhesions 
are  frequent,  and  seriously  handicap  the  heart,  greatly  increasing  the 
tendency  to  dilatation.  The  effect  upon  the  heart  of  poor  food,  un- 
hygienic surroundings,  and  general  malnutrition  is  much  more  marked 
than  in  adults. 

These  unfavorable  conditions  are  in  part  offset  by  others  in  which 
the  child  has  an  advantage  over  the  adult.  Disease  of  the  coronary 
arteries  is  very  rare,  and  the  valvular  lesion  which  is  most  frequently  met 
with — mitral  insufficiency— is  that  which  admits  of  the  most  complete 
compensation. 


602  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

In  making  a  ]orognosis  in  any  given  case,  the  amount  of  hypertrophy 
or  dilatation  which  exists,  and  the  presence  or  absence  of  pericardial  ad- 
hesions are  more  important  than  the  location  or  the  special  character  of 
the  murmur.  The  presence  of  valvular  disease  in  childhood  increases 
the  danger  from  every  acute  disease,  especially  pertussis,  diphtheria, 
pneumonia,  and  scarlet  fever.  The  chances  of  recurring  attacks  of  rheu- 
matism must  also  be  taken  into  account. 

Probably  the  most  important  factor  in  the  prognosis  of  chronic  cardiac 
disease  in  childhood  is  the  care  and  attention  which  the  patient  receives. 
While  as  a  rule,  if  properly  treated,  these  children  do  well  among  the 
well-to-do,  they  do  very  badly  among  the  poor  where  suitable  protection 
and  treatment  is  impossible. 

Diagnosis. — ^Valvular  disease  iS  to  be  distinguished  particularly  from 
conditions  in  which  there  are  heard  functional  or  accidental  murmurs. 
According  to  our  experience  the  latter  are  very  common  even  in  young 
children.  Mistakes  usually  arise  from  attaching  too  much  importance 
to  the  presence  of  murmurs,  and  too  little  to  the  changes  in  the  walls 
and  cavities  of  the  heart,  with  which  valvular  disease  is  almost  invariably 
associated.  It  is  not  always  possible  to  decide  whether  a  murmur  is 
organic  or  functional  until  the  patient  has  been  for  some  time  under 
observation  and  treatment,  particularly  when  anemia  is  present.  The 
diagnostic  points,  so  far  as  the  murmurs  are  concerned,  are  mentioned 
in  connection  with  accidental  murmurs. 

Treatment. — The  first  and  altogether  the  most  important  indication 
for  every  case  of  recent  endocarditis  is  to  secure  for  the  heart  as  complete 
rest  as  possible,  not  only  during  the  period  of  active  inflammation,  but 
for  several  succeeding  weeks.  The  reason  for  this  is  that  some  dilatation 
is  always  present  and  this  very  readily  increases.  With  children,  proper 
rest  can  be  secured  only  by  keeping  them  in  bed  and  in  a  recumbent  posi- 
tion. The  duration  of  the  period  of  rest  after  mild  attacks  of  endocarditis 
should  be  at  least  six  weeks,  and  after  severe  attacks,  three  months.  In 
these  young  patients  changes  in  the  walls  of  the  heart  take  place  very 
rapidly  and  the  gravest  consequences  are  liable  to  follow  a  neglect  of  these 
precautions.  In  old  cases  rest  is  indicated  during  every  acute  exacerba- 
tion ;  also  whenever  there  is  much  dilatation  and  little  hypertrophy,  and 
whenever  the  signs  of  failing  compensation  are  present.  In  these  older 
cases  rest  is  often  impossible  in  the  recumbent  position;  if  secured  at 
all,  it  must  be  obtained  with  the  child  in  the  sitting  posture  or  at  least 
propped  up  with  pillows.  AVhether  much  can  be  accomplished  by  the 
administration  of  anti-rheumatic  remedies  after  endocarditis  has  de- 
veloped is  very  doubtful.  Salicylates  or  aspirin  and  alkalis  may  be 
used  unless  they  disturb  the  stomach.  A  child  who  is  the  subject  of  a 
cljroiiic  valviilnr  disease  sltould  ])e  constantly  uiidcr  a  ])hysician's  observa- 


CHRONIC  VALVULAR  DISEASE  603 

tiou.  Irreparable  harm  often  results  from  ignorant  disregard  of  the 
simplest  and  most  important  rules  of  life  for  these  patients. 

Several  distinct  conditions  may  be  present  which  call  for  quite  differ- 
ent management.  The  essential  points  may  be  stated  in  a  few  words: 
For  all  recent  cases  and  during  all  exacerbations,  rest,  complete  and  pro- 
longed; for  deformed  valves  with  good  heart  walls  and  perfect  compen- 
sation, fresh  air,  moderate  exercise,  and  general  tonics;  for  feeble  heart 
walls,  failing  com^pensation  and  dilatation,  rest  and  cardiac  tonics. 

During  the  stage  of  compensation,  treatment  directed  especially  to 
the  heart  is  rarely  necessary.  The  main  purpose  should  be  to  maintain 
the  patient's  general  nutrition  at  the  highest  possible  point  during  the 
period  of  active  growth.  At  the  very  least  the  patient  should  be  carefully 
examined  three  or  four  times  each  year,  in  order  that  the  physician  may 
note  the  progress  of  the  disease,  and  be  able  to  direct  the  child's  educa- 
tion, occupation,  exercise,  and  surroundings  so  as  to  meet,  as  far  as 
possible,  the  changing  conditions.  To  this  end,  diet,  sleep,  study,  and 
exercise  should  receive  the  most  careful  attention.  If  malnutrition  and 
anemia  are  allowed  to  go  on  unchecked  until  they  become  severe,  the 
cardiac  disease  may  make  rapid  strides,  and  as  much  harm  be  done  in  a 
few  months  as  otherwise  might  not  occur  in  years.  The  question  of  ex- 
ercise and  recreation  is  always  a  difficult  one  to  settle.  Often  too  little 
latitude  is  given,  and  the  heart,  like  the  voluntary  muscles,  loses  its  tone. 
Every  form  of  exercise  requiring  a  prolonged  severe  strain  should  be 
forbidden,  particularly  swimming  and  competitive  games,  like  ball  and 
tennis,  and  others  requiring  much  running;  but  skating,  rowing,  horse- 
back exercise,  regulated  gymnastics,  and  cycling  on  the  level — all  in 
moderation — may  be  allowed  not  only  without  harm,  but  with  positive 
benefit;  but  any  of  these,  used  immoderately,  may  be  productive  of 
great  injury.  All  exercise  should  be  taken  with  regularity  and  system, 
the  amount  being  carefully  measured  by  the  child's  condition,  and 
increased  freedom  allowed  only  after  watching  the  effect.  If  the  patient 
is  a  boy  who  must  earn  his  own  living,  the  physician  should  see  to  it 
that  the  occupation  chosen  is  not  one  likely  to  make  special  demands 
upon  the  heart  or  to  expose  him  unduly  to  conditions  likely  to  induce 
rheumatism. 

Special  watchfulness  is  required  at  the  time  of  puberty  to  prevent 
overpressure  in  schools,  and  the  development  of  anemia.  The  first  symp- 
toms of  these  conditions  should  be  treated  energetically,  and  if  the  heart 
seems  to  be  overtaxed  the  child  should  be  put  to  bed.  Those  who  are 
specially  liable  to  rheumatic  attacks  should,  if  possible,  spend  the  winter 
and  spring  months  in  a  warm,  dry  climate. 

In  the  stage  of  failing  compensation,  the  same  general  conditions  are 
present  as  in  adults,  and  they  are  to  be  managed  in  pretty  much  the  same 


604  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

way.  When  such  symptoms  are  first  seen,  prolonged  rest  in  bed  should 
be  insisted  upon  as  the  thing  most  likely  to  restore  the  normal  conditions. 
Digitalis  and  strophanthus  are  useful  in  children  with  about  the  same 
indications  as  in  adults,  viz.,  dilatation,  dropsy,  low  arterial  tension,  and 
weak  pulse.  They  may  be  used  in  doses  of  from  five  to  ten  drops  of  the 
tincture  every  four  to  six  hours  for  a  child  of  ten  years.  If  there  is 
much  dilatation  of  the  right  side  of  the  heart  the  same  treatment  is 
indicated  as  described  in  pericarditis.  One  should  be  cautious  about 
using  digitalis  for  an  irregular  and  overacting  heart,  opium  being  de- 
cidedly preferable  under  these  conditions.  An  overloaded  venous  circula- 
tion may  be  relieved  by  diuretics,  by  saline  purgatives,  or  even  by 
venesection.  Iron  and  tonics  generally  are  indicated,  particularly  strych- 
nin and  cod-liver  oil. 


MALIGNANT  ENDOCARDITIS 

Malignant  or  ulcerative  endocarditis  is  rare  in  childhood.  Among 
the  youngest  .cases  reported  are  one  by  Bond  in  an  infant  of  two  and 
a  half  months,  and  one  by  Harris  in  a  boy  four  years  old.  In  Bond's 
case  the  mitral  valve  was  afffected.  The  infection  was  with  the  B.  pyo- 
cyaneus.  In  Harris'  case  the  right  side  of  the  heart  was  affected  and  the 
lesion  was  secondary  to  a  congenital  malformation.  We  have  seen  endo- 
carditis of  the  mitral  valve  in  an  infant  of  six  months  following  a  septic 
arthritis  of  the  knee.  Of  the  cases  reported  in  early  life,  most  have  been 
in  children  over  ten  years  of  age.  Malignant  endocarditis  is  never  pri- 
mary. It  may  be  seen  in  any  infectious  disease  or  septic  process.  In  sev- 
enty-five per  cent  of  the  cases  it  is  ingrafted  upon  a  previous  valvular  dis- 
ease. In  the  series  of  collected  cases  of  congenital  malformations  of  the 
heart,  there  were  four  deaths  from  malignant  endocarditis,  all  but  one, 
however,  occurring  in  adult  life.  The  bacteria  most'  frequently  concerned 
are  the  staphylococcus  or  streptococcus,  next  the  pneumococcus,  and 
rarely  the  gonococcus,  the  influenza  or  the  pyocyaneus  bacillus. 

Malignant  endocarditis  presents  a  great  variety  of  symptoms,  often 
making  the  diagnosis  extremely  difficult.  There  is  generally  a  remittent 
type  of  fever,  sometimes  repeated  rigors,  sweating,  low  delirium,  stupor 
or  coma,  and  extreme  prostration.  There  is  often  a  fine  petechial  erup- 
tion. Usually  there  is  a  cardiac  murmur,  the  location  of  which  depends 
upon  the  seat  of  the  disease ;  it  is  most  frequently  the  murmur  of  mitral 
regurgitation.  It  is  sometimes  faint,  and  may  be  absent.  From  the 
emboli  there  may  result  hemiplegia,  rapid  swelling  of  the  spleen,  bloody 
urine  or  pneumonia.  The  disease  lasts  from  three  weeks  to  three  months, 
death  being  the  almost  invariable  termination.    The  most  characteristic 


MYOCARDITIS  605 

features  of  malignant  endocarditis  are  the  development  of  2)yeniic  or 
typhoid  symptoms  with  a  petechial  eruption,  in  a  patient  who  has  pre- 
viously had  valvular  disease.  Blood  cultures  in  most  cases  give  positive 
results,  tbongli  not  always  early  in  the  disease. 

The  treatmeut  is  symptomatic.  The  use  of  vaccines  has  not  met 
expectations;  in  the  most  acute  cases  no  benefit  has  followed  their  ad- 
ministration, and  even  in  the  more  prolonged  types  it  is  very  doubtful 
if  they  have  any  value. 

MYOCARDITIS 

Disease  of  the  muscular  wall  of  the  heart  is  rare  in  children,  and  of 
comparatively  little  importance,  except  in  connection  with  acute  endo- 
and  pericarditis  and  the  acute  infectious  diseases.  It  is  almost  invariably 
secondary  to  some  infectious  process.  Aside  from  the  rheumatic  condi- 
tions already  considered  the  diseases  wliich  furnish  most  of  the  cases  are 
scarlet  fever  and  diphtheria.  The  most  important  local  cause  is  peri- 
carditis with  adhesions. 

Lesions. — In  extra-uterine  life,  myocarditis  as  a  rule  affects  chiefly 
the  wall  of  the  left  ventricle,  the  papillary  muscles,  or  the  septvmi,  but 
the  entire  organ  is  involved.  The  heart  is  of  a  grayish  or  yellowish-red, 
sometimes  mottled  color,  very  soft,  friable,  and  flabby,  and  there  is  fre- 
quently dilatation  of  the  cavities. 

Two  varieties  of  myocarditis  are  described,  the  parenchymatous  and 
the  interstitial.  In  the  parenchymatous  form  there  is  a  degeneration  of 
the  muscle  fiber  which,  according  to  Eomberg,  is  most  frequently  al- 
buminous, next  fatty,  and  least  frequently  hyaline.  There  is  a  loss  of 
the  transverse  striations,  and  there  may  be  complete  disintegration  of 
the  fibers.  This  process  may  be  circumscribed,  but  it  is  usually  diffuse. 
In  the  interstitial  form  the  lesion  usiially  occurs  in  small,  circumscribed 
areas.  Tliere  is  an  infiltration  of  round  cells,  chiefly  mononuclear',  be- 
tween the  muscular  fibers  of  the  heart.  The  process,  when  acute,  may 
result  in  absorption  or  in  the  production  of  small  abscesses.  In  chronic 
cases  it  may  lead  to  the  formation  of  areas  of  dense  connective  tissue 
resembling  cicatrices,  in  the  heart  wall.  Either  the  interstitial  or  the 
parenchymatous  form  may  occur  alone,  but  in  most  of  the  acute  cases 
they  are  combined.  In  addition,  there  is  usually  some  degree  of  mural 
endocarditis  and  inflammation  of  the  pericardium  next  to  the  heart  wall- 
Dilatation  frequently  follows.  Cardiac  aneurism  and  even  rupture  have 
been  known  to  occur  in  a  child  of  six  years  (Hadden's  case). 

Symptoms. — In  many  cases  in  which  advanced  lesions  have  been 
found  at  autopsy  there  have  been  no  symptoms  appreciated  during  life. 
Careful  examination  of  the  heart,  however,  will  usually  show  an  altcra- 
31 


606  DISEASES  OF  THE  CIPXTLATOEY  SYSTEM 

tion  in  the  first  cardiac  sound,  the  muscular  quality  diniinisliing  and 
the  valvular  quality  increasing.  This  may  go  on  even  to  a  total  disap- 
pearance of  the  muscular  quality  and  only  a  flapping  valvular  sound  vislj 
remain.  The  first  and  the  second  sounds  are  then  almost  alike.  In  such 
severe  cases  diastole  is  relatively  short  aiifl  tlie  rliythm  is  much  like  that 
of  fetal  life.  A  systolic  murmur  due  to  dilatation  of  the  auriculo ven- 
tricular ring,  or  to  imperfect  action  of  the  papillary  muscles,  may  be 
heard  at  the  apex.  The  heart  is  usually  slightly  dilated,  but  may  be 
excessively  so.  Its  action  is  generally  increased  in  rapidity  and  may  be 
irregular ;  a  slow  heart,  oO  to  70,  with  feeble,  valvular  sounds  is  less 
frequent  but  very  characteristic.  The  apex  beat  is  diminished  in  intensity 
and  the  pulse  is  soft  and  weak.  The  Idood  pressure  is  low,  frequently 
60  mm.  or  even  less.  Other  symptoms  may  be  present  that  are  dependent 
upon  feeble  heart  action — pallor,  dyspnea,  slight  cyanosis,  and  attacks 
of  syncope.'  Less  frequently  there  may  be  dropsy  of  the  feet  or  the  serous 
cavities,  and  scanty  urine  sometimes  containing  albumin.  Death  may 
occur  suddenly  from  cardiac  paralysis  or  gradually  from  circulatory  fail- 
ure. Eecovery  may  take  place  after  alarming  symptoms  have  been 
present,  these  slowly  abating.  It  may  be  many  weeks  before  the  normal 
cardiac  sounds  are  heard. 

Treatment. — This  is  mainly  symptomatic.  After  severe  attacks  of 
those  infectious  diseases  in  which  myocardi+is  is  liable  to  occur,  and  at 
any  time  when  it  is  suspected,  patients  should  be  kept  recumbent  for 
several  weeks,  and  special  care  exercised  to  prevent  any  sudden  exertion, 
as  death  has  resulted  from  so  slight  a  thing  as  suddenly  sitting  up  in 
bed.  Once  definite  symptoms  have  developed,  absolute  rest  is  imperative. 
Much  more  is  to  be  expected  from  complete  rest  than  from  drugs,  which 
as  often  employed  may  do  positive  harm.  Digitalis  should  be  used  with 
caution,  and  never  in  large  doses.  In  some  cases  with  symptoms  indicat- 
ing imminent  heart  failure  rather  striking  benefit  has  followed  the  use 
of  morphin  hypodermically. 


ACCIDENTAL  MURMURS 

Under  this  term  are  included  those  murmurs  that  do  not  depend 
upon  organic  change  in  the  heart  or  are  not  functional  in  the  sense  that 
actual  regurgitation  takes  place  through  a  dilated  orifice. 

In  early  life  such  murmurs  are  exceedingly  common.  Our  own  ob- 
servations confirm  those  published  by  Hamill  and  others,  that  murmurs 
may  be  heard  on  careful  examination  in  nearly  fifty  per  cent  of  all 
cliildren.  Their  existence  is  often  a  cause  of  much  needless  anxiety 
and  of  many  unnecessary  restrictions  of  a  child's  activities.     'HiCf,-  aie 


ACCIDENTAL  MURMURS  607 

almost  invariably  systolic  in  time ;  they  are  usually  of  moderate  intensity, 
soft  and  blowing  in  character,  and  are  not  transmitted.  They  are  unac- 
companied by  changes  in  the  size  of  the  heart  or  by  symptoms  referable 
to  its  function.  They  are  apt  to  be  inconstant  in  occurrence,  and  often 
change  in  character  or  disappear  altogether  by  changing  the  posture  of 
the  child. 

The  exact  method  of  their  production  is  still  a  matter  of  doubt. 
In  certain  instances  they  are  apparently  dependent  upon  changes  in  the 
blood  occurring  in  anemia.  In  several  of  our  patients,  infants  with 
grave  anemia,  quite  loud  murmurs  have  disappeared  after  transfusion. 
In  other  cases  there  can  be  no  doubt  that  the  murmurs  are  produced 
in  the  lungs,  air  being  forced  through  the  bronchi  by  the  tnovements  of 
tlie  contracting  heart.  The  term  cardiopulmonary  is  applicable  to  mur- 
murs of  this  origin.  This  murmur  is  not  loud,  is  never  heard  to  the 
right  of  the  sternum  and  disappears  when  the  breath  is  held.  It  is 
usually  loudest  over  the  pulmonary  artery,  intensified  by  excitement  or 
exertion,  and  often  disappears  when  changing  from  a  standing  to  a 
supine  position. 

Atonic  murmurs  are  probably  due  to  lack  of  tone  in  the  cardiac 
muscle  leading  to  a  real  but  temporary  insufficiency,  usually  at  the  mitral 
orifice.  These  murmurs  correspond  in  most  cases  to  a  slight  mitral 
regurgitant  murmur.  They  are  heard  in  the  course  of  a  number  of 
acute  febrile  diseases — notably  scarlet  and  typhoid  fevers;  also  in  many 
pale,  delicate,  nervous  children,  especially  between  the  ages  of  eight  and 
fourteen  years. 

Anemic  murmurs  are  usually  accompanied  by  a  venous  hum,  but  not 
by  an  accentuated  pulmonic  second  sound.  Other  causes  of  accidental 
murmurs  such  as  a  functional  stenosis  of  the  pulmonary  artery  and 
infundibulum,  functional  mitral  insufficiency  and  eddy  currents  within 
the  ventricles  are  not  so  well  substantiated  by  clinical  or  experimental 
proof. 

Probably  the  most  frequent  of  all  accidental  murmurs  is  the  soft 
systolic  murmur  which  is  heard  over  the  body  of  the  heart  near  the  left 
border  of  the  sternum  at  about  the  nipple  level ;  it  is  increased  by  placing 
the  child  on  his  back  and  in  many  patients  is  heard  only  in  this  position. 
This  murmur  is  usually  intensified  by  overaction  of  the  heart  whether 
due  to  excitement,  exertion  or  fever.  It  is  accompanied  by  no  symptoms 
referable  to  the  heart  or  circulation  and  it  may  be  met  with  in  children 
who  are  in  perfect  health.  This  murmur  is  more  often  heard  in  infants 
and  young  children,  but  may  be  present  for  many  years.  It  is  often 
confused  with  murmurs  due  to  cardiac  malformation,  but  it  is  not  loud 
as  are  they,  and  is  heard  only  over  a  localized  area. 

The  differentiation  from  murmurs  due  to  organic  cardiac  disease 


608  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

may  be  difficult  and  ouly  possible  by  continuous  observation  for  some 
time;  but  in  any  infant  or  child  one  should  hesitate  to  make  a  diagnosis 
of  congenital  or  acquired  organic  disease  from  the  mere  presence  of  a 
soft  systolic  murmur. 


FUNCTIONAL  DISTURBANCES  OF  THE  HEART 

Disturbances  of  the  heart's  action  unconnected  with  organic  disease 
are  quite  common  in  children,  especially  from  the  seventh  or  eighth 
year  up .  to  puberty.  Common  causes  are  disorders  of  digestion,  the 
excessive  use  of  tea,  coffee  or  tobacco,  especially  in  the  form  of  cigarette 
smoking,  anemia,  over  pressure  in  schools  or  other  conditions  leading, 
to  nervous  exhaustion.  The  exciting  cause  is  sometimes  a  great  emo- 
tional disturbance  such  as  fright  or  excitement,  or  it  may  follow,  any 
serious  acute  illness.  As  a  rule  there  are  more  sul^jective  symptoms  with 
functional  than  with  organic  disease  unless  the  latter  Ls  advanced.  Func- 
tional disturbance  may  take  the  form  of  attacks  of  palpitation,  tachy- 
cardia, bradycardia  or  arrhythmia. 

With  attacks  of  paliniation  there  may  be  a  sense  of  oppression  in 
the  precordium ;  there  may  be  some  dyspnea  or  even  orthopnea ;  the  pulse 
■is  generally  rapid,  often  slightly  irregular.  There  is  strong  pulsation 
of  the  carotids  and  sometimes  headache  or  vertigo.  There  may  be  cold 
extremities  and  general  perspiration.  The  duration  of  the  attack  is 
from  a  few  minutes  to  several  hours.  The  treatment  is  that  of  the 
general  nervous  condition  upon  which  the  j)alpitation  depends. 

Tachycardia  (rapid  heart)  occurs  in  certain  susceptible  children 
from  slight  cause,  most  frequently  when  the  general  health  is  below  par, 
in  conditions  of  anemia,  and  in  nervous  children — particularly  girls 
about  the  time  of  puberty. 

In  the  same  patient  the  symptoms  may  occur  at  intervals  for  years. 
The  pulse  at  such  times  may  be  from  120. to  IGO  per  minute  or  even 
more  rapid  than  this.  The  condition  may  persist  for  days  or  weeks  at 
a  time,  then  sul^siding,  but  the  symptoms  recurring  at  variable  intervals. 
In  some  children  a  very  rapid  pulse  must  be  considered  an  idiosyncrasy. 

In  a  patient  with  an  attack  of  tachycardia  position  makes  little 
difference  with  the  heart  rate.  Sometimes  it  is  even  more  rapid  when 
the  child  is  recumbent.  It  is,  however,  almost  invariably  much  lower 
during  sleep  and  at  such  time  may  even  be  quite  normal.  The  rhythm 
of  the  heart  is  not  disturbed.  It  is  important  not  to  confound  this 
condition  with  Graves'  disease.  The  treatment  is  to  be  addressed  to  the 
nervous  condition  present,  to  which  as  a  rule  the  cardiac  symptom  is 
secondary. 


FUNCTIONAL  DISTURBANCES  OF  THE  HEART  609 

In  certain  children  there  is  seen  a  more  rare  but  severe  form  of 
this  condition  known  as  paroxijsm,al  tachycardia,.  It  has  been  observed 
in  children  as  yonno-  as  three  years.  There  develops  abruptly  and  Math- 
out  assignable  cause  an  extraordinary  heart  rate  which  may  be  200  to  250 
per  minute.  Such  attacks  may  last  from  a  few  minutes  to  several  weeks, 
both  beginning  and  ending  abruptly.  After  an  attack  the  pulse  may  for 
a  time  be  abnormally  slow.  In  prolonged  cases  some  cardiac  dilatation 
often  occurs,  and  a  systolic  murmur  may  develop.  Serious  consequences 
may  follow,  such  as  swelling  of.  the  liver,  dropsy,  etc.  The  cause  and 
mechanism  of  such  an  abnormal  cardiac  stimulus  are  as  yet  obscure. 
Curiously,  attacks  may  often  be  cut  short  by  vomiting.  The  indications 
for  treatment  are  nervous  sedatives,  complete  rest  and  prolonged  treat- 
ment with  digitalis  in  full  doses. 

Bradycardia  (slow  heart)  is  a  much  less  frequent  condition  than 
tachycardia.  It  is  seen  in  a  variety  of  pathological  conditions  not  involv- 
ing the  heart,  such  as  jaundice,  certain  poisons,  etc.  Its  persistence  in 
young  children  is  always  a  suspicious  symptom  suggesting  cerebral  dis- 
ease, though  in  some  children  an  abnormally  slow  pulse  is  an  idiosyn- 
crasy. Existing  by  itself,  no  importance  is  to  be  attached  to  it  as  a  sign 
of  cardiac  disease. 

Arrliytlimia. — Like  all  other  nervous  adjustments  the  heart-regulat- 
ing mechanism  does  not  work  with  the  same  uniformity  in  children  as 
in  older  subjects.  In  consequence  of  this,  disturbances  of  cardiac  rhythm 
are  more  frequently  seen  and  occur  from  slighter  causes  in  early  life  than 
later.  Cardiac  irregularity  is  exceedingly  common  in  children,  and  is 
often  seen  in  those  who  are  apparently  in  excellent  health.  Of  321 
unselected  children  studied  by  Friberger  only  37  per  cent  had  a  fairly 
regular  pulse,  while  over  12  per  cent  had  a  very  irregular  pulse.  A 
certain  degree  of  cardiac  irregularity  up  to  the  time  of  puberty  is  so 
common  that  it  must  almost  be  regarded  as  the  rule.  Only  exceptionally 
does  it  indicate  disease  of  the  heart ;  particularly  is  this  the  case  when  it 
occurs  with  slow  heart  action.  The  higher  forms  of  irregularity  are 
usually  seen  in  younger  children.  In  general,  it  is  more  often  observed 
in  girls,  but  is  not  affected  by  general  development  nor  by  cardiac  weak- 
ness.    It  is  slightly  more  frequent  in  nervous  subjects. 

Sinus  arrhythmia,  reflex  arrhythmia  or,  as  it  is  sometimes  called, 
vagus  irregularity,  is  the  characteristic  type  of  arrhythmia  in  early  life. 
The  alteration  in  cardiac  rhythm  is  brought  about  by  stimuli  which  arise 
outside  of  the  heart  and  reach  it  by  one  of  the  cardiac  nerves.  The  point 
of  origin  of  the  impulse  is  probably  the  sinus  region.  Eeflex  stimuli  are 
constantly  reaching  the  heart.  The  regulation  of  beats  is  usually  so 
perfect,  however,  that  they  do  not  influence  its  rate.  If  the  resistance 
to  outside  stimuli  is  less  than  normal  these  stimuli  may  reflexly  affect 


610  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

the  rate.  It  has  been  shown  by  Einthoven  and  others  that  stimuli  pass 
up  the  vagus  nerves  with  each  respiration.  The  nervous  control  of  the 
various  functions  of  the  body  is  imperfectly  developed  in  children  and 
sinus  arrh}i;hmia  is  in  them  a  frequent  finding.  It  bears,  in  many  in- 
stances, a  close  relationship  to  the  respiration.  The  irregularity  is 
generally  but  not  always  shown  in  the  pulse  at  the  wrist.  It  is  best 
determined  b}'  auscultation.  The  irregularity  is  often  rhj^thmical,  vary- 
ing with  the  respiration.  With  inspiration,  the  action  of  the  heart  be- 
comes rapid  and  with  expiration  slow.  Other  varieties  are,  irregular 
pauses  or  a  sudden  retardation  of  frequency  at  irregular  intervals. 

There  are  no  subjective  symptoms  and  the  patient  is  seldom  con- 
scious of  the  condition.  The  arrhythmia  is  present  during  sleep,  often 
most  marked  at  that  time  and  associated  with  irregular  respiration.  A 
diagnosis  of  sinus  arrhythmia  is  made  chiefly  by  its  association  with 
respiration;  it  disappears  with  rapid  respiration  or  wlien  the  breath  is 
held.  It  is  also  characteristic  of  this  condition  that  it  is  seen  only  with 
a  slow  heart  action,  disappearing  at  once  when  the  heart's  action  from 
any  cause  becomes  rapid. 

This  form  of  irregularity  is  not  in  itself  significant.  It  is  not  a 
symptom  of  cardiac  disease,  nor  does  it  affect  the  patient's  health  or  his 
development.  It  may  safely  be  ignored  altogether.  In  certain  children, 
however,  it  may  be  a  constant  phenomenon  and  may  persist  for  many 
years.  Sinus  arrhythmia  may  be  met  with  as  a  temporary  condition 
after  any  severe  acute  illness;  it  may  be  seen  in  children  of  the  neuras- 
thenic type  associated  with  other  evidences  of  nervous  instabilit}'.  In 
many  eases,  even  of  the  most  pronounced  type,  no  adequate  cause  can 
be  discovered. 

Another  type  of  irregularity  is  due  to  the  production  of  extra  systoles. 
These  are  occasional,  irregular  beats  caused  by  single  abnormal  stimuli, 
arising  within  the  heart,  either  in  the  auricle  or  ventricle.  Extra  systoles 
are  seldom  observed  in  young  children, — more  frequently  in  those  over 
eight  or  ten  years  old.  The  extra  systoles  may  be  followed  by  a  long 
pause  the  following  normal  beat  being  omitted,  or  two  beats  may  occur 
very  close  together.  Extra  systoles  are  usually  not  sufficiently  forcible 
to  open  the  aortic  valves.  Eor  this  reason  they  cannot  often  be  felt  at 
the  wrist  but  may,  in  thin  subjects,  be  recognized  by  palpation  and  they 
can  be  determined  by  auscultation  or  tracings.  There  may  be  no  sub- 
jective symptoms  or  there  may  be  complaint  of  precordial  anxiety  and 
unrest  when  the  extra  systoles  occur.  This  form  of  irregularity  is  seldom 
a  constant  phenomenon,  but  with  susceptible  persons  it  comes  and  goes 
from  apparently  slight  causes.  It  is  most  marked  when  the  pulse  is  slow 
and  may  disappear  when  it  becomes  rapid,  sometimes  also  on  assuming 
a  recumbent  position. 


DISEASES  OF  THE  BLOOD-VESSELS  611 

Extra  systoles  are  usually  not  associated  with  other  signs  or  symptoms 
of  cardiac  disease  in  children  and  under  such  circumstances  may  be 
practically  ignored.  The  condition  is  not  a  serious  one.  Its  causes  may 
be  disorders  of  the  stomach,  an  extremely  sensitive  nervous  system,  or 
convalescence  from  an  acute  febrile  disease,  especially  pneumonia.  The 
treatment  should  be  addressed  to  the  general  condition,  not  to  the  heart. 
Exercise  need  not  be  restricted. 


DISEASES   OF  THE   BLOOD-VESSELS 

Coarctation  of  the  Arch  of  the  Aorta. — This  is  a  rare  congenital  lesion 
in  which  there  is  a  partial  or  complete  occlusion  of  the  aorta  at  or  near 
the  Junction  with  the  ductus  arteriosus.  The  ductus  may  remain  patent 
and  the  systemic  circulation  be  carried  on  almost  exclusively  by  means  of 
the  blood  which  passes  by  way  of  the  ductus  from  the  pulmonary  artery 
to  the  aorta  below  the  constriction.  Coarctation  of  the  arch  may  be  the 
only  lesion  or  there  may  be  associated  lesions  with  death  in  the  first  few 
months.  When  the  stenosis  is  beyond  the  opening  of  the  ductus  arterio- 
sus a  very  complete  collateral  circulation  develops  chiefly  by  means  of  the 
superior  intercostals  and  mammary  arteries  above,  and  the  aortic  inter- 
costals  and  superficial  and  deep  epigastric  arteries  below.  In  consequence 
of  this  there  may  be  no  symptoms  of  the  condition.  Instances  are  on 
record  where  persons  with  this  lesion  have  lived  to  advanced  age,  but 
often  they  are  stunted  in  growth,  poorly  nourished,  and  complain  of 
dyspnea. 

The  physical  signs  are  at  times  very  characteristic.  The  collateral 
circulation  may  show  superficially  over  the  thorax  and  upper  abdomen. 
A  marked  disproportion  in  intensity  between  the  radial  pulse  and  the 
femoral  pulse  may  be  present.  There  is  frequently  marked  pulsation 
and  a  thrill  in  the  suprasternal  notch  owing  to  dilatation  of  the  arch  of 
the  aorta.  A  loud  systolic  murmur  may  be  heard  in  the  second  or  third 
spaces  on  the  left  side,  well  out  from  the  sternum.  Death  may  be  due 
to  intercurrent  disease,  to  failing  circulation  and  sometimes  to  rupture 
of  the  heart  or  of  the  arch  of  the  aorta. 

Abnormally  Small  Arteries  (Arterial  hypoplasia). — This  condition  is 
not  a  common  one.  The  only  thing  which  is  abnormal  in  the  cir- 
culatory system  may  be  that  the  aorta,  and  sometimes  all  the  large 
vessels  are  only  two-thirds  or  three-fourths  their  usual  caliber,  or 
even  less.  This  may  interfere  seriously  with  the  growth  and  de- 
velopment of  the  body,  especially  of  the  genital  organs,  although  this  re- 
sult is  not  a  constant  one.  The  condition  is  found  occasionally  in  cases  of 
chlorosis.  There  is  sometimes  associated  a  certain  amount  of  hypertrophy 
of  the  heart.   The  other  symptoms  are  anemia,  and  sometimes  an  imperfect 


612  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

development  of  the  body.    A  positive  diagnosis  during  life  is  impossible. 

Aneurism  and  Atheroma. — In  early  life  chronic  disease  of  the  blood- 
vessels is  exceedingly  rare,  yet  a  sufficient  number  of  observations  have 
been  recorded  to  show  that  even  young  children  are  not  exempt  from  this 
form  of  disease.  Sanne  records  the  youngest  case,  which  occurred  in  a 
fetus  born  at  about  the  eighth  month,  in  whose  body  there  was  found  a 
large  aneurism  of  the  abdominal  aorta  just  below  the  origin  of  the  renal 
arteries.  Le  Boutillier  has  collected  seven  cases  of  thoracic  aneurism  in 
children  under  ten  years ;  the  arch  of  the  aorta  was  the  usual  seat. 

Probably  the  most  important  etiological  factor,  as  in  adult  life,  is 
syphilis,  but  in  only  a  few  of  the  cases  reported  was  the  evidence  of 
syphilis  conclusive.  In  two  cases  there  was  general  tuberculosis.  In  at 
least  two  cases  whooping-cough  appeared  to  act  as  a  contributing  cause. 
Aneurism  may  also  be  due  to  some  local  condition,  such  as  an  erosion 
from  a  bony  growth,  an  abscess  in  the  neighborhood,  or  to  embolism. 
The  symptoms  and  course  of  aneurism  in  young  children  do  not  differ 
essentially  from  those  of  the  disease  as  seen  in  adults. 

In  addition  to  the  cases  of  aneurism  referred  to  above,  we  have  found 
reports  of  seven  cases  of  atheroma  in  very  young  subjects.  In  Sanne's 
case  the  patient  was  but  two  years  old,  and  patches  of  atheromatous  de- 
generation were  found  in  several  places  in  the  aorta.  In  Hawkins'  case, 
eleven  years  old,  there  was  found  extensive  atheromatous  disease  of  the 
aorta,  subclavian  and  carotid  arteries.  In  Filatow's  case,  atheromatous 
degeneration  affected  the  arteries  at  the  base  of  the  brain,  causing  death 
from  cerebral  hemorrhage.  It  is  interesting  to  note  that  in  this  patient, 
who  was  only  eleven  years  old,  there  was  also  present  chronic  diffuse 
nephritis  with  contracted  kidneys.  A  similar  condition  of  the  kidneys 
and  arteries  was  observed  by  Dickinson  in  a  girl  of  six  years.  We  have 
seen  extensive  arterio-sclerosis  the  result  of  hereditary  syphilis  in  a  boy 
of  five.    Death  occurred  from  hemorrhage  into  the  lateral  ventricle. 

Embolism  and  Thrombosis. — Embolism  is  very  rare  in  early  life,  even 
with  acute  endocarditis.  The  emboli  are  usually  swept  into  the  circu- 
lation from  vegetations  upon  the  valves  of  the  heart.  The  symptoms 
which  they  produce  will  depend  upon  the  nature  of  the  emboli  and  the 
vessels  occluded  by  them.  If  they  lodge  in  the  brain  they  may  cause 
paralysis  or  convulsions;  if  in  the  spleen,  pain  and  swelling  of  this 
organ ;  if  in  the  kidneys,  pain,  tenderness,  aiul  sometimes  hematuria ; 
if  in  the  lungs,  cough,  sometimes  accompanied  by  hemoptysis  and  occa- 
sionally by  a  sharp  thoracic  pain.  If  the  emboli  are  infectious,  they 
may  give  rise  to  abscesses.  The  pathological  results  following  embolism 
are  similar  to  those  wliich  are  seen  in  adults. 

The  most  frequent  form  of  thrombosis,  that  occurring  in  the  sinuses 
of  the  brain,  is  discussed  in  connection  with  Diseases  of  the  Nervous 


DISEASES  OF  THE  BLOOD-VESSELS  613 

System.  Cardiac  thrombi,  especially  of  the  right  side  of  the  heart,  are 
not  infrequently  found  in  patients  dying  from  cardiac  disease,  pneumonia, 
and  occasionally  also  from  other  acute  inflammatory  processes  and  acute 
infectious  diseases,  particularly  diphtheria.  These  thrombi  are  in  most 
cases  produced  during  the  last  few  hours  of  life,  or  just  at  the  time  of 
death,  an'd  are  of  no  clinical  importance.  They  frequently  extend  from 
the  heart  into  the  large  blood-vessels,  particularly  the  pulmonary  artery. 
Thrombosis  occasionall}^  occurs  in  any  of  the  large  vascular  trunks  in 
childhood  as  well  as  in  adult  life. 

Thrombosis  of  the  Internal  Jugular  Vein. — M.  Pasteur  has  reported 
a  ease  in  a  child  two  and  a  half  years  old,  in  which  the  middle  of  the 
vein  was  filled  Avith  an  organized  thrombus,  and  the  lower  portion  ob- 
literated and  reduced  to  a  fibrous  cord.  The  symptoms  were  swelling, 
edema,  and  cyanosis  of  the  face,  and  dilatation  of  the  facial  vein,  but 
not  of  the  external  jugular.  There  were  clubbing  of  the  fingers  and 
edema  of  the  feet,  but  not  of  the  arms.  The  heart  was  dilated  and 
hypertrophied,  but  there  was  no  valvular  disease.  The  symptoms  had 
existed  since  an  attack  of  pneumonia,  eighteen  months  before  death. 

'lliromhosis  of  the  Vena  Cava. — Quite  a  number  of  cases  are  on 
record  where  this  has  occurred  as  the  result  of  pressure  from  large 
abdominal  tumors;  it  has  followed  new  growths  of  the  kidney  and  large 
masses  of  tuberculous  13'mph  nodes.  Neurutter  and  Salmon  have  re- 
corded a  case  of  thrombosis,  apparently  of  marantic  origin,  in  a  child 
seven  years  old.  The  thrombus  filled  the  vena  cava,  and  extended  to  the 
origin  of  the  hepatic  veins  and  into  both  femorals.  Death  occurred  from 
tuberculosis.  In  Scudder^s  case  (seventeen  years  old)  there  was  appar- 
ently obliteration  (probably  congenital)  of  the  inferior  vena  cava;  there 
was  an  extensive  varicose  condition  of  all  the  abdominal  veins.  The 
symptoms  of  thrombosis  of  the  vena  cava  are  swelling  and  edema  of  the 
feet — sometimes  of  the  abdominal  walls  and  tlie  groin — and  very  great 
dilatation  of  the  superficial  abdominal  veins. 

Thrombosis  of  the  Aorta. — A  case  has  been  reported  by  Leopohl  in 
a  newly-born  child  who  was  delivered  by  version.  The  thrombus  was 
of  recent  origin,  and  filled  the  lower  aorta,  extending  into  the  femoral 
artery.  A  case  of  thrombosis  of  the  aorta  occurring  in  a  girl  of  thir- 
teen years  has  been  reported  by  Wallis.  The  aorta  was  very  narrow,  and 
probably  the  seat  of  .syphilitic  disease.  The  thrombus  extended  from  the 
origin  of  the  renal  arteries  to  the  celiac  axis. 

Thrombosis  in  Infectious  Diseases. — There  is  occasionally  seen  in 
typhoid  fever,  but  more  frequently  in  diphtheria,  thrombosis  of  some  of 
the  large  venous  trunks,  usually  of  one  of  the  lower  extremities.  Tlie 
symptoms  are  pain,  localized  swelling,  and  partial  paralysis.  If  Iho 
artery  is  affected,  there  may  be  gangrene. 


SECTION  VI 
DISEASES  OF  THE  UEOGENITAL  SYSTEM 

CHAPTEK  I 
THE  URINE  IN  INFANCY  AND  CHILDHOOD 

While  a  .«tudy  of  the  urine  is  of  much  less  importance  in  early  life 
than  of  the  symptoms  referable  either  to  the  digestive  or  respiratory 
system,  it  is  deserving  of  much  more  attention  than  it  has  generally  re- 
ceived. In  infancy  especially  it  is  attended  with  some  difficulty,  owing 
to  the  fact  that  it  is  by  no  means  an  easy  matter  to  seeure  readily  speci- 
mens for  examination. 

Methods  of  Collecting  TTrine.— In  male  infants  this  may  he  done  by 
placing  the  penis  in  the  neck  of  a  small  bottle  or  test  tube  which  lies 
between  the  thighs,  and  is  secured  in  position  by  pieces  of  tape  passing 
over  the  hips  and  beneath  the  perineum.  The  urine  of  female  infants  can 
sometimes  be  collected  in  a  similar  way  by  placing  a  small  cup  or  a  large- 
mouthed  bottle  over  the  vulva  and  holding  it  in  place  by  the  napkin  or 
by  pieces  of  adhesive  plaster.  A  plan  often  successful  is  to  put  the  infant 
upon  a  chamber  after  a  long  sleep.  It  should  be  done  at  the  instant  of 
waking  or  the  child  may  be  wakened  for  the  purpose.  When  an  infant 
has  not  voided  for  one  or  two  hours  the  application  of  a  cold  hand  or  a 
cloth  wrung  out  of  ice  water  to  the  abdomen  or  the  buttocks  will  usually 
cause  emptying  of  the  bladder.  A  small  amount  of  urine,  sufficient  to 
test  for  albumin,  may  often  be  obtained  by  placing  absorbent  cotton  over 
the  vulva  or  penis.  The  most  certain  of  all  means,  however,  is  catheter- 
ization, which,  however,  should  not  be  resorted  to  unless  absolutely  neces- 
sary. A  soft-rubber  catheter,  size  6  or  7,  American  scale  (9  or  11 
French),  should  be  used  for  infants. 

Daily  Quantity. — This  is  relatively  much  larger  in  infants  than  in 
older  children  and  in  adults,  on  account  of  the  large  amount  of  water 
taken  with  the  food.  The  quantity  fluctuates  widely  from  day  to  day, 
according  to  the  amount  of  fluid  food  taken  and  the  activity  of  the  skin 
and  bowels.  The  figures  following  are  the  averages  obtained  by  com- 
bining the  results  of  the  investigations  of  Schabanowa,  Cruse,  Camerer, 
Pollak,  Martin-Euge,  Berti,  Schiff,  and  Herter. 

615 


616 


DISEASES  OF  THE  UROGENITAL  SYSTEM 


Average  Daily  Quantity  of  Urine  in  Health 


Age. 


Grams. 


Ounces. 


First  twenty-four  hours .  .  . 
Second  twenty-four  hours . 

Three  to  six  days 

Seven  days  to  two  months 

Two  to  six  months 

Six  months  to  two  years . . 

Two  to  five  years 

Five  to  eight  years 

Eight  to  fourteen  years .  .  . 


Oto 

60 

Oto  2 

10  " 

90 

M  "  3 

90  " 

250 

3  "  8 

150  " 

400 

5  "   13 

210  " 

500 

7  "  16 

250  " 

600 

8  "  20 

500  « 

800 

16  "  26 

600  " 

1,200 

20  "  40 

1,000  " 

1,500 

32  "  48 

Frequency  of  Micturition. — This  is  greatest  in  young  infants,  and 
diminishes  steadily  as  age  advances,  In  infancy,  during  the  waking 
hours,  the  urine  is  passed  very  frequently,  often  ^two  or  three  times  an 
hour,  while  during  sleep  it  is  retained  from  two  to  six  hours.  By  the 
third  year  the  urine  may  be  held  during  sleep  for  eight  or  nine  hours, 
and  at  other  times  for  two  or  three  hours.  Such  control  of  the  sphinc- 
ter of  the'  bladder  is  often  obtained  at  two  years,  and  sometimes  even  at 
an  earlier  period.  From  slight  nervous  disturbances  or  minor  ailments 
of  any  kind,  this  control  is  impaired,  and  the  urine  may  be  passed  by 
children  of  four  or  five  years  with  the  frequency  seen  in  infants. 

Physical  Character  and  Composition. — The  urine  of  the  newly  born 
is  usually  highly  colored.  During  later  infancy  it  is  pale  and  frequently 
turbid,  even  when  practically  normal,  owing  to  the  presence  of  mucus; 
this  turbidity  often  no  amount  of  filtration  will  entirely  remove.  Less 
frequently  the  turbidity  depends  upon  urates.  The  urine  of  the  first 
few  days  of  life  often  shows  a  deposit  of  urates  Ox-  uric  acid  in  the  form 
of  a  pink  or  reddish-yellow  stain  upon  the  napkin.  The  reaction  of  the 
urine  at  this  time  is  usually  strongly  acid,  but  throughout  the  rest  of 
infancy  it  is  faintly  acid  or  neutral. 

The  specific  gravity  is  higher  during  the  first  two  days  than  at  any 
time  in  infancy  on  account  of  the  scanty  supply  of  fluid  taken;  it  is 
usually  lowest  from  the  third  to  the  sixth  day,  but  from  this  time  it  rises 
steadily  until  puberty  is  reached.  The  specific  gravity  varies  with  the 
quantity.  From  the  writers  already  referred  to,  the  following  figures 
are  taken: 

Specific  gravity. 

First  to  third  day 1 .010  to  1 .012 

Fourth  to  tenth  day 1 .004  "  1 .008 

Tenth  day  to  sixth  month 1 .004  "  1 .010 

Six  months  to  two  years 1 .  006  "  1 .  012 

Two  to  eight  years 1 .008  "  1 .016 

Eight  to  fourteen  years 1 .012  "  1 .020 

Microscopically,  the  urine  of  the  newly  born  shows  the  presence  of 
many  squamous  epithelial  cells,  mucus,  granular  matter,  crystals  of  uric 


LORDOTIC,  ORTHOSTATIC  OR  CYCLIC  ALBUMINURIA  617 

acid  and  amorphous  or  crystalline  urates  and  amorphous  bilirubin  crystals 
which  are  insoluble  in  urine  not  containing  bile  acids.  It  is  not  uncom- 
mon to  find  hyaline  and  even  granular  casts.  Martin-Euge  found  hyaline 
casts  in  the  urine  of  fourteen  out  of  twenty-four  healthy  nursing  infants 
examined  during  the  first  week.    Granular  casts  were  much  less  frequent. 

The  inorganic  salts  (phosphates,  chlorids,  sulphates)  are  all  present 
in  the  urine  of  the  newly  born,  but  in  relatively  5mall  quantities,  in- 
creasing as  age  advances.     The  coloring  matters  are  also  less  abundant. 

Albumin  is  often  present  in  the  urine  during  the  first  days,  but 
usually  in  small  amount.  Cruse  found  it  twenty-eight  times  in  ninety 
observations  upon  healthy  infants;  usually  the  quantity  was  small, 
amounting  to  traces  only,  but  in  two  cases  it  was  quite  large  upon  the 
second  day.  These  observations  are  confirmed  by  the  investigations  of 
Martin-Ruge,  and  also  of  Pollak. 

Sugar  is  frequently  found  in  the  urine  of  healthy  infants  during  the 
first  two  months.  It  may  be  made  to  appear  in  the  urine  of  healthy 
infants  by  simply  increasing  the  quantity  ingested.  The  different  sugars 
vary  as  regards  the  amount  which  can  be  taken  before  it  is  thus  elim- 
inated. According  to  Grosz,  lactose  appears  if  the  quantity  is  increased 
to  three  or  four  grams  per  kilo,  of  body  weight;  glucose^,  only  when 
five  grams,  and  maltose,  not  until  seven  and  seven-tenths  grams  per  kilo, 
are  given. 

LORDOTIC,  ORTHOSTATIC  OR  CYCLIC  ALBUMINURIA 

This  condition,  although  uncommon  in  young  children,  is  frequently 
seen  between  the  ages  of  six  and  fifteen  years.  It  is  much  more  common 
in  males  than  in  females.  A  recurrent  but  benign  albuminuria  in  chil- 
dren has  been  recognized  for  many  years  and  has  been  referred  to  numer- 
ous causes  such  as  cold  bathing,  fatigue  following  muscular  exertion, 
dyspeptic  conditions  or  a  diet  rich  in  nitrogenous  food.  It  is  doubtful  if 
any  of  these  are  of  etiological  importance,  for  the  condition  persists  when 
their  influence  is  entirely  eliminated.  The  most  important  factor  is 
undoubtedly  a  mechanical  one.  The  albuminuria  is  due  to  the  upriglit 
position.  When  this  is  not  assumed  there  is  no  albuminuria,  or  the 
merest  trace.  There  can  also  be  no  doubt  that  lordosis  plays  a  very 
important  part,  if  not  the  most  important  part.  The  majority  of  cases 
occur  in  children  with  a  considerable  degree  of  lordosis.  How  this  acts, 
by  producing  congestion  of  the  kidney  by  pressure  on  the  vessels  at  the 
pelvis  or  otherwise  is  not  quite  clear. 

Symptoms. — Some  of  the  patients  exhibiting  orthostatic  albuminuria 
are  well  nourished  and  have  no  other  signs  of  disease;  the  majority, 
however,  while  they  may  be  considered  healthy,  are  not  vigorous.     They 


618  DISEASES  OF  THE  UROGEXITAL  SYSTEM 

are  usually  anemic  and  rather  poorly  nourished.  They  suffer  from 
gastro-intestinal  symptoms  of  which  constipation  is  a  frequent  one  and 
often  have  headaches  aiid  various  neuroses.  Cardiac  palpitation  and 
vasomotor  symptoms  are  common.  The  trunk  is  usually  long  in  pro- 
portion to  the  height  and  a  degree  of  lordosis  is  the  rule.  The  abdomen 
is  usually  prominent.  Sometimes  symptoms  of  angioneurotic  edema 
have  directed  attention  to  the  urine.  Except  for  these  there  are  no 
symptoms  that  Avould  direct  attention  to  the  genito-urinary  tract  and 
the  condition  is  usually  discovered  in  an  attempt  to  explain  the  poor 
general  condition  of  the  patient. 

The  urine  is  usually  clear  and  that  which  is  secreted  while  the  child 
is  lying  down  presents  nothing  abnormal.  Shortly  after  assuming  the 
upright  position  albumin  appears  in  greater  or  less  quantity.  This  is 
serum  albumin  plus  a  substance  which  is  precipitated  by  acetic  acid  in 
the  cold.  Eecent  studies  have  shown  that  this  is  probably  ehondroitin 
sulphuric  acid  united  with  serum  albumin.  The  amount  of  albumin 
present  may  vary  from  a  trace  to  50  per  cent  by  volume  or  even  more. 
The  substance  precipitated  by  acetic  acid  is  never  in  large  quantity.  It 
causes  clouding  of  the  urine  or  an  appreciable  precipitate  but  no  more. 
It  is  sometimes  found  alone  and  always  when  serum  albumin  is  present. 
The  assumption  of  a  markedly  lordotic  position  increases  greatly  the 
amount  of  albuminuria.  Infrequently  casts  may  be  present;  they  are 
usually  liyaline  casts  and  few  in  number.  Thoy  may  occasionally  be 
associated  with  a  temporary  glycosuria  but  the  kidney  does  not  show  a 
greater  permeability  to  other  substances  used  for  renal  tests.  Evidences 
of  nephritis,  high  arterial  tension,  cardiac  hypertrophy,  etc.,  are  absent. 

Orthostatic  albuminuria  is  not  a  dangerous  coiidition,  nor  does  it 
interfere  with  health.  It  disappears  usually  at  or  shortly  after  puberty. 
Occasionally  it  may  persist  well  on  into  adult  life. 

It  is  important  that  orthostatic  albuminuria  should  not  be  confused 
with  nephritis.  Children  are  not  infrequently  confined  to  bed  for  a  long 
time  and  placed  upon  a  rigid  diet  with  the  mistaken  idea  that  nephritis 
is  present.  If,  after  repeated  examinations,  it  is  found  that  albumin  is 
present  only  when  the  upright  or  lordotic  position  is  assumed,  if  a  sub- 
stance precipitable  by  acetic  acid  in  the  cold  is  present  and  other  evi- 
dences of  nephritis  absent,  the  diagnosis  of  orthostatic  albuminuria  may 
properly  be  made. 

Treatment. — If  lordosis  is  present,  as  is  usually  the  case,  much  can 
be  done  to  prevent  the  albuminuria.  The  abdominal  muscles  should  be 
strengthened  by  appropriate  gymnastic  exercises.  The  children  should 
practice  assuming  and  maintaining  a  proper  position  in  standing  and 
sitting.  Exercise  is  of  value  but  prolonged  standing  should  be  avoided. 
If  the  lordosis  persists  in  spite  of  these  measures  a  light  form  of  appara- 


IIEMOGLOBIXURIA  619 

tus  may  be  worn  Avhich  prevents  the  lordotic  position  but  does  not  inter- 
fere with  exercise.  Associated  conditions  such  as  anemia,  constipation, 
and  the  various  neuroses  should  receive  their  appropriate  treatment. 


HEMATURIA 

Hematuria  is  characterized  by  the  presence  of  red  blood-cells  in  the 
urine,  and  is  to  be  distinguished  from  hemoglobinuria  where  only  blood 
pigment  is  present. 

Hematuria  may  result  from  local  or  general  causes.  In  infancy  it 
may  be  due  to  new  growths  of  the  kidney.  Such  hemorrhages,  though 
rare,  may  be  abundant,  and  may  be  seen  early.  Hematuria  may  occur 
also  as  a  symptom  of  acute  nephritis,  especially  that  complicating  scarlet 
fever,  or  it  may  result  from  the  irritation  of  a  calculus  in  the  kidney,  the 
ureter,  or  the  bladder.  In  rare  instances  its  cause  is  a  new  growth  of 
the  bladder,  and  it  may  be  due  to  traumatism.  It  may  sometimes  be 
produced  by  the  irritation  of  a  highly  concentrated  urine,  owing  to  the 
fact  that  too  little  fluid  is  taken.  We  once  saw  a  marked  example  of  this 
in  an  infant  eight  months  old,  when  no  other  explanation  could  be  found. 
Hematuria  is  occasionally  seen  following  uric-acid  infarctions  in  the 
newly  born.  It  may  also  occur  at  this  age  as  one  of  the  symptoms  of 
sepsis.  Among  the  general  causes  the  most  important  are,  the  hemor- 
rhagic disease  of  the  newly  born ;  the  blood  dyscrasiae,  such  as  scurvy, 
purpura,  and  hemophilia,  and  infectious  diseases,  particularly  typhoid, 
scarlet  fever,  influenza,  and  malaria.  In  most  of  these  cases  the  amount 
of  blood  passed  is  small.  When  it  is  large  it  may  appear  in  the  urine  as 
clear  blood,  or  as  clots,  or  it  may  impart  simply  a  reddish  or  smoky  color 
to  the  urine.  The  color,  however,  is  not  so  reliable  as  a  microscopical 
examination. 

Large  hemorrhages  are  much  more  likely  to  come  from  the  kidneys 
than  from  the  bladder.  The  presence  of  blood  casts  from  the  renal 
tubules,  or  larger  ones  from  the  ureter,  are  conclusive  evidence  of  the 
renal  origin  of  the  hemorrhage. 

The  treatment  of  hematuria  should  be  directed  to  the  cause  upon 
which  it  depends.    In  infancy  scurvy  especially  should  not  be  overlooked. 


HEMOGLOBINURIA 

In  this  condition  blood  pigment  appears  in  the  urine  in  large  quan- 
tity, l>ut  red  blood-cells  are  very  few  in  number  or  are  absent  altogether. 
In  severe  cases  the  urine  mav  be  almost  black.     There  is  commonly  a 


620  DISEASES  OF  THE  UKOGENITAL  SYSTEM 

small  amount  of  albumin.  This  condition  may  be  recognized  by  the 
appearance  of  granules  of  pigment  under  the  microscope^  or  by  Heller's 
test;  the  most  conclusive  means  of  diagnosis,  however^  is  by  the  spectro- 
scope. 

Ej)idemic  hemoglobinuria  (Winckel's  disease)  has  already  been  de- 
scribed in  the  chapter  on  Diseases  of  the  Newly  Born.  Hemoglobinuria 
may  be  due  to  certain  poisons,  as  carbolic  acid  or  chlorate  of  potash,  or 
to  certain  infectious  diseases,  as  scarlet  fever,  typhoid  fever,  malaria, 
syphilis,  or  erysipelas. 

Paroxysmal  hemoglobinuria  occurs  in  childhood,  although  it  is  an 
exeedingly  rare  condition.  In  most  of  the  recorded  cases  there  has  been 
a  history  of  syphilis  and  the  Wassermann  reaction  has  been  positive.  It 
is  now  regarded  as  a  syphilitic  affection.  Paroxysms  may  be  excited  by 
exposure  to-  cold,  by  chilling  the  surface  of  the  body  or  by  merely  im- 
mersing the  hands  in  cold  water.  Vigorous  antiluetic  treatment  is  in- 
dicated. It  is  not  yet  clear  that  it  is  always  entirely  successful;  it  may, 
however,  greatly  improve  the  condition.  For  further  description  text- 
books on  general  medicine  should  be  consulted. 


PYURIA 

Pus  in  the  urine  may  exist  as  an  acute  or  a  chronic  condition.  In 
either  case,  in  a  child,  it  is  much  more  likely  to  come  from  the  pelvis  of 
the  kidney  than  from  any  other  source.  It  may,  however,  come  from 
any  part  of  the  genito-urinary  tract — the  kidney  or  its  pelvis,  the  ureters, 
the  bladder,  the  urethra,  or  the  vagina.  Sometimes  it  comes  from  an 
outside  source,  as  Avhen  an  abscess  from  perinephritis,  appendicitis,  or 
caries  of  the  spine  opens  into  the  urinary  tract. 

Coming  from  the  pelvis  of  the  kidney,  pus  may  indicate,  if  the  con- 
dition is  an  acute  one,  pyelitis,  pyelonephritis,  or  pyonephrosis;  if  it  is 
chronic,  it  may  point  to  renal  tuberculosis  or  calculus.  The  amount  of 
pus  in  any  of  these  conditions  may  be  quite  large.  The  urine  is  turbid 
and  usually  acid  in  reaction.  It  contains  many  epithelial  cells  of  the  tran- 
sitional variety.  A  urine  containing  much  pus  is  always  albuminous. 
It  is  rare  that  pus  comes  from  the  ureters  except  in  connection  with 
congenital  malformations  or  the  im.paction  of  calculi.  Pus  from  the 
bladder  is  not  usually  in  large  quantity,  and  may  be  mixed  with  mucus. 
The  urine  may  be  alkaline  or  acid  in  reaction ;  there  may  be  associated 
the  symptoms  of  vesical  irritation  or  of  cystitis.  Pus  from  the  lower 
genital  tract  is  rare  in  children,  and  its  causes  may  often  ])e  recognized 
by  a  local  examination.  When  the  cause  of  pyuria  is  the  opening  of 
an  abscess  into  the  urinary  tract  there  is  generally  a  sudden  appear- 


DIABETES  INSIPIDUS  621 

ance  of  pus  in  large  ainoiiiit.  The  pyuria  is  usually  in  such  cases  of 
short  duration,  possibly  only  a  few  days,  and  it  may  disappear  quite 
rapidly. 

The  nature  of  the  infection  can  be  determined  only  by  cultures  made 
from  a  catheterized  specimen.  This  information  is  of  considerable  aid 
both  in  diagnosis  and  prognosis. 

The  treatment  of  pyuria  depends  altogether  upon  its  cause.  Im- 
provement in  the  symptoms  sometimes  follows  the  use  of  hexamethyl- 
ena,min,  which  may  be  given  in  doses  of  from  five  to  ten  grains  three 
times  a  day  to  a  child  of  five  years. 

ANURIA 

By  this  term  is  meant  an  arrest  of  the  urinary  secretion.  To  that 
form  which  occurs  in  the  course  of  renal  disease  the  term  "suppres-. 
sion"  is  generally  applied.  x\nuria  is  to  be  carefully  distinguished  from 
retention,  from  the  scanty  secretion  which  occurs  whenever  food  is  re- 
fused or  withheld  on  account  of  illness,  and  also  from  that  which  accom- 
panies acute  diarrhea,  with  large,  watery  discharges.  Anuria  is  some- 
times seen  in  the  newly  born,  where  it  depends  upon  some  malformation 
of  the  genital  tract;  or,  more  frequently,  upon  uric-acid  infarctions  in 
the  kidneys.  The  first  urine  passed  after  such  an  attack  is  very  often 
highly  acid,  and  may  contain  an  abundance  of  uric-acid  crystals  and 
larger  masses  visible  to  the  naked  eye.  Other  cases  admit  of  no  such 
explanation.  For  the  time,  the  secretion  appears  to  be  completely  ar- 
rested, as  the  bladder,  both  by  palpation  and  catheterization,  is  found  to 
be  empty.  This  condition  is  very  uncommon  in  infancy,  and  it  may  con- 
tinue for  from  twelve  to  thirty-six  hours.  So  long  as  infants  appear  to 
be  perfectly  normal  in  every  other  respect,  the  suspension  of  the  urinary 
secretion  even  for  twenty-four  hours  need  excite  no  anxiety. 

The  treatment  consists  in  the  administration  of  the  acetate  or  citrate 
of  potash,  and  plenty  of  water.  To  a  newly-born  infant  one  grain  of 
the  citrate  of  potash  may  be  given  every  hour  or  two,  in  water,  until  the 
urinary  secretion  is  established,  which  will  usually  be  in  six  or  eight 
hours.  ]f  the  urine  is  very  highly  acid  and  stains  the  napkins,  the 
jjotash  should  be  continued  for  several  days.  Hot  fomentations  over  the 
kidneys  may  be  used. 

DIABETES  INSIPIDUS   (POLYURIA) 

This  is  a  chronic  disease  characterized  by  the  excretion  of  a  very 
large  amount  of  pale  urine  of  low  s-pecific  gravity.  It  is  invariably 
accompanied  by  polydipsia.     The  disease  is  a  rare  one  in  children. 


622  DISEASES  OF  THE  UROGENITAL  SYSTEM 

Etiology. — Of  eight^^-five  cases  collected  by  Strauss,  twenty-one  were 
in  children  under  ten  years  of  age  and  nine  under  five  years.  In  Eob- 
erts's  collection  of  seventy  cases,  the  disease  began  in  twenty-two  chil- 
dren before  ten  years,  and  in  seven  during  infancy.  In  some  cases  it 
begins  soon  after  birth.  Males  are  more  frequently  affected  than  females, 
and  in  certain  cases  heredity  is  an  important  factor.  Weil  has  published 
a  remarkable  example  of  the  disease  existing  in  many  members  of  a 
single  family.  Falls  or  blows  upon  the  head,  concussion  of  the  brain, 
tumors  of  the  brain,  and  chronic  hydrocephalus,  all  have  been  found  asso- 
ciated with  diabetes  insipidus.  It  sometimes  has  followed  the  acute 
infectious  diseases;  but  in  many  cases  no  cause  whatever  can  be  found. 
The  association  of  diabetes  insipidus  with  lesions  at  the  base  of  the  brain 
has  long  been  observed.  More  recently  this  symptom  has  been  connected 
with  lesions  of  the  pituitary  body.  Since  one  of  the  most  frequent  lesions 
of  the  base  is  chronic  syphilitic  meningitis,  syphilis  must  be  considered 
a  possible  etiological  factor.  It  is  altogether  probable  that  a  number  of 
quite  distinct  causes  may  produce  diabetes  insipidus. 

Symptoms. — The  quantity  of  urine  is  enormous,  usually  exceeding 
even  that  in  diabetes  mellitus.  From  five  to  twenty  pints  daily  may  be 
passed.  The  urine  is  pale,  the  specific  gravity  from  1.001  to  1.006,  and 
it  contains  neither  albumin  nor  glucose.  In  a  few  cases  the  presence  of 
inosite  (muscle  sugar)  has  been  found.  Eestricting  the  amount  of  fluid 
taken  causes  a  very  marked  diminution  in  the  amount  of  urine.  The 
intense  thirst  leads  patients  to  drink  enormously  of  water  and  other 
fluids. 

Nervous  symptoms  are  usually  present.  There  may  be  disturbed 
sleep  from  the  frequent  micturition,  palpitation,  flushing  of  face  and 
other  vasomotor  disturbances,  headache,  restlessness,  and  neuralgia. 
There  may  be  incontinence  of  urine.  The  bladder  sometimes  becomes 
enormously  distended.  In  one  of  our  cases  it  held  forty-five  ounces  and 
reached  above  the  uml^ilicus.  The  skin  is  pale  and  dry,  and  perspiration 
is  scanty.  The  general  health  may  not  be  much  disturbed.  In  most 
cases,  however,  it  is  affected,  and  there  may  be  the  usual  symptoms 
of  malnutrition,  and  even  neurasthenia.  If  it  affects  young  children, 
their  growth  is  generally  retarded.  The  appetite  usually  remains  quite 
good  but  anorexia  may  be  marked.  The  temperature  is  at  times  slightly 
subnormal.  The  course  of  the  disease  is  indefinite.  It  is  very  chronic, 
and  may  last  for  many  years,  death  taking  place  from  intercurrent  affec- 
tions. ' 

Prognosis. — Occasionally  a  patient  will  recover  spontaneously.  Of 
the  chronic  cases  in  which  the  disease  is  well  established  very  few  are 
controlled.  The  prognosis  is  especially  bad  if  there  are  marked  disturb- 
ances of  the  digestive  tract  or  organic  brain  disease. 


MALFORMATIONS  AND  MALPOSITtONS  G23 

Diagnosis. — This  is  easily  made  from  the  two  marked  symptoms, 
excessive  thirst  and  polyuria.  From  diabetes  mellitus  it  is  easily  distin- 
guished by  the  lower  specific  gravity  and  the  absence  of  sugar  from  the 
urine.  In  older  children,  chronic  nephritis  with  contracted  kidney  may 
be  confounded  with  it.  Its  occasional  association  with  syphilis  should  be 
remembered  and  a  Wassermanu  test  made  as  a  possible  basis  of  treat- 
ment. 

Treatment. — Fluids  should  be  moderately  restricted.  It  is  a  serious 
mistake  to  reduce  the  quantity  of  fluids  too  much,  since  the  drinking  is 
not  the  cause  of  the  diuresis.  The  diet  should  be  simple  and  nutritious. 
The  general  treatment  should  be  directed  to  the  condition  of  malnutri- 
tion. The  clothing  should  be  warm,  and  a  moderate  amount  of  exercise 
should  be  allowed.  Drugs,  in  most  cases,  are  of  little  use.  Bromids  and 
belladonna  continued  for  many  months  are  claimed  to  be  of  value.  Co- 
dein  too  is  said  at  times  to  cause  decided  improvement.  It  is  doubtful 
if  the  prospect  of  cure  justifies  its  use  for  a  prolonged  time.  Treatment 
must  be  continued  for  many  months  to  be  of  any  value. 


CHAPTEE  II 

DISEASES  OF  THE  KIDNEYS 
MALFORMATIONS   AND   MALPOSITIONS 

Malformations  of  the  kidney  are  not  infrequent.  In  seven  hun- 
dred and  twenty-six  consecutive  autopsies  at  the  New  York  Infant  Asy- 
lum malformations  of  the  kidney  or  ureters  were  met  with  in  seventeen 
cases.  This  does  not  represent  the  actual  frequency  with  which  they 
occur,  for  in  about  half  that  number  of  autopsies  in  two  other  institu- 
tions only  a  single  example  was  seen.  Adding  to  the  cases  mentioned 
two  others  seen  elsewhere,  there  are  twenty  cases  of  renal  malformation 
of  which  we  have  notes,  classed  as  follows: 

Fusion  of  the  kidneys,  or  horseshoe  kidney 4  cases. 

Supernumerary  ureters 4      " 

Hydronephrosis  (alone)   8      " 

Congenital  cystic  kidney  (alone)   2      " 

Hydronephrosis  and  cystic  kidney 1  case. 

Single  kidney 1      " 

In  all  malformations  the  left  kidney  is  much  more  frequently  affected 
than  the  right,  the  proportion  being  nearly  two  to  one.     Malformations 


624  DISEASES  OF  THE  UROGENITAL  SYSTEM 

are  more  often  seen  in  males  than  in  females.  Only  two  of  these  con- 
ditions are  of  clinical  importance — viz.,  cystic  degeneration  and  hydro- 
nephrosis. 

Cystic  Kidneys. — Two  varieties  of  this  malformation  are  met  with. 
In  one  the  cysts  are  few  in  number  and  large;  in  the  other  they  are  very 
numerous  and  small.  When  the  cysts  are  large  the  renal  tumor  may  fill 
the  abdominal  cavity,  even  interfering  with  the  birth  of  the  child.  The 
condition  is  generally  bilateral,  and  the  patients  die  in  early  infancy. 
The  more  common  form,  that  with  small  cysts,  also  affects  both  sides 
as  a  rule.  The  organ  often  is  not  enlarged,  and  it  may  even  be  smaller 
than  normal.  The  surface  of  the  kidney  is  .studded  with  small  cysts, 
which  usually  vary  in  size  from  a  pin's  head  to  that  of  a  pea.  The  entire 
organ  may  consist  of  nothing  but  a  mass  of  cysts,  held  together  by 
loose  connective  tissue.  In  other  cases  the  cysts  are  less  numerous,  and 
much  renal  tissue  remains.  The  cysts  are  formed  by  the  dilatation  of 
the  urinif erous  tubules  owing  to  occlusion,  which  occurs  in  the  devel- 
opment of  the .  kidney.  The  large  cysts  are  recognized  as  abdominal 
tumors;  the  small  ones  usually  give  no  symptoms  during  infancy  and 
childhood  and  are  found  accidentally  at  autopsy  in  patients  dying  from 
other  diseases.  In  either  form  uremic  symptoms  may  develop  if  an 
insufficient  quantity  of  functionating  renal  substance  remains. 

Hydronephrosis. — This  renal  lesion  in  a  mild  form  is  not  very  un- 
common at  autopsy  when  no  physical  signs  or  symptoms  have  been  given 
during  life.  In  more  severe  form  it  is  associated  with  many  of  the  mal- 
formations of  the  organ  such  as  horseshoe  kidney,  cystic  kidney,  etc.  It 
may  affect  one  or  both  sides  and  be  found  in  both  males  and  females. 
Hydronephrosis  is  undoubtedly  the  result  of  some  obstruction  to  the  out- 
flow of  urine  from  the  kidney,  ureter  or  bladder,  but  this  obstruction 
may  be  very  difficult  to  demonstrate.  Obvious  causes  for  hydronephrosis 
are  stones  in  the  kidney,  ureter  or  bladder  and  pressure  upon  the  urinary 
tract  by  tumors. 

The  ureter  is  generally  dilated  to  a  diameter  of  from  one  fourth  to 
one  half  inch  and  it  may  be  so  large  as  to  be  easily  mistaken  for  the 
intestine.  Usually  the  ureters  appear  much  elongated  and  sacculated; 
the  pelvis  and  the  calices  of  the  kidney  may  be  slightly  dilated  or  the 
greater  part  of  the  kidney  may  be  destroyed,  leaving  only  a  series  of 
communicating  pockets  surrounded  by  a  thin  cortex  of  renal  tissue. 
After  a  time  chronic  nephritis  usually  develops.  This  may  involve  both 
kidneys,  even  though  the .  hydronephrosis  is  unilateral. 

If  hydronephrosis  is  unilateral  there  may  be  no  symptoms  until  the 
dilatation  of  the  pelvis  of  the  kidney  has  reached  a  sufficient  size  to 
form  an  abdominal  tumor.  In  most  of  the  cases  in  children  this  condi- 
tion has  been  noted  between  the  third   and  the  eleventli   vears.     This 


MALFORMATIONS  AND  MALPOSITIONS  625 

tumor  may  be  situated  in  the  lumbar  region,  or  it  may  fill  the  abdomen. 
It  is  cystic,  and  may  be  confounded  with  a  dermoid  cyst  of  the  ovary. 
On  aspiration  a  fluid  is  withdrawn  which  may  be  clear,  or  of  a  brownish 
color,  and  recognized  as  urine  by  the  fact  that  it  contains  urates  and 
urea.  After  aspiration  the  urine  passed  per  urethram  may  be  bloody. 
Aspiration  affords  only  temporary  relief,  as  the  tumor  quickly  refills. 
The  treatment  is  surgical.  When  the  other  kidney  is  normal  nephrectomy 
often  results  in  a  permanent  cure. 

Double  hydronephrosis  occurs  much  more  frequently  in  the  male. 
In  infants  and  young  children  it  not  infrequently  causes  a  definite  and 
characteristic  group  of  symptoms.  It  may  be  found  in  infants  a  few 
weeks  old  or  throughout  childhood.  Double  hydronephrosis,  however, 
is  generally  associated  with,  or  results  in,  such  changes  in  the  kidneys 
that  the  patients  die  during  infancy. 

The  cause  of  double  hydronephrosis  is  usually  to  be  found  in  the 
posterior  urethra.  While  several  abnormalities  have  lieen  described  the 
most  common  one  is  an  exaggeration  of  the  normal  folds  of  mucous 
membrane  that  lead  from  the  verumontanum  to  the  wall  of  the  urethra. 
These  folds  are  sometimes  greatly  hypertrophied  and  so  situated  as  to 
make  a  diaphragm  across  the  urethra  in  which  there  is  usually  a  small, 
slit-like  opening.  There  is  thus  produced  a  great  obstacle  to  the  passage 
of  urine.  The  changes  produced  in  the  bladder,  ureters  and  kidney  are 
very  extensive.  The  bladder  is  much  increased  in  thickness  but  is  not 
dilated.  The  walls  of  the  bladder  may  be  as  much  as  a  quarter  or  a 
third  of  an  inch  in  thickness.  The  ureters  are  greatly  dilated  and  are 
often  an  inch  or  more  in  diameter.  They  are  tortuous,  their  walls  are 
thickened  and  thrown  into  folds.  The  kidneys  are  increased  in  size,  due 
entirely  to  the  hydronephrosis,  for,  as  a  result  of  this,  the  renal  substance 
may  be  reduced  to  a  minimum.  They  consist  of  a  mass  of  dilated,  com- 
municating cystic  spaces  surrounded  by  a  shell  of  renal  tissue.  The 
structure  of  cortex  and  medulla  may  be  indistinguishable.  Secondary 
infection  not  infrequently  occurs,  in  which  case  the  bladder,  ureters  and 
kidneys  may  contain  pus  and  there  may  be  abscesses  in  the  substance  of 
the  kidney.  An  excellent  example  of  this  condition  is  shown  in  Fig.  84. 
The  damage  to  the  kidneys  may  be  so  great  that  the  infant  dies  shortly 
after  birth.    When  it  is  less,  life  may  be  prolonged  for  months  or  years. 

The  history  is  at  times  quite  characteristic.  There  may  have  been 
difficulty  in  urination  and  dribbling  of  urine  from  birth  or  it  may  not 
have  been  noticed  until  the  child  was  a  year  or  two  old,  or  perhaps  even 
later.  With  each  attempt  to  pass  urine  only  a  small  quantity  is  expelled 
after  much  straining.  Examination  of  the  abdomen  shows  a  firm, 
globular  mass  in  the  hypogastrium  which  remains  even  after  urination. 
Leading  up  from  this  into  the  loin  on  each  side  there  may  often  be  felt 


626  DISEASES  OF  THE  UROGENITAL  SYSTEM 

masses  sometimes  elongated,  sometimes  globular,  which  are  the  twisted 
tortuous  ureters.  The  kidneys  may  or  may  not  be  felt.  In  the  bilateral 
form  of  hydronephrosis  the  renal  tumors  are  usually  not  large,  as  life 
would  be  impossible  with  the  destruction  of  much  renal  substance  on 
both  sides.  The  masses  may  vary  in  size  but  the  tumor  formed  by  the 
bladder  is  the  most  constant  one. 


Fig.  84. — Congenital    Hydronephrosis,    Dilated    Ureters,    and    Htpertrophibd 
Bladder.     (From  a  child  one  month  old.) 

Changes  in  the  urine  may  not  be  present  until  the  condition  is  far 
advanced.  There  may  be  all  the  symptoms  of  chronic  diffuse  nephritis  or 
when  infection  of  the  genital  tract  occurs,  there  are  added  the  symptoms 
of  pyonephrosis.  The  course  is  usually  progressive.  More  and  more 
damage  to  the  kidneys  takes  place  until  death  results  from  uremia,  from 
secondary  infection,  or  from  some  intercurrent  disease. 

■  The  treatment  is  surgical.     The  obstruction  should  be  removed.     If 


URIC-ACID  INFARCTIONS  627 

this  is  done  early  before  extensive  changes  in  the  kidneys  have  taken  place 
life  may  be  indeiinitely  prolonged.  ,  We  have  had  two  patients,  three  and 
fonr  years  of  age,  operated  upon  with  very  satisfactory  results. 

Movable  Kidney. — This  is  a  rare  condition  in  young  children. 
Comby  has  collected  eighteen  cases,  of  which  sixteen  were  in  girls  and  two 
in  boys.  Movable  kidney  was  recognized  before  the  tenth  year  in  eight 
cases,  and  in  two  of  these  before  the  fourth  month.  It  has  been  ascribed 
to  too  long  a  pedicle,  which  may  be  congenital;  also  to  pressure  from 
abdominal  tumors  and  to  injury.  The  most  important  symptoms  are 
paroxysmal  pain  which  may  follow  exertion,  and  a  movable  tumor.  A 
twist  in  the  ureter  may  produce  hydronephrosis. 


URIC-ACID  INFARCTIONS 

These  consist  in  a  deposit  in  the  straight  tubes  of  the  kidneys  of  uric 
acid  or  of  amorphous  or  crystalline  urates;  usually  both  kidneys  are 
afEected,  and  all  the  pyramids  of  each  kidney.  The  infarctions  appear 
to  the  naked  eye  as  fine,  brownish-yellow,  fan-shaped  striae.  Associated 
with  them. there  may  be  granular  deposits  of  uric-acid  salts  in  the  pelvis 
of  the  kidney,  and  sometimes  evidences  of  catarrhal  inflammation  of  the 
pelvis,  including  even  the  presence  of  blood.  This  condition  probably 
occurs,  to  some  degree  at  least,  in  nearly  all  infants  during  the  first  ten 
days  of  life.  It  was  formerly  supposed  that  the  discovery  of  these  ap- 
pearances was  proof  that  an  infant  had  breathed,  and  a  certain  medico- 
legal importance  was  therefore  attached  to  them.  This  is  now  known 
not  to  be  the  case,  as  they  are  sometimes  found  in  still-born  infants. 

The  cause  of  this  condition  is  the  excretion  of  uric  acid  before  there 
is  sufficient  water  to  dissolve  it,  so  that  the  crystals  are  deposited  in  the 
tubes.  Uric-acid  infarctions  are  found  chiefly  in  children  dying  before 
the  end  of  the  second  week,  although  it  is  not  uncommon  to  see  them  as 
late  as  the  third  or  fourth  or  even  the  sixth  month.  In  most  of  the 
cases,  as  the  urinary  secretion  becomes  more  abundant,  the  deposits  are 
washed  out  in  the  urine  and  appear  as  brownish-red  or  pink  stains  upon 
the  napkins.  Infarctions  may  give  rise  to  a  slight  inflammation  of  the 
renal  tubules,  but  very  rarely  to  any  serious  lesion;  sometimes  they 
remain  as  deposits  in  the  calices  or  the  pelvis  of  the  kidney  or  in  the 
bladder,  forming  the  nuclei  of  calculi.  The  symptoms  to  which  they 
give  rise  are  mainly  scanty  urination  during  the  first  week  of  life,  and 
occasionally  anuria  for  the  first  day  or  two.  Sometimes  there  is  evidence 
of  severe  pain ;  priapism  may  be  present,  and  there  is  the  stain  upon  the 
napkin  already  referred  to.  The  treatment  is  to  give  water  freely  and 
some  alkaline  diuretic  such  as  citrate  of  potash.     One  grain  should  be 


628  DISEASES  OF  THE  UROGENITAL  SYSTEM 

given  every  two  hours  until  the  secretion  is  fully  established ;  this  in  most 
cases  will  be  within  twenty-four  hours. 


CHRONIC  CONGESTION   OF  THE  KIDNEYS 

This  results  from  interference  with  tlie  return  circulation  of  th^e 
kidney,  and  may  be  caused  by  congenital  malformation  or  valvular  dis- 
ease of  the  heart,  chronic  bronchopneumonia  or  chronic  pleurisy;  also 
by  the  pressure  of  any  abdominal  tumor  upon  the  inferior  vena  cava 
or  the  renal  veins. 

The  kidneys  are  generally  enlarged,  firmer  than  normal,  and  dark- 
colored.  All  the  capillary  vessels  are  swollen  and  distended  with  blood, 
and  their  walls  are  thickened.  In  addition  to  the  symptoms  of  the  pri- 
mary disease,  the  amount  of  urine  passed  is  usually  scanty  and  of  higli 
specific  gravity.  Albumin  and  casts  are  generally  present,  but  are  not 
constant.  The  treatment  should  be  directed  toward  the  primary  condi- 
tion, and,  in  addition,  an  effort  should  be  made  to  increase  the  amount  of 
urine  by  alkaline  diuretics,  caffein,  digitalis,  and  the  sodium  salicylate  of 
theobromin. 

ACUTE  DEGENERATION  OF  THE  KIDNEYS 

In  the  succeeding  pages  devoted  to  the  kidney  Prudden's  classifica- 
tion in  the  main  has  been  followed. 

In  acute  degeneration  of  the  kidney  the  principal  or  only  change  is 
in  the  epithelium  of  the  tubules.  It  is  exceedingly  common  both  in  in- 
fancy and  in  childhood,  being  found  to  a  greater  or  less  degree  in  all 
autopsies  upon  patients  dying  of  acute  infectious  diseases,  but  it  is  most 
marked  in  cases  of  scarlet  fever,  diphtheria,  and  acute  pleuropneumonia. 
It  may  be  found  in  any  disease  characterized  by  prolonged  high  tempera- 
ture, and  it  is  the  explanation  of  the  cases  of  so-called  febrile  albu- 
minuria. The  cause  is  in  all  probability  direct  irritation  of  the  epi- 
thelium of  the  tubules  by  the  toxins  eliminated  by  the  kidneys.  It  may 
also  be  induced  by  irritating  drugs,  such  as  cantharides  or  turpentine.  By 
some  writers  these  cases  have  been  classed  as  examples  of  acute  nephritis ; 
hence  the  great  discrepancy  which  exists  in  statements  made  as  to  the 
frequency  of  nephritis  in  the  different  infectious  diseases. 

The  kidneys  are  usually  slightly  enlarged,  softer,  and  paler  than 
normal.  On  section  the  cortex  may  be  somewhat  thickened,  and  the 
straight  tubules  marked  by  yellowish-gray  lines.  It  is  the  appearance 
commonly  spoken  of  as  cloudy  swelling.  The  kidneys  are  seldom  much 
congested.    The  microscope  shows  a  granular  degeneration  of  the  epithe- 


ACUTE  DIFFUSE  NEPHRITIS  629 

Hum  of  the  tubules,  and  when  severe  this  may  be  accompanied  by  conges- 
tion and  the  exudation  of  serum. 

Acute  degeneration  of  the  kidneys  gives  rise  to  no  symptoms  in  addi- 
tion to  those  of  the  original  disease,  except  the  appearance  of  a  moderate 
amount  of  albumin  in  the  urine,  with  a  few  hyaline,  granular,  or  epi- 
thelial casts.  It  can  not  be  said  that  such  a  condition  adds  much  to  the 
danger  from  the  original  disease.  In  cases  that  recover,  the  condition  of 
the  kidney  becomes  entirely  normal.  The  development  of  the  symptoms 
of  degeneration  of  the  kidneys  in  infectious  diseases  calls  for  no  special 
treatment  beyond  a  continuance  of  the  fluid  diet. 


ACUTE  DIFFUSE  NEPHRITIS 

(Acute  Interstitial   Nephritis;    Acute  Exudative  Nephritis;    Glomerulonephritis; 

Acute  Bright's  Disease. ) 

Etiology. — This  variety  of  nephritis  occurs  apparently  as  a  primary 
disease  both  in  infants  and  in  older  children.  Most  such  cases  are  un- 
doubtedly of  infectious  origin,  although  the  point  of  entrance  of  the 
infection  it  may  be  difficult  or  impossible  to  determine.  Acute  diffuse 
nephritis  is  very  frequently  secondary  to  the  acute  infectious  diseases, 
especially  to  scarlet  fever  and  diphtheria.  It  occasionally  follows  measles, 
varicella,  empyema,  typhoid  fever,  acute  diarrheal  diseases,  pneumonia, 
meningitis,  influenza,  and  malaria.  It  is  the  characteristic  variety  of 
secondary  nephritis  occurring  in  severe  septic  conditions.  Some  children 
exhibit  a  predisposition  to  this  disease  and  develop  acute  nephritis  with 
almost  any  infectious  disease,  however  mild,  which  they  contract.  The 
exciting  cause  of  the  inflammation  is  in  some  cases  the  irritation  from 
toxins ;  but  usually  there  is  in  addition  the  entrance  of  pathogenic  organ- 
isms carried  by  the  circulation.  Thus  in  post-scarlatinal  nephritis,  of 
which  the  one  under  consideration  is  the  characteristic  form,  the  cause  is 
now  generally  admitted  to  be  the  toxins  of  the  primary  disease,  to  which 
in  many  cases  is  added  infection  by  the  streptococcus.  While  nephritis 
is  more  frequent  after  severe  attacks  of  scarlet  fever,  it  may  occur  after 
those  which  are  very  mild,  even  when  patients  have  been  kept  in  bed 
throughout  the  disease.  The  frequency  of  nephritis  as  a  sequel  of  scarlet 
fever  varies  much  in  different  epidemics;  the  average  is  from  six  to  ten 
per  cent.  We  have  seen  two  cases  of  acute  nephritis  in  infants,  the 
apparent  cause  of  which  was  the  irritation  of  a  highly  concentrated  urine. 
This  was  the  result  of  the  infants  taking  for  a  long  time  very  little 
food  and  almost  no  water. 

Lesions. — In  severe  cases  the  kidneys  are  usually  enlarged,  soft,  and 
edematous.    The  capsule  is  non-adherent.    The  cortex  is  thickened,  either 


630  DISEASES  OF  THE  UROGENITAL  SYSTEM 

reddened  or  jjale ;  frequently  it  is  mottled  with  red^  owing  to  the  presence 
of  small  hemorrhages.  There  may  be  congestion  of  the  entire  organ; 
or  the  pyramids  may  seem  unusually  red  by  contrast  with  the  pale  and 
thickened  cortex. 

iVU  the  structures  of  the  kidney — glomeruli,  tubular  epithelium,  and 
interstitial  tissue — are  involved  in  the  inflammatory  process.  The  cells 
covering  the  glomerular  tufts  of  capillaries  are  swollen  and  proliferated. 
They  have  frequently  undergone  fatty  degeneration.  The  epithelial  cells 
lining  Bowman's  capsule  may  undergo  the  same  changes,  but  usually  to 
a  lesser  degree.  The  space  between  the  capsule  and  the  tuft  may  contain 
exfoliated  epithelium  in  considerable  quantity,  also  cell-detritus,  albu- 
minous (granular)  exudate,  leucocytes,  and  red  blood-cells.  The  tubular 
epithelium  undergoes  albuminous  and  fatty  degeneration  and  may  des- 
quamate. Thus  the  tubules  may  contain  epithelial  fragments,  serum, 
red  blood-cells,  leucocytes,  and  casts.  The  interstitial  connective  tissue  is 
infiltrated  with  serum  and  in  places  with  small  round  cells.  In  cases  of 
longer  duration  a  general  increase  of  the  connective  tissue  may  take 
place,  which  is  permanent. 

When  the  glomerular  changes  are  especially  marked,  as  in  acute 
nephritis  following  scarlet  fever,  the  process  is  often  spoken  of  as 
glomerulonephritis.  If  the  degeneration  of  the  tubular  epithelium  is 
extreme,  as  in  severe  cases  of  diphtheria  dying  shortly  after  the  onset, 
the  nephritis  may  be  described  as  the  parenchymatous  or  degenerative 
type.  In  the  hemorrhagic  form  there  are  hemorrhages  into  the  tubules, 
glomeruli,  or  interstitial  tissue.  In  infants  and  young  children  the  exu- 
dative type  of  acute  diffuse  nephritis  is  especially  frequent.  In  this 
there  is  an  exudative  inflammation  with  large  accumulations  of  leucocytes, 
serum,  and  red  blood-cells  in  the  glomeruli  and  tubules,  the  parenchyma 
and  interstitial  tissue  sometimes  being  markedly  and  sometimes  but 
slightly  changed.  Should  the  interstitial  tissue  suffer  early  and  severely, 
the  nephritis  l^ecomes  of  the  productive  or  interstitial  type.  This  form  is 
most  frequently  seen  Avith  severe,  protracted  cases  of  scarlet  fever  and 
diphtheria,  especially  in  older  children.  It  sometimes  occurs  as  an  ap- 
parently independent  process. 

Symptoms. — 1.  Primary  Form  in  Infants. — These  cases  are  not  com- 
mon, and  the  symptoms  are  so  obscure  that  they  are  often  overlooked. 
A  number  of  such  cases  have  come  under  our  observation.  The  inflamma- 
tion in  most  of  them  was  of  the  exudative  ty^pe. 

The  onset  in  nearly  every  instance  was  abrupt,  usually  with  high 
fever  and  vomiting,  the  temperature  being  in  several  cases  over  104°  F. 
Dropsy  was  exceptional;  in  most  of  these  it  was  slight,  and  seen  only 
toward  the  close  of  the  disease.  Fever  Avas  present  in  all  cases.  In  those 
observed  by  us  it  was  high  and  irregular  in  type,  ranging  from  101°  to 


ACUTE  DIFFUSE  XEPHRITIS  631 

]()5°  r.  The  duration  of  the  disease  was  from  one  to  four  weeks,  the 
average  being  about  two  and  a  half  weeks.  Vomiting  and  diarrhea  were 
noted  in  half  the  cases,  but  were  rarely  prominent,  and  marked  either 
the  onset  of  the  attack,  or  were  traceable  to  indigestion  accompanying 
the  fever;  very  rarely  did  they  exist  as  symptoms  of  uremia.  Anemia 
was  a  prominent  symptom  in  nearly  every  case,  and  it  was  this  which 
called  attention  in  several  instances  to  the  renal  condition.  Nervous 
symptoms  were  usually  prominent.  In  several  patients  there  was 
dyspnea  without  pulmonary  disease  and  without  cyanosis,  partly  due 
perhaps  to  the  marked  anemia,  but  probably  due  chiefly  to  the  develop- 
ment of  acidosis.  In  nearly  all  cases  there  was  marked  restlessness  or 
muscular  twitchings,  and  in  three  there  were  convulsions.  Dullness 
and  apathy  were  present  in  the  majority  of  the  fatal  cases,  but  deep 
coma  was  never  seen.  The  urine  was  rarely  scanty  until  near  the  close 
of  the  disease,  and  sometimes  not  even  then.  Suppression  of  urine 
was  seldom  seen.  Albumin  was  frequently  absei:it  early  in  the  attack, 
but  was  invariably  present  at  a  late  period,  although  rarely  in  large 
amount.  Casts  were  found  in  all  cases  that  were  carefully  examined 
microscopically.  They  were  not  usually  numerous,  and  were  chiefly  of 
the  hyaline,  granular,  and  epithelial  varieties.  ISTo  blood  casts  were 
seen.  There  were  usually  many  pus  cells  and  renal  epithelial  cells, 
together  with  red  blood-cells  in  moderate  numbers. 

Of  the  thirty-four  cases  collected,  including  our  own,  twenty-five 
died  and  only  nine  recovered.  Whether  these  figures  represent  the  actual 
mortality  of  the  disease  it  is  difficult  to  say.  Xo  doubt  there  are  many 
mild  cases  which  are  unrecognized.  The  severe  ones,  however,  are  quite 
uniformly  fatal,  chiefly  on  account  of  the  tender  age  of  the  patients. 

2.  Prima/ry  Form  in  Older  Children. — This  also  is  a  rare  form  of 
renal  disease.  The  onset  is  usually  less  abrupt  than  in  infants,  the 
febrile  symptoms  are  less  marked,  and  the  termination  is  less  frequently 
fatal.  Dropsy  is  rarely  marked,  and  often  is  absent.  The  urine  is  only 
slightly  diminished  in  quantity;  the  amount  of  albumin  is  small;  casts 
are  not  numerous,  and  usually  hyaline,  epithelial,  or  granular;  very  rarely 
is  there  much  blood  present.  Uremia  is  infrequent,  and  the  prognosis  is 
Ijetter  than  in  infancy.  The  course  may  be  very  prolonged;  but  even 
when  albuminuria  has  lasted  several  months  recovery  may  be  complete. 

The  interstitial  type  may  begin  abruptly  with  febrile  symptoms, 
dropsy,  headache,  lumbar  pains,  scanty  urine,  and  often  with  vomiting; 
or  it  may  come  on  somewhat  insidiously  with  few  constitutional  symp- 
toms, but  with  dropsy  and  changes  in  the  urine. 

3.  Secondary  Form. — The  secondary  nephritis  of  acute  infectious  dis- 
eases may  occur  at  the  height  of  the  febrile  process  or  at  a  later-  period, 
and  its  severity  is  generally  proportionate  to  the  intensity  of  the  infection. 


632  DISEASES  OF  THE  UROCENTTAL 'SYSTEIM 

The  general  symptoms  of  nephritis  are  often  not  marked,  and  dropsy 
is  rare;  so  that  unless  the  nrine  is  examined  the  condition  may  be  over- 
looked. The  urinary  changes  are  essentially  the  same  as  those  already 
mentioned  in  the  primary  cases.  Suppression  of  nrine  and  the  develop- 
ment of  the  symptoms  of  acute  uremia  are  infrequent.  While  nephritis 
adds  considerably  to  the  danger  from  the  primary  disease,  it  is  seldom 
itself  the  cause  of  death,  although  this  is  sometimes  the  case  in  scarlet 
fever  and  diphtheria. 

The  characteristic  type  of  nephritis  which  follows  scarlet  fever  most 
frequently  develops  during  the  third  or  fourth  week  of  the  disease.  The 
onset  may  be  gradual,  dropsy  being  first  noticed.  Or  it  may  begin 
abruptly  without  dropsy,  but  with  headache,  vomiting,  scanty  urine,  fever, 
and  even  convulsions.  The  temperature  generally  ranges  from  100°  to 
101.5°  F.,  but  in  very  severe  attacks  it  may  be  104°  or  105°  F.  While 
dropsy  is  usually  present,  it  may  be  slight  or  absent  in  severe  and  even  in 
fatal  cases.  It  is  first  seen  in  the  face,  next  in  the  feet,  legs,  and  scrotum; 
there  may  be  general  anasarca,  with  dropsy  of  the  serous  cavities  of  the 
body,  the  pleura,  or  the  peritoneum,  rarely  the  pericardium.  As  the 
disease  progresses  there  is  always  a  very  marked  degree  of  anemia. 

The  urine  is,  as  a  rule,  greatly  diminished  in  quantity,  and  may  be 
suppressed.  Albumin  is  invariably  present,  although  not  always  at  first; 
it  is  usually  in  large  amount,  often  enough  to  render  the  urine  solid 
upon  boiling.  The  urine  is  of  a  dark,  reddish-brown  or  smoky  color, 
owing  to  the  presence  of  red  blood-cells  or  hemoglobin.  The  specific 
gravity  may  be  low,  even  though  the  quantity  is  very  small.  Casts  are 
present  in  great  numbers,  chiefly  hyaline,  granular,  and  epithelial  casts 
from  the  straight  tubes;  not  infrequently  there  are  blood  casts.  Eed 
blood-cells  are  present  in  great  numbers ;  also  many  leucocytes,  and  renal 
epithelium. 

The  duration  of  the  active  symptoms  in  cases  terminating  in  recovery 
is  from  one  to  three  weeks.  The  temperature  and  dropsy  gradually  sub- 
side. Improvement  in  the  urine  is  shown  ^Dy  an  increase  in  quantity,  by 
an  increased  elimination  of  urea,  and  by  a  diminution  in  the  amount  of 
blood,  albumin,  and  the  number  of  casts.  A  few  casts  may  persist  for 
several  weeks,  and  a  small  amount  of  albumin  for  two  or  three  months. 

In  the  graver  cases,  when  the  onset  is  accompanied  by  high  temper- 
ature, pain  in  the  back  and  loins,  and  a  rapid,  full  pulse  of  high  tension, 
the  urine  is  very  scanty  and  is  often  suppressed.  Then  follow  the  symp- 
toms of  uremia.  In  children  this  is  usually  manifested  by  vomiting, 
great  restlessness  or  apathy,  and  often  by  diarrhea.  Hyperpnea  is  not 
infrequent  and  is  usually  evidence  of  acidosis.  Less  frequently  there  is 
headache,  dimness  of  vision,  stupor  developing  into  coma,  or  convul- 
sions.    If  the  secretion  of  urine  is  ro-ostablislicd.  Iho  ner\oiis  symptoms 


ACUTE  DIFFUSE  NEPHRITIS  633 

abate  and  the  patient  may  recover.  This  has  been  known  to  occur 
after  complete  suppression  has  lasted  thirty-six  hours.  Care  should  be 
taken  not  to  mistake  retention  for  suppression.  If  doubt  exists,  percus- 
sion of  the  bladder  and  the  use  of  the  catheter  will  quickly  settle  the 
question. 

There  are  several  complications  for  which  the  physician  must  con- 
stantly be  on  the  lookout  during  attacks  of  acute  nephritis;  the  most 
frequent  are  pneumonia,  pleurisy,  pericarditis,  and  endocarditis;  more 
rarely  there  may  be  meningitis  and  edema  of  the  glottis.  It  is  from 
complications  or  acute  uremia  that  death  usually  occurs. 

Prognosis. — This  is  to  be  considered  from  two  points  of  view:  first, 
the  danger  to  life  during  the  acute  stage  of  the  disease,  and,  secondly, 
the  danger  of  the  development  of  chronic  nephritis.  The  majority  of 
patients  survive  the  acute  stage,  and  not  infrequently  even  those  re- 
cover who  have  presented  grave  symptoms  of  uremic  poisoning.  The 
quantity  and  specific  gravity  of  the  urine,  the  delayed  elimination  of 
phenolsulphonephthalein,  and  the  number  and  variety  of  the  casts,  are 
a  much  better  guide  in  prognosis  than  the  amount  of  albumin.  The 
existence  of  acidosis  and  of  severe  nervous  symptoms,  such  as  stupor, 
intense  headache,  dimness  of  vision,  and  persistent  vomiting,  add  much 
to  the  gravity  of  the  case,  as  does  also  the  presence  of  any  serious  com- 
plication. In  general  it  may  be  said  that  if  there  is  no  suppression  of 
urine,  or  if  there  are  no  symptoms  of  uremia  and  no  complications, 
recovery  is  almost  certain  if  the  child  is  over  three  years  old ;  in  younger 
children  the  outlook  is  less  favorable.  The  general  opinion  prevails  that 
acute  diffuse  nephritis  in  childhood,  whether  it  is  primary  or  occurs  as 
a  complication  of  scarlet  fever,  is  rarely  followed  by  the  chronic  form 
of  the  disease;  and  such  was  the  view  we  formerly  held.  Larger  experi- 
ence, however,  has  convinced  us  that  this  sequel  is  not  very  uncommon. 
The  interval  of  apparent  health  may  sometimes  cover  a  period  of  several 
years,  and  the  later  nephritis  may  be  attributed  to  other  causes;  but  all 
cases  of  scarlatinal  nephritis  should  be  carefully  watched  for  a  long  time, 
and  after  a  severe  attack  a  guarded  prognosis  should  always  be  given  as 
regards  the  ultimate  result.^ 

Treatment. — Prophylaxis  is  important,  and  relates  principally  to  the 

^The  following  case  may  be  cited  as  an  illustration  of  this  point:  A  girl 
at  the  age  of  seven  years  had  scarlet  fever,  followed  by  nephritis;  the  dropsy 
having  lasted,  it  was  reported,  for  three  months.  She  was  believed  to  have 
recovered  perfectly,  and  remained  in  apparent  health  until  she  was  sixteen,  when, 
as  a  supposed  result  of  a  severe  chilling,  she  developed  dropsy  and  all  the  symp- 
toms of  acute  nephritis.  From  that  time,  although  she  lived  for  three  years, 
and  was  often  for  months  at  a  time  seemingly  in  the  best  of  health,  her  urine 
was  never  free  from  casts  and  albumin,  and  she  finally  died  in  viremic  convul- 
sions. 


634  DISEASES  OF  THE  UROGENITAL  SYSTEM 

secondary  form  which  occurs  in  the  course  of  infectious  diseases,  espe- 
cially to  post-scarlatinal  nephritis ;  but  the  measures  here  outlined  apply 
equally  to  all  varieties.  The  inflammation  of  the  kidney  being  in  most 
of  these  cases  the  result  of  direct  irritation  by  the  toxins  which  are  elim- 
inated by  them,  it  follows  that  elimination  through  the  skin  and  intes- 
tines should  be  increased,  and  that  the  urine  should  be  rendered  as  little 
irritating  as  possible  by  largely  increasing  its  quantity.  The  first  indi- 
cation is  met  by  frequent  sponging,  warm  baths,  and  keeping  the  bowels 
freely  opened  by  saline  cathartics,  sufficient  being  given  to  produce  one 
or  two  loose  movements  daily.  To  meet  the  second  indication,  the  pa- 
tient should  be  kept  upon  a  diet  of  milk  and  farinaceous  food,  at  least 
for  the  first  three  weeks  of  the  disease,  and,  if  possible,  for  a  full  month. 
At  the  same  time  he  should  drink  very  freely  of  alkaline  mineral  waters, 
or  of  plain  water.  If  milk  is  not  well  borne,  kumyss,  whey,  or  butter- 
milk may  be  used,  or  thin  gruels  mixed  with  milk.  When  the  first 
trace  of  albumin  appears  in  the  urine  this  plan  of  treatment  should  in- 
variably be  followed.  In  addition  to  these  measures,  after  an  attack  of 
scarlet  fever  the  patient  should  be  kept  in  bed  for  at  least  a  week  after 
the  temperature  has  become  normal. 

The  mild  cases  of  acute  nephritis  tend  to  spontaneous  recovery  under 
the  hygienic  and  dietetic  treatment  outlined,  i.  e.,  rest  in  bed,  the  diet 
mentioned,  the  drinking  of  large  quantities  of  water,  and  attention  to  the 
action  of  the  skin  and  bowels.  These  measures  should  be  continued  so 
long  as  the  urine  contains  any  considerable  amount  of  albumin,  or  so 
long  as  the  patient's  general  condition  will  permit.  Should  he  become 
very  anemic,  or  lose  much  in  weight,  it  may  be  necessary  to  enlarge  the 
diet  by  the  addition  of  more  solid  food.  An  increase  in  the  diet  and 
exercise  should  be  made  very  gradually,  and  the  effect  upon  the  urine 
carefully  watched. 

The  severe  cases,  with  scanty  urine,  fever  and  marked  dropsy,  re- 
quire more  active  treatment.  Free  diaphoresis  should  be  maintained  by 
the  hot  pack  or  vapor  bath.  Active  counter-irritation  should  be  used 
over  the  kidneys  by  dry  cups  followed  by  poultices,  or  the  mustard 
paste.  Two  or  three  loose  movements  from  the  bowels  should  be  secured 
by  the  administration  of  calomel  or,  better  by  Eochelle  or  Epsom  salts. 
Harm  is  sometimes  done  by  carrying  this  depletion  too  far,  and  its 
effect  upon  the  patient's  general  condition  must  be  closely  watched.  If 
suppression  of  urine  occurs  with  the  development  of  uremic  symptoms — 
delirium,  vomiting,  diarrhea,  and  a  pulse  of  high  tension — venesection 
should  be  practiced ;  from  three  to  six  ounces  of  blood  may  be  drawn  from 
a  child  of  five  years,  according  to  his  general  condition  and  the  urgency 
of  the  symptoms.  The  depressing  effect  may  largely  be  overcome  by  im- 
mediately following  this  with  an  intravenous  injection  of  a  normal  salt 


CHRONIC  NEPHRITIS  635 

solution.  Twice  as  much  as  the  fluid  drawn  should  be  introduced.  This 
will  almost  invariably  give  at  least  temporary  relief,  which  may  afford 
time  for  the  operation  of  other  measures,  such  as  catharsis  and  diaphore- 
sis. Pulmonary  edema  is  rather  an  indication  to  bleeding;  the  best  of 
all  guides  as  to  its  use  is  a  pulse  of  very  high  tension. 

In  addition  to  these  measures  rectal  injections  of  a  normal  salt  solu- 
tion may  be  given  high  in  the  colon,  at^U  "temperature  of  from  104° 
to  108°  F.  At  least  two  quarts  should  be  given  several  times  a  day,  to  be 
continued  until  a  free  flow  of  urine  is  established.  This  is  one  of  the 
most  valuable  means  we  possess  of  increasing  elimination  by  the  kidneys 
and  skin. 

The  nervous  symptoms  of  uremia  are  best  relieved  by  chloral,  which 
should  be  given  per  rectum.  When  such  symptoms  are  marked,  from 
six  to  ten  grains  are  required  for  a  child  of  five  years,  to  be  repeated 
in  two  hours  if  no  improvement  is  seen.  Uremic  convulsions  may  some- 
times be  averted  by  the  use  of  morphin  hypodermically. 

One  should  always  be  on  the  lookout  for  complications,  especially 
dropsy  of  the  serous  cavities,  pericarditis,  and  edema  of  the  lungs.  Con- 
valescence is  nearly  always  slow,  and  a  patient  who  has  suffered  from 
nephritis  needs  careful  attention  for  a  long  time.  Anemia  is  always 
present,  and  iron  is  required.  The  diet  should  be  carefully  restricted 
for  several  months;  much  nitrogenous  food  should  be  avoided.  If  the 
disease  tends  to  pass  into  a  subacute  form,  the  child  should,  if  possible, 
be  sent  to  a  warm  climate,  and  kept  there  during  the  succeeding  winter, 
and  every  means  taken  to  improve  the  general  nutrition.  Flannels 
sliould  be  worn  next  to  the  skin,  and  special  precautions  taken  against 
any  exposure  which  might  cause  an  exacerbation  of  the  disease. 


CHRONIC  NEPHRITIS 

Chronic  inflammation  of  the  kidney  is  an  infrequent  condition  in 
childhood.  In  infancy  it  is  almost  unknown,  except  in  connection  with 
congenital  hydronephrosis  or  other  malformations  of  the  kidney.  Two 
pathological  varieties  are  met  with :  ( 1 )  chronic  diffuse  nephritis  of 
the  parenchymatous  or  degenerative  type;  (2)  chronic  diffuse  nephri- 
tis of  the  interstitial  or  productive  type.  As  the  disease  progresses  the 
former  may  assume  the  characteristics  of  the  latter  variety. 

Etiology. — Chronic  nephritis  is  most  frequently  seen  as  a  sequel  of 
the  acute  nephritis  of  scarlet  fever,  less  often  after  other  acute  infections. 
The  only  other  important  causes  in  early  life  are  hereditary  syphilis, 
chronic  tuberculosis,  and  valvular  disease  of  the  heart.  Nearly  all  the 
cases  occur  in  children  over  five  years  of  age. 


G36  DISEASES  OF  THE  UROGENITAL  SYSTEM 

Lesions. — The  lesions  of  chronic  nephritis  in  childhood  do  not  differ 
essentially  from  those  seen  in  later  life.  In  the  chronic  parenchymatous 
type  the  kidneys  are  usually  enlarged,  the  surface  is  smooth  or  slightly 
nodular,  and  the  thickened  cortex  yellowish-white  on  section.  These  are 
often  called  "large  white  kidneys."  On  the  other  hand,  the  kidneys 
may  be  nearly  normal  in  appearance,  or  smaller  and  with  a  thinner  cortex 
than  is  usual.  Tn  the  so-called  "large  red  kidneys"  the  cortex  is  red  or 
mottled  red  and  yellow,  owing  to  hemorrhages  into  the  tubules  or  in- 
terstitial tissue.  The  microscope  shows  that  the  renal  epithelium  is 
swollen,  granular,  fatty,  and  degenerated.  The  tubes  contain  leucocytes, 
red  cells,  cast  matter,  and  the  detritus  of  broken-down  epithelial  cells. 
In  some  places  they  are  dilated,  in  others  atrophied.  In  the  glomeruli 
there  is  a  growth  of  cells,  compression  and  atrophy  of  the  tufts,  with  the 
formation  of  new  connective  tissue. 

In  the  chronic  diff'use  nephritis  of  the  interstitial  type  (granular 
kidney)  the  organs  are  smaller  than  normal,  with  a  nodular  surface  and 
adherent  capsule.  The  cortex  is  thinned,  and-  the  color  is  gray  or  red. 
In  addition  to  the  lesions  found  in  the  preceding  variety,  there  is  an 
extensive  production  of  new  connective  tissue,  which  is  irregularly  dis- 
tributed throughout  the  kidneys.  The  tubules  in  some  places  are  dilated 
to  form  cysts  of  considerable  size,  while  in  others  they  have  completely 
disappeared.  The  glomeruli  may  be  atrophied  to  little  fibrous  balls; 
or  if  chronic  congestion  has  preceded  the  inflammation,  some  may  be 
large  and  the  capillaries  dilated  with  hyaline  degeneration  of  their 
walls. 

Symptoms. — 1.  Chronic  Nephritis  of  the  Parenchymatous  Type. — ■ 
This  form  of  the  disease  may  be  chronic  from  the  outset,  or  follow  an 
acute  attack  from  which  the  patient  is  often  believed  to  have  recovered 
completely.  The  symptoms  sometimes  immediately  follow  the  acute 
attack;  at  otliers  there  is  an  interval  of  apparent  recovery,  extending 
over  a  few  months  or  even  years.  Very  rarely  no  such  history  of  an 
antecedent  acute  attack  can  be  obtained  and  the  symptoms  come  on 
gradually  and  insidiously.  Such  cases  occur  chiefly  in  older  children, 
and  their  clinical  features  do  not  differ  essentially  from  those  of  adult 
life. 

As  a  rule  dropsy  is  present,  although  it  is  variable  in  amount,  and 
fluctuates  considerably  from  time  to  time.  There  may  be  not  only 
edema  of  the  cellular  tissue,  but  effusion  into  the  pleura,  the  peritoneum, 
and  even  the  pericardium.  As  the  case  progresses,  anemia  is  always  a 
marked  symptom.  There  are  various  disturbances  of  digestion — loss  of 
appetite,  occasional  vomiting,  and  attacks  of  diarrhea.  From  time  to 
time  nervous  symptoms  may  be  quite  prominent,  such  as  headaches,  sleep- 
lessness, neuralgia,  fatigue  upon  slight  exertion,  and  dyspnea.    Acidosis 


CTTKOXIC  NEPHPJTIS  637 

may  dc'velup  as  it  does  in  the  nephritis  of  adults.  Attacks  of  epistaxis 
are  not  infrequent. 

For  the  greater  part  of  the  time  the  urine  contains  albumin  and 
easts.  The}'  vary  much  in  amount  at  different  periods  in  the  disease, 
according  to  the  rapidity  of  its  progress.  During  periods  of  exacerbation, 
both  albumin  and  casts  are  very  abundant,  while  in  the  intervals  the 
amount  of  albumin  may  be  small  and  the  casts  few.  The  casts  are 
hyaline,  granular,  epithelial,  and  fatty.  The  daily  quantity  of  urine  is 
much  reduced  during  the  periods  of  exacerbation,  while  at  other  times 
it  may  be  nearly  normal.    The  specific  gravity  is  usually  normal  or  high. 

If  amyloid  degeneration  is  present,  there  are  generally  associated  with 
the  renal  symptoms,  others  dependent  upon  amyloid  changes  in  other 
organs.  The  spleen  and  liver  are  enlarged;  there  may  be  ascites  and 
diarrhea,  and  there  is  usually  present  a  peculiar  alabaster  cachexia. 

The  duration  of  this  form  of  chronic  nephritis  depends  much  upon 
the  surroundings  of  the  patient  and  the  treatment.  It  is  rarely  shorter 
than  two  years,  and  it  may  last  for  many  years.  The  progress  is  always 
irregular  and  marked  by  periods  of  exacerbation  and  remission.  The 
patients  die  from  acute  uremia,  from  some  intercurrent  disease,  or  from 
complicating  pneumonia,  pleurisy,  pericarditis,  endocarditis,  or  from 
pulmonary  edema. 

2.  Chronic  Nephritis  of  the  Interstitial  Type. — This  is  a  very  rare 
disease  in  early  life,  being  much  less  frequent  even  than  the  preceding 
variety  of  nephritis.  In  some  cases  there  is  a  history  of  hereditary 
sj'philis;  in  others,  of  chronic  alcoholism.  The  early  symptoms  are  few, 
and  the  disease  usually  develops  insidiously.  The  urine  is  pale,  exces- 
sive in  amount,  and  of  low  specific  gravity — 1.001  to  1.008.  Albumin 
is  often  absent,  and,  when  found,  the  quantity  is  small.  Dropsy  like- 
wise is  rare,  and  never  marked.  Nervous  symptoms  are  often  prominent, 
such  as  headache,  attacks  of  spasmodic  dyspnea  resembling  asthma, 
neuralgias,  and  disturbances  of  vision.  High  blood-pressure  and  hyper- 
trophy of  the  left  ventricle  are  regular  symptoms ;  and  even  atheroma- 
tous degeneration  of  the  arteries  may  be  present.  Dickinson  reports  an 
instance  of  this  in  a  patient  only  six  years  of  age.  Late  in  the  disease, 
hemorrhages  may  occur,  and  these  may  be  the  cause  of  death.  Filatow 
has  reported  a  cerebral  hemorrhage  in  a  child  of  eleven  years.  Acute 
uremia  with  acidosis  is,  however,  the  usual  termination  of  this  form  of 
nephritis.  The  course  is  slow,  and  the  disease  may  be  overlooked  until 
the  final  uremic  symptoms  occur. 

Prognosis. — The  prognosis  of  chronic  nephritis  as  to  complete  recov- 
ery is  always  unfavorable;  and  although  cases  are  seen  in  which  symp- 
toms are  absent  for  several  years,  they  almost  invariably  return.  As 
to  the  duration  of  the  disease,  no  exact  prognosis  can  be  given,  because 


638  DISEASES  OF  THE  UE0C4EXITAL  SYSTEM 

from  the  symptoms  it  is  difficult  or  impossible  to  determine  exactly  the 
extent  of  the  disease  in  the  kidney  and  the  rapidity  of  its  progress.  The 
continued  passage  of  a  large  amount  of  urine  of  low  specific  gravity  is  in- 
variably to  be  interpreted  as  evidence  of  fibroid  changes  in  the  Mal- 
pighian  tufts,  and  is  a  bad  symptom.  A  large  amount  of  dropsy,  the 
coexistence  of  valvular  disease  of  the  heart,  and  marked  renal  insuf- 
ficiency, as  shown  by  the  quantitative  examination  of  the  urine  and 
by  the  phenolsulphonephthalein  test,  are  all  very  unfavorable  symp- 
toms. 

Diagnosis. — Chronic  nephritis,  like  the  acute  forms,  is  likely  to  be 
overlooked  because  of  the  failure  to  examine  the  urine  in  children. 
Eegular  and  frequent  examinations  should  be  made  in  all  cases  of  con- 
vulsions, of  persistent  or  frequent  headaches,  severe  anemia,  hypertrophy 
of  the  heart,  high  blood-pressure  and  of  general  malnutrition,  as  well 
as  when  the  more  obvious  symptoms  of  renal  disease,  such  as  dropsy  and 
scanty  urine,  are  present.  Kor  should  one  be  too  ready  to  make  the 
diagnosis  of  functional  albuminuria  because  he  finds  albumin  only  oc- 
casionally and  in  small  quantity.  All  such  cases  demand  most  careful 
observation  and  the  closest  attention  for  a  long  period  before  excluding 
organic  renal  disease. 

Treatment, — Children  with  chronic  nephritis  are  to  be  treated  on  the 
same  general  plan  as  adults.  The  purpose  of  treatment  is  to  retard  as 
much  as  possible  the  progress  of  the  disease  and  to  relieve  the  symptoms 
as  they  arise.  It  is  of  the  greatest  importance  to  remove  the  patient 
from  conditions  in  which  exacerbations  are  liable  to  occur.  If  it  is  pos- 
sible, he  should  be  sent  to  a  warm,  dry  climate  in  winter,  and  all  exposure 
to  cold  avoided ;  an  out-door  life  is  desirable.  Most  patients  require  gen- 
eral tonic  treatment  with  very  moderate  but  regular  exercise,  never  car- 
ried to  the  point  of  fatigue,  as  much  rest  as  possible  in  a  recumbent 
position,  a  fluid  diet,  consisting  largely  of  milk  as  long  as  this  can  be 
borne,  and  the  adininistration  of  iron.  Dropsy  calls  for  a  salt-free  diet, 
diuretics,  saline  cathartics,  and  vascular  stimulants.  If  uremia  de- 
velops, with  high  arterial  tension  and  stupor,  headache,  and  convul- 
sions, venesection  should  be  resorted  to,  or  nitroglycerin  used.  Mor- 
phin  may  be  given  hypodermically  if  the  nervous  symptoms  are  very 
marked. 

Decapsulation  of  the  kidney  is  to  be  considered  in  cases  growing 
progressively  worse  in  spite  of  medical  treatment.  The  immediate  risks 
of  the  operation  are  rather  less  than  would  be  expected.  We  have  seen 
striking  temporary  benefit  in  several  cases  when  this  operation  was 
done  upon  young  children.  In  no  ease,  however,  was  the  improve- 
ment permanent,  all  the  patients  dying  within  a  year  after  it  was  per- 
formed. 


TUMORS  OF  THE  KIDNEY  639 


TUBERCULOSIS   OF   THE   KIDNEY 

In  general  tuberculosis,  miliary  tubercles  are  frequently  seen  both 
upon  the  surface  of  the  kidney  and  in  its  substance.  These  give  rise  to 
no  symptoms  and  are  of  no  clinical  importance.  Larger  tuberculous 
deposits  are  extremely  rare  in  early  life.  They  usually  occur  in  patients 
who  are  the  subjects  of  general  tuberculosis,  and  are  associated  with 
tuberculosis  of  other  parts  of  the  genito-urinary  tract,  or  they  may  exist 
as  apparently  the  primary  and  only  tuberculous  lesion  in  the  body.  As- 
cending infection  occurs  occasionally  but  it  is  rare ;  nearly  all  cases  are  of 
the  descending  type,  i.  e.,  j)rimary  in  the  kidney.  Infection  of  the  kidney 
therefore  generally  takes  place  through  the  circulation  and  not  from  the 
bladder.  Aldibert's  figures  show  that  in  children  the  bladder  usually 
escapes  even  when  the  kidneys  are  tuberculous,  for  of  thirteen  cases  of 
renal  tuberculosis  the  bladder  was  involved  in  but  two.  The  disease  when 
primary  begins  in  the  cortex,  but  soon  extends  to  the  mucous  membrane 
of  the  pelvis  and  the  calices  of  the  kidney,  and  also  to  the  pyramids. 
As  a  rule,  but  one  kidney  is  affected.  The  process  may  be  confined  to 
the  pyramids,  where  are  found  cheesy  nodules  which  may  be  single  or 
multiple.  These  ultimately  break  down  and  form  abscesses.  The  process 
may  result  in  almost  complete  destruction  of  the  pyramids,  and  even  of 
portions  of  the  cortex,  so  that  the  kidney  may  consist  of  a  mere  shell  of 
renal  tissue.  Suppuration  in  the  neighborhood  of  the  kidney  (peri- 
nephritic  abscess)  often  coexists. 

The  symptoms  are  quite  indefinite.  There  may  be  localized  pain  and 
tenderness  in  the  region  of  the  kidney,  and  a  tumor  if  there  is  peri- 
nephritis. The  symptoms  of  irritability  of  the  bladder  may  be  almost  as 
severe  as  in  cases  of  calculus.  Pus  usually  appears  in  the  urine  as  a  con- 
stant symptom,  and  blood  is  often  present.  But  the  only  thing  that  is 
diagnostic  is  the  discovery  of  tubercle  bacilli  in  the  urine. 

The  treatment  is  the  same  as  in  adults. 


TUMORS  OF  THE  KIDNEY 

In  the  great  majority  of  cases  tumors  of  the  kidneys  are  malignant. 
Of  fifty-one  cases  collected  by  Aldibert  which  were  operated  upon,  forty- 
eight  were  malignant,  and  three  benign. 

Malignant  growths  are  almost  invariably  primary.  In  children  under 
five  years,  although  not  common,  they  are  yet  more  frequent  than  any 
other  variety  of  malignant  tumor  of  the  abdomen.  Nearly  all  these 
tumors  belong  to  the  class  of  embryonal  adenosarcoma.     They  contain 


64Q  DISEASES  OF  THE  UROGENITAL  SYSTEM 

renmauts  of  fetal  tissue  and  in  many  instances  are  undonbtedly  congeni- 
tal. Tnmors  growing  from  the  adrenals  belong  to  a  different  group — 
hypernephroma.  Eenal  tumors  may  grow  from  the  cortex  of  the  kidney, 
or  from  the  pelvis,  sometimes  from  the  adrenals.  They  may  infiltrate 
the  whole  kidney,  so  that  there  is  no  trace  of  renal  structure  remaining, 
or  they  may  form  an  immense  tumor  on  one  side  of  the  kidney,  which  is 
only  partially  invaded.  These  tumors  are  very  rarely  cystic,  but  they 
are  quite  soft,  and  hemorrhages  often  occur  into  their  substance.  There 
may  be  secondary  growths  in  the  liver,  the  lungs,  the  retroperitoneal 
glands,  in  the  opposite  kidney,  the  intestines,  the  pancreas,  and  rarely  in 
the  skull.  Pressure  of  the  tumor  upon  the  ureter  may  lead  to  hydro- 
nephrosis, and  upon  the  inferior  vena  cava,  to  thrombosis  of  that  vessel. 
As  it  grows,  the  tumor  sometimes  becomes  adherent  to  nearly  all  the 
abdominal  organs  by  localized  peritonitis.  It  may  lead  to  ascites,  but  it 
very  rarely  causes  general  peritonitis.  The  growth  may  reach  a  great 
size,  usually  from  five  to  fifteen  pounds,  but  in  one  case  reported  by 
Jacobi  it  weighed  thirty-six  pounds.  In  Seibert's  collection  of  forty- 
eight  cases  the  right  kidney  was  involved  in  twenty-four,  the  left  in 
twenty-two,  and  both  kidneys  in  two  cases. 

Etiology. — These  tumors  of  the  kidney  may  be  congenital.  This 
was  true  of  5  cases  in  a  series  of  55  collected  by  Jacobi.  The  majority 
occur  in  early  childhood.  In  the  collection  of  130  cases  by  Longstreet 
Taylor  in  which  the  ages  are  given,  106  were  observed  during  the  first 
five  years,  and  57  of  these  in  the  first  two  years  of  life.  The  sexes  were 
about  equally  affected. 

Symptoms. — The  principal  symptoms  are  tumor,  hematuria,  and 
cachexia.  The  tumor  is  usually  first  noticed.  It  is  in  most  cases  dis- 
covered in  the  loin,  but  grows  forward  toward  the  median  line.  Its  sur- 
face may  be  lobulated  and  irregular  or  quite  smooth ;  and  although  solid, 
it  is  sometimes  so  soft  as  to  give  an  obscure  sensation  of  fluctuation. 
It  may  grow  to  an  enormous  size,  causing  displacement  of  the  liver, 
spleen,  intestines,  and  lungs.  The  progress  of  the  growth  is  usually 
rapid,  so  that  from  the  size  of  a  fist,  the  tumor  may  grow  in  the  course 
of  five  or  six  months  so  as  nearly  to  fill  the  abdomen.  By  careful  palpa- 
tion it  will  be  found — certainly  when  the  tumor  is  small — that  although 
it  may  be  quite  freely  movable,  its  attachment  is  near  the  lumbar 
sjDine. 

Hematuria  may  in  rare  cases  be  the  first  symptom  noticed.  The 
amount  of  blood  passed  is  sometimes  quite  large,  but  is  usually  small,  and 
blood  may  be  discovered  only  by  the  microscope.  Pain  is  rare,  and  is  due 
to  localized  peritonitis.  Constitutional  symptoms  are  usually  absent  until 
tbe  tumor  has  attained  a  large  size,  when  a  cachexia  develops  and  the 
patient  wastes  steadily.    The  j)ressure  effects  are  dyspnea,  from  compres^ 


TUMORS  OF  THE  KIDNEY 


641 


sion  of  the  lungs ;  edema  of  the  lower  extremities,  from  pressure  upon  or 
thrombosis  of  the  vena  cava;  vomiting  and  indigestion  from  pressure 
upon  the  stomach  and  intestines.  Tumors  of  the  suprarenals  have  a 
marked  tendency  to  produce  metastaes  in  the  skull.  The  tumor  may  re- 
main small  and  the  metastasis  may  be  considered  the  primary  growth. 
Precocious  sexual  development  is  often  seen  with  suprarenal  tumors. 

The  course  of  the  dis- 
ease is  steadily  from  bad  to 
worse.  The  usual  duration 
of  life  in  patients  not  oper- 
ated upon  is  from  three  to 
ten  months  after  the  tumor 
is  large  enough  to  be  discov- 
ered. 

Diagnosis. — The  impor- 
tant points  are,  the  position 
and  attachment  of  the  tu- 
mor, its  steady  growth  and 
solid  character,  hematuria, 
and  the  age  of  the  patient 
(under  five  years).  It  may 
he  confounded  with  hydro- 
]iephrosis,  dermoid  cyst  of 
the  ovary,  enlargement  of 
the  spleen,  retroperitoneal 
sarcoma,  tumors  of  the 
liver,  or  even  of  the  abdom- 
inal wall. 

Treatment. — Nothing  is 
to  be  said  regarding  the 
medical  treatment  of  these 
cases.  Unless  operated 
upon,  they  invariably  ter- 
minate fatally.  Some  of 
the  results  of  operation  dur- 
ing recent  years  have  been 

encouraging  and  no  case  should  be  abandoned,  no  matter  how  young 
the  patient;  but  a  recurrence  in  a  few  weeks  or  months  is  the  usual 
result. 

Benign  Tumors. — These  are  very  rare.  They  are  distinguished  by 
their  slow  growth,  and  by  the  fact  that  the  constitutional  symptoms  are 
mild  or  wanting.  Of  the  tlirce  cases  mentioned  by  Aldibert,  one  was 
adenoma,  one  fibroma,  and  one  was  fibrocystic. 


Fig.  85. — Sarcoma  of  the  Kidney.  Child  thir- 
teen months  old.  Weight  of  tumor,  seven 
pounds.  This  patient  was  followed  for  sixteen 
years  and  there  was  no  recurrence. 


642  DISEASES  OF  TTIE  TPvOCEXTTAL  SYSTEM 


PYELITIS— PYELOCYSTITIS 

Pyelitis  is  an  inflammation  of  the  mucous  membrane  lining  the  pel- 
vis of  the  kidne}';  cystitis  is  an  inflammation  of  the  mucous  membrane, 
of  the  bladder.  The_y  may  exist  separately  or  together.  With  pyelitis 
there  may  be  inflammation  of  the  ureter  or  of  the  kidney  itself  (pyelo- 
nephritis), and  it  may  be  acute  or  chronic.  It  may  result  in  the  accu- 
mulation of  pus  in  considerable  amount  in  the  pelvis  of  the  kidney 
(pyonephrosis). 

Etiology.- — Pyelitis  may  be  secondary  to  local  conditions  in  the 
genito-urinary  tract.  It  is  regularly  present  with  renal  calculi.  It  is 
also  freqviently  associated  with  congenital  malformations  of  the  kidneys 
or  ureters,  with  renal  tuberculosis  and  renal  tumors.  It  may  result 
from  an  extension  of  inflammation  from  the  tissues  surrounding  the 
kidney  (perinephritis),  or  from  an  abscess  ojiening  into  the  pelvis  of  the 
kidney.  Acute  pyelitis  sometimes  occurs  as  a  complication  of  scarlet  or 
typhoid  fever,  diphtheria,  influenza,  or  pyemia.  The  organisms  found 
in  the  urine  in  these  cases  are  the  streptococcus,  the  staphylococcus,  the 
tubercle  bacillus,  the  typhoid  laacillus,  the  bacillus  pyocyaneus,  and  very 
rarely  the  diphtheria  bacillus  and  other  bacteria  alone  or  in  combination 
with  the  colon  bacillus. 

All  these  forms,  however,  are  very  infrequent  compared  with  the 
form  of  pyelocystitis  which  often  occurs  apparently  as  a  primary  affection. 
It  may  be  found,  however,  in  the  course  of  any  disease,  and  frequently 
follows  acute  disturbances  of  the  gastro-intestinal  tract,  especially  diar- 
rhea. In  these  cases  the  evidences  of  inflammation  of  the  bladder  are 
slight  or,  more  frequently,  entirely  wanting,  'i'his  form  of  inflammation 
occurs  with  by  far  the  greatest  frequency  in  female  infants.  Male  ijifants 
and  older  girls  occasionally  are  the  subjects  of  pyelitis.  The  organism 
present  with  great  uniformity  is  the  colon  bacillus,  usually  alone.  Pyo- 
genic cocci  are  occasionally  associated  with  it. 

The  infection  has  been  assumed  to  be  an  ascending  one,  through  the 
urethra,  chiefly  because  of  the  great  preponderance  of  the  cases  in 
girls;  but  this  is  by  no  means  established.  That  infection  may  take 
place  through  the  intestinal  walls  into  the  genito-urinary  tract  seems 
probable  in  view  of  the  frequency  with  which  pyelitis  follows  diar- 
rhea and  by  its  occasional  presence  in  boys.  Infection  through  the 
blood  does  not  seem  to  be  a  likely  method,  for  blood  cultures  in  these 
cases  are  uniformly  negative.  Pyelitis  is  quite  frequent  in  the  first  two 
years,  after  that  time  the  number  of  cases  diminishes,  but  they  may  be 
found  at  any  age. 

Lesions. — When  pyelitis  develops  from  a  local  cause  it  is  usually  uni- 


PYELITIS— PYELOCYSTITIS  G43 

lateral ;  otherwise  both  sides  are  involved.  In  the  cases  of  acute  pyelitis 
or  pyelocystitis  there  are  the  usual  appearances  of  an  acute  catarrhal 
inflammation  of  the  mucous  membrane  with  congestion,  swelling  and 
sometimes  minute  hemorrhages.  There  may  be  an  accumulation  of  pus 
of  considerable   size  distending  the  pelvis  and  calices    (pyonephrosis). 

In  most  of  the  severe  cases  of  pyelitis  there  is  also  present  a  certain 
amount  of  nei:)hritis.  This  may  be  merely  degeneration  or  there  may  be 
collections  of  polymorphonuclear  leucocytes  and  even  the  formation  of 
numerous  small  abscesses  throughout  the  parenchyma  of  the  kidney.  If 
the  condition  is  one  depending  upon  a  calculus  or  congenital  deformity, 
and  in  all  protracted  and  severe  cases,  the  mucous  membrane  of  the  pelvis 
is  extensively  altered.  It  may  be  granular,  irregularly  thickened  and 
present  more  or  less  ulceration.  In  the  rare  cases  of  diphtheritic  pyelitis 
there  is  a  false  membrane.  The  kidney  in  all  these  forms  is  in- 
volved to  a  greater  or  less  degree;  the  extent  of  the  nephritis  will 
depend  upon  the  nature  of  the  exciting  cause  and  the  duration  of  the 
process. 

Symptoms. — There  are  few  diseases  in  which  there  is  such  a  great 
difference  in  the  severity  of  the  symptoms.  In  perhaps  the  majority 
of  cases  pyelitis  is  so  mild  as  to  cause  no  symptoms  but  a  slight 
elevation  of  temperature  of  one  or  two  degrees,  which  may  be  very 
temporary.  It  would  entirely  escape  detection  but  for  an  examination 
of  the  urine.  The  pus  may  be  present  only  in  small  amount,  i.  e.,  four  to 
six  cells  in  each  microscopical  field  of  uncentrifugalized  urine,  and  for 
only  a  few  days. 

In  other  cases  the  symptoms  may  be  quite  severe.  The  history  of 
the  following  case  illustrates  the  main  clinical  features  of  acute  pyelitis, 
in  this  instance  occurring  apparently  as  a  primary  disease: 

A  previously  healthy  female  infant  of  eight  months  was  taken  sud- 
denly with  a  chill,  followed  by  a  very  high  fever.  The  child  was  ill  for 
ten  days  before  the  nature  of  the  disease  was  suspected.  During  this 
time  the  temperature  ranged  between  101°  and  10G°  F.,  touching  105° 
nearly  every  day;  but  the  chill  was  not  repeated.  The  other  constitu- 
tional symptoms  were  not  severe.  At  the  first  examination  of  the  urine 
there  was  found  a  large  amount  of  pus,  which  on  standing  was  equal  to 
one-twelfth  of  the  volume  of  the  urine  passed ;  the  reaction  was  strongly 
acid.  There  were  no  signs  of  vaginitis  or  vulvitis,  no  ardor  urinae,  no 
evidence  of  local  pain  either  in  the  bladder  or  kidney,  no  abnormal  fre- 
quency of  micturition,  no  localized  tenderness,  and  no  vomiting.  At 
later  examinations  there  were  found  in  moderate  numbers  epithelial  cells 
I'rom  the  bladder,  and  tlio  tubules  and  pelvis  of  the  kidney,  also  a  few 
hyaline  casts,  but  not  more  albumin  than  would  be  explained  by  the 
amount  of  pus.    Under  no  treatment  except  alkaline  diuretics,  the  tem- 


644  DISEASES  OF  THE  UEOGEXITAL  SYSTE:\I 

perature  gradually  fell  to  normal,  and  the  pus  steadily  diminished  in 
quantity,  and  at  the  end  of  five  weeks  had  practically  disappeared  from 
the  urine.  The  child  remained  well  and  entirely  free  from  urinary 
symptoms. 

In  some  cases  there  are  recurring  chills,  with  Avide  fluctuations  in 
temperature;  in  others  there  may  he  only  pyuria,  with  moderate  fever 
and  few  other  constitutional  symptoms.  The  course  of  the  temperature 
is  a  very  irregular  one.  The  fever  is  seldom  continuous,  but  may  be 
interrupted  by  periods  of  normal  temperature,  lasting  several  days.  A 
polymorphonuclear  leucocytosis  is  present.  The  number  of  cells  is  usu- 
ally from  15,000  to  30,000.  An  agglutination  reaction  of  the  colon 
bacillus  with  the  patient's  blood  can  usually  be  oV)tained,  often  in  high 
dilution.  The  duration  of  the  acute  attack  may  be  from  a  few  days  to 
six  or  eight  weeks,  and  pus  cells  may  be  found  microscopically  for  a 
much  longer  time.  If  the  disease  complicates  one  of  the  acute  infectious 
diseases,  pyiiria  may  be  the  only  s}Tnptom.  If  cystitis  is  also  present 
micturition  is  frequent,  and  may  be  painful.  The  urine  in  acute 
pyelocystitis  is  turbid  from  the  presence  of  pus,  the  amount  of  which 
may  be  from  one  to  fifty  per  cent  of  the  volume  of  the  itrine.  The 
amount  of  pus  varies  greatly  from  day  to  day.  It  is  often  abundant 
when  the  temperature  is  low.  and  alnio>t  absent  when  the  temperature 
is  high,  this  fluctuation  depending  upon  the  accumulation  or  the  dis- 
charge of  the  pus.  The  quantity  of  urine  is  generally  somewhat  dimin- 
ished, and  it  may  be  quite  scanty.  The  reaction  is  usually  acid,  even 
though  the  amount  of  pus  is  large.  Albumin  is  present  in  proportion  to 
the  amount  of  pus  or  the  degree  of  nephritis.  Eed  blood-cells  are  found 
under  the  microscope  in  most  of  the  very  acute  cases,  and  may  be  in 
sufficient  number  to  color  the  urine.  The  pus  cells  in  recent  cases  are 
usually  well  jDreserved.  but  in  old  cases  they  may  be  degenerated. 
There  are  many  epithelial  cells — conical,  fusiform,  and  irregular  cells 
with  long  tails.  There  may  be  renal  epithelium  and  hyaline,  granular, 
or  epithelial  casts,  varying  in  number  with  the  severity  of  the  nephritis. 
In  a  catheterized  specimen  the  colon  bacillus  is  usually  present  in  pure 
culture. 

There  is  at  times  seen  a  particularly  severe  form  of  pyelitis.  It 
affects  boys  as  well  as  girls,  usually  in  the  first  two  years  of  life.  The 
onset  is  sharp  with  fever,  gastro-intestinal  symptoms,  occasionally  convul- 
sions, and  the  temperature  is  often  continuously  high.  The  prostration 
is  extreme,  the  loss  of  appetite  marked,  and  anemia  develops  very 
rapidly.  There  is  irritability  and  hyperesthesia,  sometimes  so  marked  as 
to  suggest  meningitis.  The  urine  contains  besirles  the  pus.  granular  casts 
in  large  numbers.  Tlie  course  is  in'uldiiged  and  tlic  mortality  relatively 
high.     About  10  per  cent  of  such  severe  cases  prove'fatal  from  exhaus- 


PYELITIS— PYELOCYSTITIS  645 

tion,  from  coniplicatious  affecting  the  gastro-Ji)testinal  tract  or  the 
lungs.  Thiemich  and  Goppert  have  reported  a  Series  of  such  cases  that 
seem  to  be  particularly  prevalent  in  certain  localities.  We  have  ourselves 
observed  a  small  number.  The  severity  of  the  disease  is  undoubtedly 
due  to  the  fact  that  the  kidneys,  as  shown  by  autopsy,  are  severely  in- 
volved.   They  are  really  cases  of  pyelonephritis. 

Pyelitis  in  older  children  usually  gives  more  local  symptoms.  There 
is  frequently  pain  on  urination.  Pain  in  the  abdomen  or  loins  may 
be  marked  and  there  may  be  tenderness  and  even  muscular  rigidity. 
When  the  right  side  is  involved  it  may  be  difficult  to  exclude  appendi- 
citis. 

Pyelitis  has  a  marked  tendency  to  recur.  It  may  do  this  after  a  few 
weeks  or  months  or  perhaps  not  for  several  years.  Some  children  may 
suffer  from  a  number  of  attacks.  Others  show  few,  if  any,  constitutional 
symptoms,  but  their  urine  for  a  long  period  may  never  be  free  from  pus 
cells  and  there  may  be  exacerbations  with  fever  from  time  to  time  for 
many  months. 

In  pyelitis  depending  upon  congenital  malformations,  pyuria  is  usu- 
ally the  only  symptom,  unless  pyonephrosis  is  present.  With  calculi 
there  is  an  acute  or  chronic  pyelitis;  there  may  be  localized  pain,  ten- 
derness, sometimes  a  tumor,  occasionally  hematuria,  and  perhaps  a  his- 
tory of  renal  colic  or  the  passage  of  gravel.  With  tuberculosis,  there  is 
chronic  pyuria  and  the  presence  of  tubercle  bacilli  in  the  urine.  The 
symptoms  of  general  tuberculosis  are  commonly  associated.  If  there 
is  perinephritis,  the  inflammation  is  usually  acute,  and  there  are  present 
the  local  symptoms  of  the  original  disease.  If  an  abscess  opens  into  the 
pelvis  of  the  kidney,  there  may  be  a  sudden  discharge  of  pus  in  large 
quantity  with  a  subsidence  of  previous  local  symptoms,  including  the 
tumor.  With  neoplasms,  both  pus  and  blood  may  be  found  in  the 
urine,  but  the  latter  is  more  frequent. 

Diagnosis. — The  characteristic  symptoms  of  acute  pyelitis  are  chills, 
which  may  be  repeated,  high  and  fluctuating  temperature,  scanty  urine 
containing  pus,  and  occasionally  pain  and  tenderness  over  the  kidneys. 
All  of  these  may  be  absent,  however,  except  the  fever  and  the  pyuria, 
and  both  the  fever  and  the  pyuria  may  be  intermittent.  The  diagnosis 
of  pyelitis  is  made  only  by  an  examination  of  the  urine,  which,  particu- 
larly in  infancy,  should  never  be  omitted  in  cases  of  obscure  high  tem- 
perature, whether  prolonged  or  only  temporary.  If  pus  is  not  found  the 
examination  should  be  repeated  several  times.  When  cystitis  is  asso- 
ciated, the  only  additional  symptoms  may  be  pain  and  other  signs  of 
vesical  irritation.  These  symptoms,  with  an  acid  urine  containing  more 
or  less  pus  and  numerous  epithelial  cells,  are  sufficient  to  establish  the 
diagnosis  of  pyelocystitis.     If  the  pus  comes  from  the  opening  of  an 


646  DISEASES  OF  THE  UEOGENITAL  SYSTEM 

abscess  into  the  bladder,  ureter,  or  pelvis  of  the  kidney,  the  local  signs 
of  such  abscess  will  iisuall}^  be  present. 

Prognosis. — In  cases  apparently  primary,  and  especially  in  those  due 
to  the  colon  bacillus,  the  prognosis  is  good.  The  danger  is  chiefly 
from  the  nephritis  which  follows  or  complicates  the  process  and  to  very 
young  and  poorly  nourished  infants  who  may  die  from  exhaustion  as 
the  result  of  gastro-intestinal  disturbance.  The  prognosis  in  the  malig- 
nant form  is  always  doubtful.  In  cases  depending  upon  local  conditions, 
the  prognosis  will  depend  upon  the  nature  of  the  exciting  cause.  Here, 
also,  the  principal  danger  is  from  nephritis.  If  calculi  are  present  and 
if  pyonephrosis  occurs,  the  patient  may  die  from  exhaustion  before  a 
serious  degree  of  nephritis  has  developed. 

Treatment. — Water  should  be  given  freely,  and  alkalis  up  to  the 
point  of  neutralizing  the  excessive  acidity  of  the  urine.  A  large  amount 
of  alkali  is  necessary  to  accomplish  this.  Citrate  of  potash  sufficient  to 
render  the  urine  alkaline  in  this  condition  is  apt  to  cause  diarrhea  or 
vomiting.  It  is  therefore  wise  to  give  not  more  than  five  or  ten  grains  of 
this  three  times  a  day,  but  to  give  bicarbonate  of  soda  from  twenty  to 
thirty  grains  every  four  hours,  according  to  the  age  of  the  patient.  The 
urine  should  be  kept  alkaline  for  some  time  after  the  subsidence  of  all 
symptoms.  The  most  widely  used  remedy  is  he^amethylenamin  (uro- 
tropin),  which  may  be  given  in  doses  of  one  or  two  grains  every  three 
hours  to  an  infant  of  a  year,  and  proportionate  doses  to  older  children. 
In  order  that  this  drug  should  have  an  antiseptic  action  the  urine  must 
be  acid.  It  is  improper,  therefore,  to  combine  hexamethylenamin  with 
alkalis.  We  have  seen  it  used  in  large  and  small  doses  in  cases  of  acute 
pyelitis,  but  have  not  been  convinced  of  its  value.  Occasionally  pyelitis  is 
very  resistent  to  any  form  of  treatment,  the  exacerbations  and  remissions 
continuing  for  many  weeks.  For  such  obstinate  cases  vaccines,  preferably 
the  autogenous  variety,  should  be  tried.  Striking  benefit  has  sometimes 
followed  their  use.  If  calculi  are  present  or  other  conditions,  such  as 
perinephritis,  etc.,  the  methods  of  treatment  applicable  to  these  diseases 
are  indicated. 

RENAL  CALCULI 

Small  renal  calculi  are  very  common  in  infancy.  In  the  autopsy 
room  we  frequently  see,  on  opening  the  kidneys  of  young  infants,  fine 
brown  granules  in  the  pelvis  and  calices,  and  occasionally  a  calculus  as 
large  as  a  small  pea  is  found.  They  are  usually  composed  of  uric  acid. 
Only  once  in  over  two  thousand  autopsies  of  wliich  we  have  records,  was 
a  stone  of  any  consideraljle  size  seen  in  an  infant.  In  tlvis  case  it  was 
an  inch  in  length  and  half  an  inch  wide.    It  is  surprising  that  these  are 


KENAL  CALCULI  647 

so  rare,  when  we  consider  how  very  frequently  the  minute  calculi  are 
met  with.  The  probable  explanation  is,  that  the  majority  of  them  are 
dissolved  or  washed  down  into  the  bladder  and  passed  per  urethram 
because  of  the  fluid  diet  of  the  first  two  years.  The  granular  deposits 
are  usually  lodged  in  the  pelvis  of  the  kidney,  and  are  generally  seen 
upon  both  sides.  With  the  larger  collections  there  is  often  a  slight 
catarrhal  pyelitis. 

Symptoms. — The  small  deposits  give  no  symptoms,  and  even  quite 
large  calculi  may  be  found  at  autopsy  when  no  indication  of  their  pres- 
ence had  existed  during  life,  as  in  the  case  above  mentioned.  In  some 
cases  symptoms  are  produced  which  resemble  those  of  renal  calculi  in 
the  adult.  In  infants  less  definite  symptoms  are  often  passed  over  as 
merely  intestinal  colic. 

In  well-marked  cases  in  older  children  there  is  tenderness,  pain  local- 
ized over  the  affected  kidney,  or  radiating  to  the  bladder,  the  perineum, 
and  even  the  opposite  kidney,  and  there  may  be  irritation  and  retraction 
of  the  testicle.  The  urine  may  show,  especially  after  exercise,  a  trace  of 
blood;  there  piay  be  the  added  symptoms  of  pyelitis,  with  some  fever, 
localized  tenderness,  and  the  appearance  in  the  urine  of  pus  and  epi- 
thelial cells  from  the  pelvis  of  the  kidney. 

Eenal  colic  is  produced  when  a  stone  of  any  considerable  size  passes 
from  the  kidney  to  the  bladder.  It  is  characterized  by  symptoms  similar 
to  those  seen  in  the  adult.  There  are  sudden  attacks  of  severe  sickening 
pain  in  the  loins,  shooting  down  the  thigh  or  to  the  testicle.  There  may 
be  vomiting  and  even  collapse.  The  urine  is  passed  frequently,  in  small 
quantities,  and  contains  blood.  The  symptoms  quickly  subside  when 
the  stone  reaches  the  bladder.  The  calculus  may  sometimes  become  im- 
pacted in  the  ureter  and  give  rise  to  hydronephrosis  or  pyonephrosis, 
which  soon  becomes  pyelonephritis. 

The  existence  of  small  calculi  may  be  suspected  from  the  symptoms 
above^  mentioned;  the  diagnosis  is  made  positive  by  the  appearance  of 
gravel  in  the  urine.  The  use  of  the  X-ray  is  of  service  in  recognizing 
even  small  calculi. 

Treatment. — The  only  medical  treatment  consists  in  a  fluid  diet,  the 
free  use  of  alkaline  mineral  waters,  and  a  sufficient  quantity  of  some 
drug  to  render  the  urine  alkaline.  Such  measures  will  relieve  only  the 
milder  conditions.  With  larger  calculi  and  more  marked  symptoms,  a 
surgical  operation  should  be  considered  and  should  be  urged  in  propor- 
tion to  the  severity  of  the  symptoms  and  the  clearness  of  the  diagnosis. 
If  calculous  pyelitis  exists,  it  is  certain  sooner  or  later  to  lead  to  serious 
nephritis,  and  it  is  only  a  question  of  time  when  the  kidney  will  be  dis- 
abled. The  same  is  true  of  hydronephrosis  from  the  impaction  of  a  cal- 
culus in  the  ureter,    Aldibert  has  collected  four  cases  of  nephrectomy  in 


648  DISEASES  OF  THE  UEOGENITAL  SYSTEM 

children  for  renal  calculi  in  which  the  kidney  was  healthy,  with  three 
recoveries  and  one  death  from  shock.  In  nine  cases  of  operation  for 
calculous  pyonephrosis,  there  were  six  recoveries  and  three  deaths.  The 
earlier  the  operation  the  greater  the  chances  of  success,  because  of  the 
better  condition  of  the  other  kidney.  Although  the  continued  use  of 
water  and  the  use  of  drugs  may  relieve  some  of  the  symptoms,  it  is  very 
'questionable  whether  they  do  more. 


PERINEPHRITIS 

This  consists  in  an  inflammation  in  the  cellular  tissue  surrounding 
the  kidney,  which  may  terminate  in  resolution  or  in  suppuration.  It  is 
not  of  very  uncommon  occurrence.  Perinephritis  may  be  secondary  to 
suppurative  processes  in  the  kidney  itself,  whether  from  calculi  or  tuber- 
culous' deposits,  or  it  may  be  primary.  In  children  the  latter  is  the 
common  form.  Primary  perinephritis  is  attributed  to  traumatism,  cold, 
or  exposure,  or  it  may  develop  without  assignable  cause.  It  usually  runs 
an  acute  or  subacute  course;  very  rarely  it  may  be  chronic. 

For  the  clinical  picture  of  this  disease  we  are  chiefly  indebted  to  a 
paper  by  Gibney,  who  has  published  a  report  of  twenty-eight  cases  of 
primary  perinephritis  in  children.  The  ages  of  these  patients  were  be- 
tween one  and  a  half  and  fifteen  years,  the  majority  being  between  three 
and  six  years.  The  two  sides  and  the  two  sexes  were  about  equally 
affected.  About  one-third  of  the  cases  were  clearly  traceable  to  trau- 
matism; in  the  others  no  adequate  exciting  cause  could  be  discovered. 
The  majority  of  the  cases  were  referred  to  the  hospital  with  the  diag- 
nosis of  hip-joint  disease  or  caries  of  the  spine.  Resolution  followed  in 
twelve  of  these  cases,  and  sixteen  terminated  in  suppuration. 

When  abscess  forms,  it  usually  burrows  between  the  lumbar  muscles 
and  comes  to  the  surface  posteriorly  near  the  middle  of  the  iliocostal 
space ;  it  may  burrow  forward  between  the  abdominal  muscles  and  point 
just  above  Poupart's  ligament;  very  rarely  it  may  follow  the  psoas 
muscle  and  appear  at  the  upper  and  inner  aspect  of  the  thigh,  like  an 
ordinary  psoas  abscess ;  or  it  may  open  into  the  peritoneal  cavity. 

Symptoms. — The  onset  of  acute  perinephritis  may  be  quite  abrupt, 
with  chill,  fever,  and  localized  pain ;  or  it  may  be  gradual,  with  stiffness 
of  the  spine,  lameness  referred  to  the  hip,  and  deformity  due  to  the  con- 
traction of  the  flexors  of  the  thigh.  The  pain  is  usually  felt  in  the  loin, 
but  may  be  referred  to  the  groin,  to  the  inner  side  of  the  thigh,  or  to  the 
knee.  It  is  often  severe,  and  increased  by  using  the  limb.  It  is  in  most 
cases  accompanied  by  localized  tenderness  in  the  neighborhood  of  the 
kidney.     There  is  lameness  upon  the  affected  side,  which  may  come  oji 


PERINEPHRITIS  649 

gradually,  being  sometimes  referred  to  the  hip  and  sometimes  to  the 
spine.  These  symptoms  often  develop  slowly  in  the  course  of  tv/o  or 
three  weeks.  They  are  usually  accompanied  by  a  slight  elevation  of  tem- 
perature. In  the  most  acute  cases  the  temperature  is  high  (102°  to  104° 
F.),  and  prostration  severe. 

As  the  disease  progresses,  fever  is  a  constant  symptom,  the  tempera- 
ture usually  varying  between  101°  and  103°  F.  There  is  in  most  cases 
increasing  deformity,  and  finally  the  patient  may  be  unable  to  walk  at 
all.  On  examination  at  the  height  of  the  disease,  there  is  found  in  a 
typical  case  a  deviation  of  the  spine  with  the  concavity  toward  the  af- 
fected side ;  the  thigh  may  be  held  flexed  to  a  right  angle ;  passive  exten- 
sion is  resisted  and  causes  pain,  although  all  the  other  movements  at  the 
hip  Joint  are  normal.  In  the  lumbar  region  there  is  tenderness,  and 
there  may  be  an  area  of  infiltration  filling  the  iliocostal  space.  At  first 
this  is  only  appreciable  by  percussion,  but  later  a  distinct  tumor  is 
present.  In  addition  to  the  tumor  in  the  usual  region,  there  is  some- 
times one  at  the  upper  and  inner  aspect  of  the  thigh,  owing  to  a  bur- 
rowing of  pus,  and  the  sacs  may  communicate. 

Lameness,  pain,  deformity,  and  fever  sometimes  exist  for  two  or 
three  weeks  before  any  tumor  can  be  made  out.  The  constitutional 
symptoms  are  often  severe.  The  size  of  the  abscess  is  sometimes  very 
great.  In  one  case  we  saw  it  extend  from  the  spine  to  the  median 
line  in  front,  and  from  the  crest  of  the  ilium  nearly,  to  the  free  border 
of  the  ribs.  The  amount  of  pus  varies  from  a  few  ounces  to  two  or 
three  pints.  Urinary  symptoms  are  sometimes  wanting;  at  other  times 
there  is  increased  frequency  of  micturition,  accompanied  by  pain  from 
an  irritation  referred  to  the  bladder.  The  urine  may  contain  pus  from  a 
complicating  pyelitis.  In  only  one  of  Gibney's  cases  was  this  present. 
It  developed  in  the  fourth  week,  and  the  child  recovered. 

The  duration  of  the  disease  in  the  acute  cases  varies  from  three  to 
eight  weeks;  in  the  subacute  it  may  be  five  or  six  months.  When  sup- 
puration occurs  the  symptoms  subside  quite  rapidly  after  the  pus  has 
been  evacuated,  and  recovery  is  complete.  When  resolution  takes  place, 
there  is  a  gradual  subsidence  of  the  symptoms,  and  often  some  stiffness 
of  the  thigh,  with  slight  lameness  for  several  months.  In  the  series  o£ 
cases  above  referred  to,  sixty-five  per  cent  recovered  completely  in  three 
months. 

Diagnosis. — In  many  cases  a  diagnosis  of  hip- joint  disease  is  made, 
but  that  disease  develops  more  insidiously,  is  very  much  more  chronic, 
and  rarel}''  produces  so  great  deformity  in  a  year  as  is  often  seen  in  peri- 
nephritis in  two  or  three  weeks;  abscess  is  infrequent  during  the  first 
year  of  the  disease.  In  perinephritis,  on  the  other  hand,  we  have  a 
tolerably  acute  onset,  sometimes  with  chill,  fever,  marked  lameness,  and 


650  DISEASES  OF  THE  UROGENITAL  SYSTEM 

deformity,  developing  in  two  or  three  weeks;  abscess  often  forms  in 
a  month,  and  complete  and  permanent  recovery  usually  follows  after  a 
few  months  at  most;  the  deformity  is  due  solely  to  flexion  of  the 
thigh;  all  other  movements  at  the  hip  may  be  free,  and  joint  tenderness 
is  absent.  Psoas  abscess  from  Pott's  disease  may  cause  deformity,  tu- 
mor, and  lameness  similar  to  that  seen  in  perinephritis,  but  on  examina- 
tion there  is  found  the  angular  prominence  and  other  signs  of  disease 
of  the  lumbar  vertebrae.  In  cases  of  doubt  the  tuberculin  test  may  give 
important  aid  in  diagnosis. 

Prognosis. — Primary  perinephritis  in  children  almost  invariably  ter- 
minates in  complete  recovery.  Of  the  twenty-eight  cases  referred  to, 
and  eight  subsequently  observed  by  Gibney,  all  recovered  perfectly.  The 
only  condition  likely  to  prove  fatal  is  rupture  of  the  abscess  into  the 
peritoneal  cavity. 

Treatment. — The  patient  should  be  put  to  bed  and  kept  as  quiet  as 
possible  throughout  the  attack.  In  the  early  stage,  hot  fomentations  or 
an  ice-bag  should  be  applied  over  the  affected  side;  heat  is  generally  to 
be  preferred.  Abscesses  should  be  opened  early,  to  prevent  burrowing 
and  the  danger  of  a  possible  rupture  into  the  peritoneal  cavity. 


CHAPTER    III 

DISEASES  OF  THE  GENITAL   ORGANS 
MALFORMATIONS 

Adherent  Prepuce. — This  condition  is  sometimes  called  false  phimo- 
sis. It  is  so  constantly  present  that  it  can  hardly  be  regarded  as  a 
malformation.  It  is,  however,  a  condition  often  needing  attention  in 
male  infants.  The  prepuce  should  be  retracted  so  as  to  expose  the  glans 
completely.  The  smegma  should  then  be  washed  away,  the  glans  covered 
with  a  drop  of  oil,  and  the  skin  drawn  forward.  This  should  be  repeated 
daily  until  there  is  no  disposition  to  a  recurrence  of  the  adhesions. 

Phimosis. — This  is  such  a  narrowing  of  the  prepuce  that  it  can  not 
be  retracted  over  the  glans.  The  degree  of  phimosis  varies  greatly.  In 
very  rare  cases  there  is  no  preputial  opening.  In  other  cases  the  orifice 
is  so  small  that  no  part  of  the  glans  can  be  exposed,  and  there  is  obstruc- 
tion to  the  outflow  of  urine ;  but  usually  a  small  part  of  the  glans  can  be 
seen.  Phimosis  may  be  complicated  by  an  elongated  prepuce  (hyper- 
trophic phimosis),  and  the  elongation  may  exist  without  any  narrowing 
of  the  orifice,  although  this  is  usually  present  to  some  degree. 


MALFORMATIONS  651 

The  presence  of  phimosis  makes  cleanliness  impossible  in  many  cases, 
and  want  of  cleanliness  leads  to  infection  and  to  balanitis.  This  is  quite 
frequent,  even  in  infants.  It  may  be  complicated  by  urethritis,  and  even 
by  cystitis.  Another  consequence  of  the  straining  induced  by  phimosis 
is  hernia,  which  may  be  either  inguinal  or  umbilical.  To  cure  the  hernia 
is  often  impossible,  unless  the  phimosis  is  relieved.  The  list  of  reflex 
phenomena  which  have  been  ascribed  to  phimosis  is  a  long  one.  There 
has  been  a  disposition  on  the  part  of  some  to  attribute  nearly  all  the 
nervous  disturbances  of  boyhood  to  phimosis,  and  an  exaggerated  impor- 
tance has  certainly  been  attached  to  this  condition.  A  very  marked 
degree  of  phimosis  often  exists  in  children  without  producing  any  symp- 
toms. That  phimosis  is  an  etiological  factor  in  many  neuroses  is  cer- 
tainly to  be  doubted.  Our  experience  with  circumcision  as  a  cure  for 
such  conditions  has  been  very  unsatisfactory.  When  cleanliness  is  im- 
possible the  irritation  and  resulting  pruritis  may  cause  frequent  priap- 
ism and  may  at  times  encourage  masturbation.  Phimosis  may  rarely 
lead  to  vesical  spasm  and  retention  of  urine,  but  more  frequently  to  noc- 
turnal incontinence. 

Treatment. — Phimosis  should  receive  attention  in  infancy.  Often 
ver,y  little  treatment  is  needed.  When  there  is  a  very  long  prepuce 
with  phimosis,  the  operation  of  circumcision  should  be  done,  even  when 
the  degree  of  phimosis  is  slight.  Many  cases  of  phimosis  in  which  the 
prepuce  is  not  long  can  be  relieved  by  stretching.  If  no  part  of  the  glans 
can  be  exposed,  the  simplest  plan  is  to  slit  up  the  dorsum  of  the  prepuce, 
with  a  pair  of  scissors  and  break  up  the  adhesions.  The  corners  of  the 
flaps  thus  made  can  then  be  snipped  oif  and  one  stitch  inserted  on  either 
side.  To  promote  cleanliness  in  older  boys  or  in  cases  of  hernia 
or  prolapse  and  when  phimosis  is  present,  circumcision  should  be  per- 
formed. 

Hypospadias. — In  this  condition  the  urethra  is  not  continued  to  the 
tip  of  the  penis,  but  opens  on  the  inferior  surface  some  distance  back, 
being  represented  in  front  of  this  only  by  a  shallow  furrow.  In  more 
severe  cases  there  is  a  deep  fissure  which  divides  the  scrotum,  and  some- 
times even  the  perineum.  Into  this  fissure  the  urethra  opens.  This  is  a 
condition  likely  to  be  mistaken  for  that  of  hermaphrodism,  especially 
as  the  testicles  are  frequently  in  the  abdominal  cavity. 

Epispadias. — This  is  a  condition  in  which  the  urethra  opens  on  the 
dorsal  surface  of  the  penis.  It  is  much  less  frequent  than  hypospadias. 
There  may  be  simply  a  division  of  the  glans,  or  the  fissure  may  extend 
the  whole  length  of  the  organ  and  be  complicated  by  exstrophy  of  the 
bladder. 

Exstrophy  of  the  Bladder. — In  the  complete  form  there  is  a  median 
fissure  from  the  umbilicus  to  the  tip  of  the  penis.     It  includes  the  an- 


652  DISEASES  OF  THE  UROGENITAL  SYSTEM 

terior  abdominal  wall,  the  pelvic  bones,  and  the  urethra.  The  bones  are 
entirely  separated  at  the  symphysis,  or  connected  behind  the  bladder  by 
a  fibrous  band.  The  hypogastric  region  is  occupied  by  a  red,  mucous 
surface,  slightly  corrugated,  which  is  all  there  is  of  the  bladder.  In  the 
lower  lateral  portions  of  the  red  mucous  membrane  two  slightly  rounded 
elevations  are  seen,  from  which  urine  oozes.  These  are  the  openings  of 
the  ureters.  The  penis  is  short,  and  presents  a  shallow  furrow  on  its 
dorsal  surface.     The  testes  are  often  in  the  abdominal  cavity. 

An  analogous  deformity  is  sometimes  seen  in  girls.  There  is  a  division 
of  the  clitoris  and  the  labia  minora  and  majora.  The  fissure  may  be  so 
deep  as  to  reach  nearly  to  the  anus.  The  vagina  is  usually  absent.  The 
rectum  may  open  into  the  prolapsed  bladder. 

All  these  deformities  are  compatible  with  long  life.  In  exstrophy  of 
the  bladder,  whether  complete  or  partial,  patients  are  a  nuisance  to  them- 
selves and  to  all  about  them.  It  is  almost  impossible  to  prevent  the 
clothing  from  being  soaked  with  urine,  which  gives  everything  connected 
with  the  patient  a  strong  ammoniacal  odor.  The  skin  is  often  excoriated. 
Operation  for  the  relief  of  these  cases  should  always  be  undertaken. 
The  operation  to  be  recommended  is  the  transplantation  of  the  ureters 
into  some  part  of  the  large  intestine,  usually  the  rectum.  The  results 
are  often  most  surprising.  The  rectum  soon  becomes  tolerant  of  the 
urine,  holds  it  for  hours  without  difficulty  and  evacuates  it  without  dis- 
comfort.    Ascending  infection  of  the  kidney  seldom  occurs. 

Undesceiided  Testicle — Cryptorchidism, — In  fetal  life  the  testes  are 
situated  in  the  abdominal  cavity  below  the  kidneys.  They  usually  descend 
into  the  scrotum  during  the  ninth  month,  but  in  children  born  at  term 
the  testicles  may  be  in  the  inguinal  canal,  or  even  in  the  abdomen.  The 
former  condition  is  quite  frequent,  being  present  in  fully  ten  per  cent  of 
all  male  children.  In  most  of  these  the  descent  takes  place  without  dif- 
ficulty during  the  first  weeks  of  life,  and  causes  no  symptoms.  In  others 
the  condition  may  persist.  Spontaneous  descent  may  take  place  at  any 
time  before  puberty,  the  chances,  however,  steadily  lessening  as  age  ad- 
vances. When  in  the  inguinal  canal,  on  account  of  its  exposed  situation, 
the  testicle  may  be  injured,  or  become  painful  and  tender  as  puberty 
approaches.  In  any  abnormal  position  it  probably  will  not  develop  prop- 
erly, and  may  remain  without  function,  but  interference  with  the  devel- 
•opment  of  the  body  is  rare.    Hernia  is  a  frequent  complication. 

When  in  the  inguinal  canal,  descent  of  the  testicle  may  sometimes  be 
facilitated  by  manipulation.  If  the  condition  is  unilateral,  operation  is 
unnecessary  except  for  relief  of  pain.  If  it  is  double,  operation  should 
be  performed  before  puberty,  preferably  from  the  ninth  to  the  eleventh 
year.  Transplantation  into  the  scrotum  is  at  tliis  time  simple,  and  usu- 
ally successful.     Should  joain  be  persistent,  and  transplantation  impossi- 


DISEASES  OF  THE  MALE  GENITALS  653 

ble,  the  testicle  may  be  replaced  in  the  abdominal  cavity.     Eemoval  is 
indicated  only  when  degeneration  has  taken  place. 

With  the  exceptions  already  mentioned,  deformities  of  the  female 
genitals  belong  rather  to  gynecology  than  to  pediatrics,  since  they  are 
chiefly  of  the  internal  organs,  and  do  not  usually  give  symptoms  before 
puberty. 

DISEASES  OF  THE   MALE  GENITALS 

Balanitis. — Balanitis,  or  inflammation  of  the  prepuce,  is  one  of  the 
results  of  phimosis.  It  may  follow  decomposition  of  the  smegma,  infec- 
tion of  the  mucous  membrane,  injury,  or  masturbation.  The  parts  are 
swollen,  edematous,  red,  painful,  and  sometimes  bathed  in  pus.  Re- 
traction of  the  prepuce  is  impossible.  Under  proper  treatment  the  in- 
flammation usually  subsides  in  two  or  three  days,  but  there  may  be  some 
discharge  for  a  considerable  time.  Abscess  may  follow,  and  even  gan- 
grene of  the  prepuce.  The  most  severe  cases  are  likely  to  be  complicated 
by  anterior  urethritis.  We  have  frequently  seen  erysipelas  start  from 
balanitis,  and  occasionally  diphtheria  occurs  here. 

The  object  of  treatment  is  to  remove  the  irritating  and  infectious 
material  lodged  beneath  the  foreskin.  This  may  be  quite  difficult.  It  is 
best  accomplished  by  syringing  with  a  1-5,000  bichlorid  solution,  and 
the  constant  application  of  a  wet  antiseptic  dressing.  Ice  is  often  useful 
when  the  edema  is  great.  It  is  sometimes  necessary  to  slit  up  the 
prepuce  before  the  parts  can  be  thoroughly  cleansed,  and  in  severe  cases 
this  is  often  the  quickest  method  of  cure.  Circumcision  should  not  be 
done  during  an  attack. 

Urethritis. — This,  like  the  same  disease  in  females,  may  be  simple 
or  specific.  Both  forms  are  much  less  frequent  in  little  boys  than  in  the 
other  sex.  In  simple  urethritis  the  inflammation  usually  affects  only  the 
anterior  part  of  the  canal,  the  fossa  navicularis.  There  is  a  slight  dis- 
charge of  pus,  and  sometimes  pain  on  micturition.  The  most  frequent 
cause  is  want  of  cleanliness. 

Gonococcus  inflammation  is  more  common.  This  occurs  even  in  in- 
fants, but  most  of  the  cases  are  in  those  over  seven  years  old.  The  usual 
cause  is  direct  contagion.  The  symptoms  are  more  severe  than  in  the 
simple  form,  and  resemble  the  same  disease  in  the  adult,  with  the  ex- 
ception that  constitutional  symptoms  are  usually  absent.  A  microscopical 
examination  of  the  discharge  is  the  only  positive  means  of  diagnosis 
between  the  two  varieties.  In  these  cases  it  reveals  the  gonococcus  in 
great  numbers.  Conjunctivitis  and  arthritis  are  seen  as  complications, 
just  as  in  the  female.  Epididymitis  is  rare,  but  balanitis  and  bubo  are 
not  infrequent.    Poynter  has  reported  a  case  in  a  boy  of  three  years,  who. 


6.54  DISEASES  OF  THE  UROGENITAL  SYSTEM 

when  five  years  old,  required  treatment  for  a  urethral  stricture.  He  was 
infected  by  a  nurse. 

The  first  thing  in  the  treatment  is  always  to  keep  the  parts  covered, 
otherwise  the  infection  may  be  carried  by  the  hands  to  other  mucous 
membranes,  usually  the  conjunctiva.  In  other  respects  the  treatment 
is  the  same  as  in  the  adult. 

Hydrocele. — ^Hydrocele  consists  in  an  accumulation  of  serum  in  some 
part  of  the  serous  pouch  brought  down  by  the  testicle  in  its  descent.  In 
infants  it  is  usually  due  to  the  imperfect  closure  of  this  pouch  at  some 
point,  where  a  fluid  accumulation  occurs.  Four  varieties  of  hydrocele 
are  met  with  in  young  children. 

1.  Cotigenital  Hydrocele. — In  this  the  condition  is  a  congenital  one, 
although  the  tumor  is  not  necessarily  present  at  birth.  The  tunica  vagi- 
nalis communicates  with  the  general  peritoneal  cavity.  There  is  present 
an  elongated  tumor,  extending  from  the  bottom  of  the  scrotum  through- 
out the  whole  length  of  the  cord.  The  tumor  is  reducible,  sometimes 
spontaneously  by  position,  sometimes,  when  the  opening  is  smaller,  only 
by  pressure.  It  reduces  slowly,  without  gurgling,  never  going  back  en 
masse  like  a  hernia.  The  tumor  is  translucent,  and  is  flat  on  percussion. 
The  testicle  is  above  and  posterior,  and  usually  indistinctly  felt.  Con- 
genital hydrocele  may  be  complicated  by  hernia. 

2.  Hydrocele  of  the  Tunica  Vaginalis  with  the  Canal  Closed. — In 
this  form  the  accumulation  of  fluid  is  in  the  scrotum,  communication 
with  the  peritoneal  cavity  having  been  entirely  cut  off  by  the  complete 
obliteration  of  this  pouch  in  the  canal  in  the  normal  way.  This  is  one  of 
the  most  frequent  forms.  It  gives  rise  to  an  oval  or  pear-shaped  tumor, 
quite  tense  and  firm,  usually  about  two  inches  in  length.  The  cord  is 
distinctly  felt  above  it,  the  testicle  is  behind  and  somewhat  above  it,  and 
not  always  felt  very  distinctly.  This  variety  gives  translucency  and  the 
usual  elastic  feeling  of  a  hydrocele. 

3.  Hydrocele  of  the  Cord. — This  is  one  of  the  rare  forms.  The  serous 
pouch  which  accompanies  the  spermatic  cord  is  open  above,  and  com- 
municates with  the  peritoneal  cavity;  but  below  it  is  closed.  The 
scrotum  is  normal,  and  the  testicle  is  in  its  usual  position.  The  tumor 
is  small,  elongated,  reducible,  and  entirely  above  the  scrotum.  Usually 
it  stops  at  some  point  in  the  inguinal  canal.  This  hydrocele  also  may 
be  completed  by  hernia.  The  diagnostic  points  are  the  same  as  in  the 
form  first  mentioned. 

4.  Encysted  Hydrocele  of  the  Cord. — The  peritoneal  pouch  of  the 
cord  in  this  variety  is  closed  for  some  distance  above,  and  again  below, 
but  somewhere  in  its  course  it  is  open,  and  here  the  fluid  accumulates  in 
the  form  of  a  cyst.  When  small  it  resembles  an  undescended  testicle ; 
but  on  examination  this  organ  is  found  below  and  in  its  normal  position. 


VAGINITIS  655 

When  in  the  canal,  it  is  often  mistaken  for  a  lymph  gland,  sometimes 
for  a  small  hernia.  The  tumor  is  usually  about  the  size  of  an  almond. 
It  is  elastic  and  irreducible,  and  translucent  like  tlie  other  varieties. 

Treatment  of  Hydrocele. — In  the  congenital  form  the  application  of 
a  tr\iss  will  sometimes  cause  obliteration  of  the  canal,  so  as  to  shut  off 
the  hydrocele  sac  from  the  general  peritoneal  cavity.  It  is  subsequently 
managed  like  an  ordinary  hydrocele  of  the  tunica  vaginalis.  In  infants 
and  young  children  it  is  rare  that  active  operative  measures  are  called 
for  in  any  variety  of  hydrocele,  as  these  usually  tend  to  disappear  spon- 
taneously in  the  course  of  a  few  months.  lodin  may  be  applied  locally 
over  a  hydrocele  of  the  cord,  but  should  not  be  applied  to  the  scrotum. 
Some  cases  are  cured  by  a  simple  puncture  with  a  needle,  allowing  the 
fluid  to  drain  off  into  the  cellular  tissue  of  the  scrotum  from  which  it 
is  absorbed;  others  by  a  single  aspiration  with  a  hypodermic  syringe. 
It  is  seldom  necessary  to  resort  to  the  injection  of  irritants  like  iodin 
or  carbolic  acid,  but  they  may  be  used  if  the  fluid  returns  after  repeated 
aspirations. 

DISEASES  OF  THE  FEMALE   GENITALS 
VAGINITIS 

This  is  a  catarrhal  inflammation  usually  affecting  only  the  vaginal 
mucous  membrane,  but  may  involve  the  urethra,  bladder,  and,  in  older 
girls,  the  lining  membrane  of  the  uterus,  the  tubes,  and  even  the  peri- 
toneum. It  may  be  either  simple  or  specific  (gonorrheal)  ;  the  purulent 
form  is  almost  invariably  specific. 

Simple  Vaginal  Catarrh. — This  may  be  seen  nt  any  age,  even  in  in- 
fancy, but  is  most  frequent  after  the  second  year.  It  occurs  especially 
in  girls  suffering  from  malnutrition  and  anemia,  and  whose  personal 
cleanliness  is  neglected.  It  may  follow  any  of  the  infectious  diseases, 
particularly  measles.  It  sometimes  complicates  varicella  with  a  local 
lesion  in  the  vagina.  It  may  be  traumatic,  as  from  attempted  rape  or 
the  introduction  of  foreign  bodies.  Other  causes  are  pinworms  and 
scabies.    It  is  sometimes  the  cause,  sometimes  the  result  of  masturbation. 

The  disease  generally  begins  as  a  subacute  catarrhal  inflammation, 
the  discharge  being  the  first,  and  in  mild  cases  the  only  symptom.  It  is 
of  a  white  or  yellowish-white  color  and  not  very  abundant.  If  the 
parts  are  not  kept  clean  the  odor  of  the  discharge  is  quite  foul.  In  severe 
cases  the  discharge  is  abundant,  and  may  excoriate  the  skin  of  the  labia 
and  thighs.  The  mucous  membrane  is  swollen  and  red,  but  there  is 
only  a  moderate  secretion.  Microscopical  examination  of  the  discharge 
shows  bacteria  in  large  numbers  and  of  many  varieties,  but  they  are 
chiefly  the  ordinajy  cocci.     With  proper  treatment  and  in  children  who 


656  DISEASES  OF  THE  UROGEXITAL  SYSTE^NI 

are  in  good  general  oondition,  the  disease  iisnally  lasts  l)ut  a  few  weeks. 
Under  unfavorable  conditions  a  leiicorrheal  discharge  may  continue  for  a 
much  longer  time. 

Cases  of  simple  vaginal  catarrh  sliould  be  irrigated  daily  with  a  warm 
saturated  solution  of  boric  acid  or  1  to  5,000  bichlorid.  Cleanliness 
should  be  secured  by  frequent  bathing  and  the  skin  protected  by  oint- 
ments. In  more  severe  cases,  astringent  injections,  such  as  sulphate 
of  zinc  and  tannic  acid  (of  each  one  dram  to  a  pint  of  water)  should  be 
used.  The  general  health  should  be  built  up  by  iron,  cod-liver  oil,  and 
other  tonics. 

Gonococcus  Vaginitis. — This  disease  once  considered  rare  in  children 
has  been  shown  to  be  exceedingly  common  in  girls  of  all  ages,  even  in 
young  infants.  Its  control  has  become  a  social  problem  of  much  im- 
portance, and  one  that  is  beset  with  peculiar  difficulties.  Gonococcus 
vaginitis  is  an  especial  scourge  in  institutions,  in  homes  and  asylums 
for  older  girls,  and  in  those  for  infants  as  well;  also  in  hospitals,  par- 
ticularly those  in  which  prolonged  residence  is  necessary.  Eoutine  ex- 
aminations made  in  large  institutions  for  children  have  revealed  the 
presence  of  this  disease,  often,  it  is  true,  in  a  mild  form,  in  from  2 
to  10  per  cent  of  the  female  inmates.  In  a  single  year,  of  1,200  children 
under  three  years,  chiefly  infants,  applying  for  admission  to  the  Babies' 
Hospital,  63,  nearly  one  per  cent  of  the  females,  were  found  to  be  suf- 
fering from  gonococcus  vaginitis.  Epidemics  in  institutions  are  fre- 
quent and  very  difficult  to  control.  Before  means  of  prevention  were  so 
well  understood  as  they  are  now,  four  epidemics  were  observed  in  the 
Babies'  Hospital  in  five  years,  with  273  cases.^  Day  nurseries  are  an- 
other common  agency  of  spreading  the  disease. 

But  gonococcus  vaginitis  is  by  no  means  confined  to  the  classes  men- 
tioned. In  out-patient  practice  and  among  the  poor  who  live  in  tene- 
ments, it  is  common  in  girls  of  the  school  age  who  have  never  been  ex- 
posed in  institutions.  Even  in  private  practice  among  the  well-to-do, 
cases  are  not  very  rare. 

The  ultimate  source  of  infection  in  children  with  this  disease  in  most 
cases  is  undoubtedly  contact  in  the  home  with  adults  suffering  from  it. 
In  several  series  of  cases  carefully  investigated  fully  one-third  have  been 
definitely  traced  to  a  mother  or  sister  suffering  from  the  disease,  with 
whom  the  young  child  has  slept.  In  the  home,  infection  may  also  take 
place  by  baths,  clothing,  dirty  toilets,  etc.  Among  companions  infection 
may  take  place  by  manual  contact,  masturbation  being  frequent  amon.o- 
infected  persons;  in  schools  and  other  public  places  it  may  unquestion- 
ably be  spread  by  the  toilet  s<'at.  Ciiininal  assault  is  a  rare  cause  amono- 
children. 


"Gonococcus  Infections  in  Institutions,"  N.  Y.  Medical  Journal,  March    1905. 


VAGINITIS  657 

In  institutions  for  infants  and  young  children  the  disease  is  most 
often  acquired  through  the  medium  of  diapers.  Other  possible  sources 
of  contagion  are  towels,  sponges,  wash-cloths,  clothing,  bed  linen,  ther- 
mometers, syringes,  bath  tubs,  and  bath  water.  Even  when  the  most 
careful  attention  is  given  to  all  these  matters  we  have  sometimes  seen 
ward  epidemics  continue.  The  most  probable  explanation  of  such  a  con- 
dition is  that  the  disease  is  spread  by  the  hands  of  the  nurse  in  washing, 
dressing,  or  the  changing  of  napkins.  In  such  cases  nurses  as  well  as 
infected  children  must  be  quarantined.  In  some  instances  it  is  impos- 
sible to  trace  the  mode  of  spreading. 

The  susceptibility  of  the  vaginal  mucous  membrane  to  gonococcus 
infection  is  very  great  in  young  children,  which  in  part  accounts  for  the 
prevalence  of  this  disease.  A  further  reason  for  the  frequency  of  infec- 
tion is  probably  to  be  found  in  the  want  of  protection  of  the  mucous  mem- 
brane owing  to  the  small  size  of  the  labiae.  Vaginitis  should  not  in 
early  life,  be  regarded  as  a  venereal  disease. 

The  constant  presence  in  cases  of  vaginitis  in  children  of  an  organism 
which  morphologically  and  culturally  is  identical  with  the  gonococcus 
found  in  acute  inflammations  in  the  adult,  has  led  to  the  belief  that 
the  tM^o  diseases  were  identical.  But-the  mildness  of  the  local  inflamma- 
tion in  the  great  majority  of  the  cases  in  young  children,  the  absence 
of  constitutional  symptoms  and  of  serious  complications  has  led  to  the 
suspicion  that  there  might  be  important  difi:erences  in  the  infecting  agent 
in  the  two  groups  of  cases.  Pearce,  of  the  Eockefeller  Institute,  has  re- 
cently shown  by  immunological  tests  (agglutination  and  complement  fixa- 
tion) that  the  type  of  organism  in  the  two  groups  is  quite  distinct.  Not 
a  single  exception  was  found  in  the  cases  studied.  The  iufrequency  of 
ophthalmia  as  a  complication  in  little  children  has  often  been  noted. 
In  our  own  experience  it  has  been  rare.  In  this  connection  it  is  inter- 
esting to  note  that  in  cases  of  ophthalmia  in  infants  studied  by  Pearce 
the  organism  corresponded  in  every  instance  to  the  adult  type.  Should 
these  differences  in  type  prove  to  be  the  rule,  we  may  find  that  gonococ- 
cus vaginitis  in  young  children,  though  a  most  troublesome  condition,  is 
not  so  serious  a  matter  as  many  have  been  inclined  to  regard  it. 

Symptoms. — In  the  mild  cases  the  disease  is  limited  to  the  mucous 
membrane  of  the  vagina.  There  is  a  moderate  yellow  discharge,  smears 
of  which  show  pus  cells  and  gonococci.  There  is  very  little  redness  of  the 
mucous  membrane  and  no  local  symptoms  of  discomfort.  In  the  more 
severe  form  the  discharge  is  copious,  often  thick  and  of  a  yellowish- 
green  color.  It  may  be  tinged  with  blood  from  slight  erosions.  It 
causes  excoriation  of  the  labiae  and  inner  surface  of  the  thighs.  Mic- 
turition may  be  frequent  and  painful  owing  to  the  involvement  of  the 
urethra.    If  a  small  speculum  is  introduced  and  the  parts  examined  witli 


658  DISEASES  OF  THE  UROGENITAL  SYSTEM 

a  good  light,  the  extent  and  severity  of  the  disease  can  be  determined. 
It  is  usually  seen  that  the  inflammation  is  a  general  one  affecting  the 
urethra,  vagina,  hymen,  and  the  cervix  uteri.  The  parts  are  intensely 
congested,  granular  in  appearance  and  the  purulent  discharge  may  be 
seen  coming  from  the  cervix.  ^Yith  these  severe  local  symptoms  there 
may  be  in  the  acute  stage  some  constitutional  symptoms  as  in  the  adult. 
But  the  cases  seen  in  little  children  are  seldom  of  this  severe  form. 

In  the  most  severe  cases,  usually  seen  in  girls  past  the  age  of  six 
or  seven  years,  the  inflammation  may  involve  not  only  the  cervix,  but 
the  entire  endometrium;  it  may  extend  to  the  Fallopian  tubes  and  even 
the  pelvic  peritoneum.  Cases  of  this  severity  may  be  seen,  though  very 
rarely,  in  children  of  only  three  or  four  years.  We  have  never  met 
with  them  in  infants.  Swelling  and  suppuration  of  the  inguinal  glands 
are  very  rare.  Other  complications  are  conjunctivitis,  arthritis,  endo-  or 
pericarditis,  meningitis,  and  proctitis.  Conjunctivitis  is  surprisingly  in- 
frequent in  very  young  patients.  Arthritis  is  usually  multiple  and  in- 
volves especially  the  small  joints  of  the  fingers,  toes,  wrists,  or  ankles, 
but  the  large  joints  may  also  be  attacked.  Symptoms  of  pyemia  are 
usually  associated.  These  cases  are  more  fully  considered  in  the  chapter 
on  Acute  Arthritis  in  Infants.  The  diagnosis  in  all  the  complicating 
conditions  rests  upon  the  presence  of  the  gonococcus.  Masturbation 
is  not  uncommon  in  these  cases  and  occasionally  it  is  associated  with 
sexual  precocity. 

Diagnosis. — A  positive  diagnosis  between  simple  and  gonococcus 
vaginitis  can  be  made  with  certainty  only  by  a  microscopical  examination 
of  the  discharge,  though  in  default  of  such  examination  an  abundant 
purulent  discharge  may  be  assumed  to  be  due  to  the  gonococcus.  In 
simple  catarrh  the  discharge  is  made  up  of  epithelial  and  pus  cells  Avith 
cpiite  a  wide  variety  of  bacterial  forms,  chiefly  cocci  and  bacilli,  occa- 
sionally a  few  diplococci.  In  gonococcus  vaginitis  the  gonococci  are 
found  in  large  numbers,  and  are  usually  the  only  bacteria  present. 
To  be  diagnostic,  they  should  be  demonstrated  within  the  pus  cells 
as  well  as  outside  them.  The  gonococcus  decolorizes  when  stained  by 
Gram's  method,  which  fact  distinguishes  it  from  the  other  organisms 
likely  to  be  present  in  the  vagina.  The  staining  is  quite  as  diagnostic 
as  the  cultural  characteristics  of  this  organism.  Cases  of  vaginitis  are 
to  be  regarded  as  suspicious  if  pus  is  found  and  few  organisms  are  de- 
tected; in  such  conditions  subsequent  examination  usually  reveals  the 
gonococcus.  In  our  hospital  experience  the  gonococcus  cases  have  out- 
numbered the  simple  purulent  forms,  fully  twenty  to  one. 

Since  the  diagnosis  rests  upon  the  microscopical  examination  of 
smears  made  from  the  vaginal  secretion,  the  manner  in  which  smears 
are  taken  is  important.    A  moist  swab  or  a  platinum  loop  may  be  used. 


VAGINITIS  650 

the  latter  being  preferred,  or  a  few  drops  of  a  1  to  10,000  bichlorid 
solution  may  be  instilled  into  the  vagina  and  withdrawn  with  a  pipette ; 
after  evaporating  the  fluid  the  residue  is  stained.  The  smear  should  be 
taken  far  inside  the  vagina,  preferably  through  a  small  speculum,  sueli 
as  a  female  urethroscope.  Unless  these  precautions  are  used  a  good  many 
cases  will  be  missed,  especially  since  smears  from  the  cervix  are  some- 
times positive  when  those  taken  from  the  vagina  may  be  negative. 
When  properly  made  and  examined  by  an  experienced  person  the  results 
of  the  examination  may  be  relied  upon  for  diagnosis.  In  a  certain 
proportion  of  the  cases,  usually  those  of  a  severe  type  with  constitutional 
symptoms,  a  positive  result  is  obtained  by  the  complement  fixation  test. 
This  reaction  is  also  at  times  of  value  in  establishing  the  fact  of  cure. 
In  cases  complicated  by  multiple  arthritis  the  gonococcus  is  usually 
found  by  blood  cultures,  even  though  the  vaginal  smears  may  be 
negative. 

Prophylaxis. — The  problem  of  controlling  this  disease  is  a  difficult 
one  owing  to  its  great  frequency,  its  extremely  contagious  character,  its 
protracted  course,  and  the  unsatisfactory  results  of  treatment.  Edu- 
cational measures  come  first  in  importance.  Mothers,  nurses,  social 
workers,  matrons  of  institutions,  hospital  and  school  authorities  should 
all  be  made  acquainted  with  the  prevalence  of  the  disease  and  the  means 
by  which  it  is  usually  spread.  The  attitude  of  the  public  toward  the 
problem  would  be  more  intelligent  if  the  idea  that  vaginitis  in  young 
children  is  a  venereal  disease  could  be  gotten  rid  of.  Even  girls  them- 
selves who  are  likely  to  be  exposed,  should  be  instructed  as  to  the 
dangers  of  infection  and  the  means  of  its  avoidance.  The  importance 
of  proper  cleansing  of  the  genitalia  is  the  first  lesson  to  be  taught.  In 
the  home,  essential  measures  of  prevention  are  that  an  infected  person 
should  sleep  alone,  should  wear  a  vulvar  pad  of  such  a  character  that 
it  can  be  destroyed,  that  sheets  and  clothing  should  be  washed  separately 
from  those  of  the  household,  and  that  especial  care  be  used  about  both 
bath  tubs  and  bath  water  and  the  toilet  seat.  In  the  school  the  greatest 
danger  is  probably  from  the  common  toilet;  scrupulous  cleanliness  of 
this  should  be  secured;  only  the  U-shaped  toilet  seat  should  be  used,  not 
merely  in  schools  but  in  all  public  places.  Another  chief  source  of  in- 
fection being  contact  with  infected  companions,  this  should  be  limited  so 
far  as  possible.  To  make  the  disease  a  reportable  one  and  exclude 
infected  children  from  public  schools  does  not  seem  a  practicable 
measure,  since  this  would  involve  the  examination  of  smears  from  all 
the  girls  attending  school.  The  importance  of  tlio  disease  does  not 
Justify  such  radical  measures. 

It  is  in  institutions  for  children  that  the  problem  of  prevention 
is  most  difficult  and  also  most  important.     In  all  day  nurseries,   bos- 


660  DISEASES  OF  THE  UROGENITAL  SYSTEM 

pitals  and  homes  similar  means  must  be  employed,  viz.,  the  examination 
of  vaginal  smears  from  every  child  on  admission  should  be  a  matter 
of  routine;  cases  showing  the  gonococcus  should  not  be  received  into 
the  same  ward  or  dormitory  with  others,  and  even  cases  showing  only 
pus  cells  but  no  gonococci  should  be  quarantined.  In  hospitals  for 
children,  routine  smears  should  be  taken  from  all  female  children  at 
least  once  a  week.  In  no  other  way  is  it  possible  to  recognize  cases 
early  and  prevent  ward  epidemics. 

The  attendants,  both  day  and  night  nurses,  as  well  as  the  affected 
children,  should  be  quarantined.  Napkins,  underclothing,  and  sheets 
from  the  beds  of  such  patients,  also  their  towels  and  wash-cloths,  should 
not  go  into  the  common  laundry,  but  should  be  first  soaked  in  a  strong 
solution  of  carbolic  acid,  and  afterward  boiled.  In  wards  or  institutions 
where  cases  have  occurred,  washable  napkins  should  be  discontinued  and 
old  muslin  and  absorbent  cotton  substituted.  These  are  to  be  destroyed 
after  using.  All  articles  connected  with  the  children's  toilet,  also 
syringes,  thermometers,  etc.,  should  be  carefully  disinfected.  But  often 
this  is  not  enough.  Separate  articles  should  be  furnished  for  each  child. 
The  essential  measure  is  a  prompt  recognition  and  isolation  of  the  first 
case  in  the  hospital.  The  danger  to  life  in  this  disease  is  not  great,  and 
is  from  the  serious  complications  mentioned  above,  all  of  which  are  very 
infrequent  in  young  children.  In  very  many  cases,  however,  the  disease 
lasts  for  years  even  in  spite  of  treatment  and  the  question  of  the  ulti- 
mate damage  to  the  general  health  or,  what  is  more  important,  to  the 
organs  involved  must  be  considered.  At  present  we  have  not  enough 
knowledge  to  warrant  positive  statements  upon  this  point.  It  is  pos- 
sible that  many  of  these  protracted  cases  ultimately  recover  spontaneously, 
or  that  after  long  continuance  of  the  disease  the  organisms  present  have 
such  a  low  virulence  that  their  capacity  for  injury  is  very  slight  indeed. 
The  disease  is  not  a  new  one  and  it  is  very  prevalent ;  were  the  ulti- 
mate dangers  as  great  as  some  have  asserted  more  evidence  of  this 
would  exist  than  now  appears  to  be  the  case.  Facts  now  at  hand  do 
not  justify  the  belief  that  the  ultimate  dangers  from  vaginitis  in 
children  are  great,  or  in  any  way  comparable  to  acute  gonococcus 
vaginitis  acquired  in  adult  life.  Some  reason  for  this  may  be  found 
in  the  biological  difference  in  the  gonococci  from  adult  and  infantile 
cases  which  has  been  already  referred  to. 

Treatment. — On  account  of  its  very  chronic  character  and  its  preva- 
lence chiefly  among  the  poor,  most  cases  of  vaginitis  must  be  treated 
in ;  out-patient  clinics.  Special  clinics  for  such  cases  should  be  estab- 
lished in  every  large  city,  attached  to  which  should  be  a  visiting  nurse 
who  should  see  that  proper  treatment  is  carried  out  in  the  home.  To 
be  at  all  successful  local  treatment  must  be  thoroughly  carried  out  by  a 


VAGINITIS  06 1 

physician  and  for  a  long  period.  The  first  essential  is  local  cleanliness 
which  must  be  secured  by  bathing  the  external  organs  twice  a  day  with  a 
solution  of  boric  acid  or  some  similar  preparation.  In  spite  of  the 
obvious  oljjections  to  their  use,  irrigations  are  probably  the  most  valuable 
of  the  local  measures  we  possess.  These  should  be  made  daily  if  possible 
and  through  a  catheter  whose  tip  is  carried  well  into  the  vagina.  Boric 
acid  solution  or  permanganate  of  potash  1-2,000  to  1-5,000,  ichthyol 
1-1,000,  or  bichlorid  1-10,000  may  be  used.  Following  the  irrigation 
local  applications  should  be  made  every  second  or  third  day  of  nitrate 
of  silver  10  per  cent,  or  argyrol  20  per  cent  strength.  These  should 
])e  made  with  an  applicator  through  some  sort  of  a  speculum — the  female 
urethroscope  answers  very  well  for  small  patients — and  the  child  kept 
upon  the  back  Avith  the  thighs  in  contact  for  a  short  time.  If  the  cervix 
is  involved  local  applications  made  in  the  manner  indicated  are  essential 
if  anything  is  to  be  accomplished. 

Eegarding  the  value  of  vaccines  there  is  still  much  difference  of 
opinion.  Some  writers  have  reported  excellent  results  while  others  with 
considerable  experience  have  seen  little  benefit  from  their  use.  Our  own 
experience  is  that  their  effects  are  very  uncertain;  that,  Avhile  in  some 
instances  striking  improvement  has-been  seen,  in  the  great  majority  of 
cases  this  does  not  occur.  The  best  results  are  seen  in  the  most  recent 
cases.  Eegarding  the  value  of  vaccines  in  some  of  the  complications, 
especially  arthritis  and  general  sepsis,  there  can  be  little  question.  The 
autogenous  appear  to  have  no  advantage  over  stock  vaccines.  The 
dosage  of  vaccines  is  still  empirical.  It  is  customary  to  give  from  50,000,- 
000  to  75,000,000  as  an  initial  dose,  to  repeat  every  five  or  six  days, 
gradually  increasing  this  to  100,000,000.  If  no  improvement  is  seen 
after  six  or  eight  injections,  their  continuance  is  useless.  In  connec- 
tion with  the  administration  of  vaccines  careful  bathing  of  the  external 
organs  should  be  combined,  but  irrigations  may  be  omitted.  Because 
of  the  favorable  results  sometimes  seen,  the  use  of  vaccines  is  to  be 
advised  in  all  recent  acute  cases  of  the  severe  form.  The  prolonged 
use  of  irrigations  has  serious  objections  in  girls  of  seven  or  eight  years 
or  older,  in  that  it  tends  to  develop  sexual  consciousness  and  may  lead 
to  masturbation. 

On  the  whole,  it  must  be  stated  that  the  results  of  treatment  in 
cases  which  have  reached  the  chronic  stage  by  any  measures  yet  proposed 
are  very  unsatisfactory,  largely  owing  to  the  difficulty  of  controlling  the 
patients  for  the  tedious  period  of  local  treatment  which  is  necessary. 

Eelapses  are  exceedingly  common  even  in  cases  in  which  there  has 
been  no  discharge  for  weeks  or  even  months.  Of  twenty-six  cases  care- 
fully followed  up  by  Spaulding  and  sul)jected  to  thorough  treatment, 
all  but  two  relapsed  after  variable  periods  from  one  to  six  months. 


662  DISEASE.S  OF  THE  UEOGEXITAL  SYSTEM 

That  such  oases  are  reinfections  seems  improbable.  It  would  rather 
appear  that  the  disease  may  have  long  periods  of  latency  and  recrudes- 
cence for  an  indefinite  time.  It  is  therefore  difficult  to  say  when  a 
given  case  is  actually  cured.  Under  most  conditions  one  is  safe  in 
pronouncing  a  case  cured  when  there  has  been  no  discharge  for  three 
months  after  the  discontinuance  of  special  treatment,  and  when  smears 
from  the  deeper  parts  continue  to  be  negative. 


GANGRENOUS   VULVITIS    (NOMA) 

This  is  the  same  process  as  that  seen  in  the  mouth  and  known  as 
cancrum  oris.  It  usually  follows  one  of  the  infectious  diseases,  most 
frequently  measles,  occurring  in  patients  whose  general  vitality  has  been 
greatly  reduced.  There  is  first  noticed  a  tense,  brawny  induration,  the 
skin  being  shiny  and  swollen  over  a  circumscribed  area.  In  the  center 
of  this  there  soon  appears,  usually  upon  one  of  the  labia  majora,  a  dark, 
circumscribed  spot.  Day  by  day  the  gangrenous  area  advances,  preceded 
by  the  induration.  It  may  involve  the  whole  labium,  extending  even  to 
the  mons  veneris  and  the  perineum.  These  cases  are  generally  fatal. 
If  recovery  takes  place,  it  is  with  considerable  deformity  of  the  parts  in 
consequence  of  the  extensive  sloughing  and  cicatrization.  As  sequelae, 
there  may  be  fistulae,  stenosis,  or  atresia  of  the  vagina.  The  only  radical 
treatment  is  early  excision,  and  the  application  of  the  actual  cautery, 
carbolic  or  nitric  acid. 


CHAPTEE    IV 
DISEASES  OF  THE  BLADDER 

ENURESIS 

{Incontinence   of    Urine;   Bed-wetting) 

Enuresis  may  be  due  to  some  malformation  of  the  genital  tract,  such 
as  an  abnormal  opening  of  the  bladder  into  the  vagina,  to  extroversion 
of  the  bladder,  or  to  the  persistence  of  the  urachus;  in  the  latter  case 
the  urine  is  discharged  from  the  umbilicus.  It  also  occurs  in  organic 
diseases  of  the  central  nervous  system,  such  as  idiocy,  cerebral  palsy, 
acute  meningitis,  tumors  of  the  brain,  certain  forms  of  myelitis,  spina 
bifida  occulta,  and  in  injuries^  of  the  cord.  In  many  of  these  conditions 
there  is  associated  incontinence  of  feces.  Both  of  the  groups  of  cases 
mentioned  are  quite  distinct  from  the  ordinary  form  of  incontinence  of 


ENURESIS  663 

urine  which  is  seen  in  childhood.  The  latter  is  the  only  variety  which 
will  be  considered  here. 

It  is  in  many  cases  possible  to  teach  infants  to  control  the  evacuation 
of  the  bladder  before  the  end  of  the  first  year ;  usually^  however,  control 
is  not  acquired  even  during  waking  hours  until  some  time  during  the 
second  year,  and  in  some  healthy  infants  not  before  the  end  of  the  second 
year.  The  time  depends  very  much  upon  the  training.  If  a  child  during 
its  third  year  can  not  control  the  evacuation  of  the  bladder  during  its 
Avaking  hours,  incontinence  may  be  said  to  exist. 

Etiology, — Incontinence  of  urine  may  be  due  to  a  continuance  of  the 
infantile  condition,  to  anything  which  increases  the  irritability  of  the 
spinal  center,  or  which  interferes  with  the  cerebral  control  over  this 
center,  or  to  anything  which  increases  the  irritability  of  the  terminal 
filaments  of  the  vesical  nerves  or  of  those  in  the  neighborhood.  The 
causes  of  incontinence  thus  may  .be  in  the  central  nervous  system,  in  the 
urine,  in  the  bladder,  or  in  any  of  the  adjacent  organs. 

The  causes  relatiiig  to  the  central  nervous  system  are  in  the  main 
those  of  the  other  neuroses  of  childhood ;  these  are  anemia,  malnntrition, 
an  inherited  nervous  constitution,  or  a  condition  of  extreme  ]iervousness 
or  neurasthenia,  the  result  of  the  child's  surroundings.  In  such  cases 
incontinence  is  often  associated  with  chorea,  epilepsy,  hysteria,  headaches, 
neuralgia,  and  other  nervous  symptoms.  In  these  conditions  there  is 
assumed  to  be  not  only  an  increased  irritability  of  the  nerve  centers,  but 
also  of  the  peripheral  nerves,  accompanied  by  loss  of  tone  of  the  vesical 
sphincter.  A  similar  condition  may  exist  with  almost  any  form  of  acute 
illness,  this  usually,  however,  being  only  temporary. 

Incontinence  may  be  caused  either  by  a  highly  acid,  concentrated 
urine  when  an  insufficient  amount  of  fluid  is  taken,  or  by  the  opposite 
condition,  when  owing  to  the  drinking  of  a  large  quantity  of  water,  often 
only  a  matter  of  habit,  the  amount  of  urine  is  very  greatly  increased  and 
passed  at  frequent  intervals. 

In  the  bladder  itself,  cystitis  and  vesical  calculus,  although  infre- 
quent, should  not  be  overlooked  as  possible  causes.  In  a  few  cases,  where 
incontinence  has  existed  a  long  time,  the  bladder  becomes  so  contracted 
that  it  will  hold  only  an  ounce  or  two  of  urine.  This  condition,  although 
not  the  primary  cause  of  enuresis,  may  be  enough  to  continue  it. 

Local  irritation  in  the  neighboring  organs  may  be  due  to  adherent 
prepuce,  balanitis,  phimosis,  or  to  a  narrow  meatus.  All  of  these  condi- 
tions are  frequently  associated  with  incontinence.  Eectal  irritation  may 
be  due  to  pinworms,  anal  fissure,  or  rectal  polypus;  and  vaginal  irrita- 
tion to  vulvovaginitis  or  adherent  clitoris;  but  these  are  rarely  the  only 
cause.  Often  there  is  incontinence  as  the  result  of  a  combination  of  sev- 
eral causes,  no  one  of  which  alone  would  have  been  sufficient  to  produce 


664  DISEASES  OF  THE  UROGEXITAL  SYSTE:M 

it.  In  many  cases  heredity  seems  to  be  a  factor  oi'  some  importance^ 
parents  often  having  suffered  in  their  childhood  from  the  same  condi- 
tion ;  quite  frequently  two  and  sometimes  even  three  children  in  the  same 
family  are  affected.  In  many  cases  the  condition  seems  to  be  mainly 
the  result  of  habit,  and  in  all  cases  habit  is  a  potent  factor  in  continuing 
the  incontinence,  sometimes  after  the  original  exciting  cause  has  l)een 
removed.  Frequently  no  adequate  cause  can  be  found.  Both  sexes 
are  about  equally  liable  to  enuresis:  it  may  be  seen  in  all  ages  up  to 
puberty  and  even  to  adult  life. 

Symptoms. — Enuresis  may  be  nocturnal  or  diurnal,  or  both.  Of  184 
cases,  T3  were  nocturnal,  9  diurnal,  and  102  were  both  nocturnal  and 
diurnal.  Cases  differ  greatly  in  severity.  Incontinence  may  be  habitual,' 
occurring  every  night,  often  several  times  during  the  night,  and  fre- 
quently during  the  day;  or  it  may  be  only  occasional  under  the  influence 
of  some  special  exciting  cause,  when  it  continues  a  few  days  or  weeks 
until  the  cause  is  removed.  In  a  considerable  number  of  cases,  the  condi- 
tion lasts  from  infancy  until  the  sixth  or  seventh  year.  It  may  even  con- 
tinue until  puberty ;  but  it  generally  ceases  at  that  period,  unless  its  cause 
is  mechanical  or  depends  upon  some  organic  disease  of  the  brain  or  cord. 
In  ordinary  enuresis  there  is  never  dribbling  of  the  urine,  but  usually  a 
contraction  of  the  walls  of  the  bladder  follows  almost  immediately  upon 
the  desire  before  the  patient  can  make  his  wants  known  or  reach  a  con- 
venient place  for  micturition.  At  night  the  same  thing  may  occur 
without  wakening  the  child,  the  contraction  being  of  purely  reflex 
origin. 

Prognosis. — The  condition  is  usually  hopeless  when  it  depends  upon 
organic  disease  of  the  brain  and  cord ;  also  in  cases  due  to  malformation, 
unless  these  are  amenable  to  surgical  treatment.  In  the  ordinary  cases 
seen,  the  prognosis  depends  upon  the  age  of  the  cliild,  the  duration  of  the 
symptom,  and  the  nature  of  the  exciting  cause.  In  children  of  from 
three  to  five  years  a  cure  can  in  most  cases  be  accomplished  with  proper 
management.  Those  who  are  older  are  much  less  amenal)lc  to  treatment, 
especially  if  the  condition  has  persisted  since  infancy;  Imt  if  the  incon- 
tinence has  begun  after  seven  or  eight  years  of  age  and  lasted  but  a  few 
weeks  or  months,  the  outlook  is  much  more  encouraging.  There  are, 
however,  some  cases  in  which  no  other  cause  than  habit  can  be  discovered 
which  resist  all  treatment,  the  condition  finally  ceasing  spontaneously 
about  puberty;  rarely  does  it  continue  beyond  this  period. 

Treatment. — The  first  indication  is  to  remove  the  cause,  when  one 
can  be  found.  If  there  are  preputial  adhesions,  they  should  be  broken 
up  and  irritating  smegma  ^emo^■ed.  If  pliiniosis  is  present,  it  shoulil  l)e 
relieved  by  circumcision.  If  stone  in  the  bladder  is  suspected,  as  it 
should  be  when  the  incontinence  is  worse  by  day  and  accompanied  by 


ENURESIS  665 

straining  and  painful  spasm  of  the  bladder,  the  patient  should  be 
sounded  for  stone.  Pinworms  in  the  rectum  should  receive  the  appro- 
priate treatment  by  injections.  While  the  local  conditions  mentioned 
should  always  be  attended  to,  the  fact  remains  that  few  cases  are  cured 
simply  by  relieving  them,  except  those  due  to  vesical  calculi.  The  ex- 
planation of  this  is  that  habit  is  the  important  factor  in  keeping  up 
incontinence. 

A  concentrated  urine  of  high  acidity  with  deposits  of  uric  acid  is 
an  indication  for  alkalis  and  the  free  use  of  all  fluids,  especially  water. 
On  the  other  hand,  when  there  is  passed  a  large  quantity  of  urine  of 
low  specific  gravity,  the  amount  of  M^ater  and  other  fluids  should  be 
greatly  restricted.  During  the  night  Avater  should  be  forbidden.  In  these 
cases  the  incontinence  is  often  simply  tlie  result  of  the  polyuria,  which 
in  turn  depends  upon  polydipsia. 

In  most  cases  the  condition  is  purely  a  habit,  often  associated  with 
other  habits  which  indicate  an  unstable  or  highly  susceptible  nervous 
system.  It  is  therefore  of  the  greatest  importance  that  a  proper  general 
regime  should  be  instituted.  Care  should  be  taken  to  secure  for  the 
child  a  simple,  natural  life,  with  no  overtaxing  of  the  nervous  system  at 
home  or  in  school.  Every  cause  of  unnatural  excitement  should  be 
avoided.  Early  hours  and  plenty  of  sleep  should  be  insisted  upon.  Cer- 
tain articles  of  diet  are  to  be  avoided,  and  coffee,  tea,  and  beer  should 
be  absolutely  prohibited.  Sweets  and  all  highly  seasoned  food  should 
be  very  sparingly  allowed,  or  not  at  all.  The  exclusion  of  meat  from 
the  diet  seems  to  us  to  be  of  no  special  advantage.  Measures  directed 
toward  improving  the  general  muscular  and  nervous  tone  are  of  the 
greatest  importance.  Anemia,  malnutrition,  indigestion,  and  constipa- 
tion should  each  receive  careful  attention. 

Punishments,  whether  corporal  or  otherwise,  do  little  good,  and 
nsually  they  are  harmful.  Eewards  are  sometimes  more  efficacious  than 
any  other  means  of  treatment.  One  should  first  find  out  what  it  is  that 
the  child  desires  most — a  new  doll,  a  bicycle,  etc. — and  allow  him  to  have 
it  if  the  bed  is  dry,  taking  it  away  if  it  is  wet.  A  reward  of  five  cents 
for  every  dry  night  sometimes  works  marvels.  Any  measures  that  pro- 
duce a  marked  impression  upon  the  mind  of  the  child  sometimes  have  a 
beneficial  effect.  The  inspiring  of  confidence  that  the  physician  will 
bring  about  a  cure  is  oftentimes  the  most  efficacious  method  of  treat- 
ment. Bad-tasting  drugs  and  mechanical  measures,  such  as  the  passing 
of  sounds,  probably  owe  their  occasional  success  to  the  mental  impres- 
sion that  they  produce. 

After  all  local  and  general  causes  which  can  be  discovered  are  so  far 
as  possible  removed,  there  remains  the  large  majority  of  the  cases  of 
enuresis  in   which   the  condition   is  simply   the   continuance   of  a  bad 


666  DISEASES  OF  THE  UROGENITAL  SYSTEM 

habit.  To  break  the  habit,  training  is  of  the  first  importance.  The 
regiilation  of  the  amount  of  fluids  is  indispensable.  Fluids  should  be 
given  freely  up  to  4  p.  m.,  but  those  who  have  nocturnal  incontinence 
should  have  no  fluids  after  that  hour,  a  dry  supper  being  given  before 
retiring.  These  children  are  often  heavy  sleepers  and  the  distention 
of  the  bladder  does  not  produce  a  sufficient  impression  to  waken  them. 
Training  should  be  begun  during  the  day  by  voiding  at  regular  intervals, 
and  gradually  lengthening  the  interval  to  accustom  the  bladder  to  dis- 
tention. At  night  also  the  child  should  be  wakened  regularly  at  certain 
hours  to  void  his  urine.  This  should  be  done  by  an  alarm  clock  if  neces- 
sary; e.  g.,  a  child  who  is  put  to  bed  at  7  is  at  first  wakened  at  10  p.  m. 
and  at  1  and  4  and  7  a.  m.,  a  record  being  kept  of  the  times  when  the 
bed  is  found  wet.  When  he  goes  three  hours  regularly  at  night  without 
voiding,  the  time  is  lengthened  to  three  and  a  half  and  finally  to  four 
hours.  A  child  can  in  tbis  way  usually  be  trained  in  a  few  weeks  to  hold 
his  urine  with  but  one  Avaking  from  10  p.  m.  until  morning;  and  in  a 
few  months  this  can  be  omitted.  The  number  of  cases  which  can  be 
permanently  cured  by  such  simple  means  is  most  surprising.  The  faith- 
ful cooperation  of  the  mother  or  nurse  is  essential  to  make  the  cure 
permanent. 

The  measures  described — removal  of  local  causes,  improvement  of  the 
general  health,  the  institution  of  a  proper  regime  and  training — consti- 
tute the  most  important  part  of  the  treatment  and  in  the  majority  of 
cases  suffice  for  a  cure.  Drugs  are  at  times  useful  as  accessories;  alone 
they  seldom  cure  and,  on  the  whole,  they  are  disappointing.  Belladonna 
is  the  most  effective  one.  Atropin,  either  in  solution  or  in  talilet  form, 
is  the  most  convenient  method  of  administration.  For  nocturnal  incon- 
tinence, 1-1,000  of  a  grain  for  each  year  of  the  child's  age  up  to  seven 
years  is  a  suitable  dose.  A  child  of  five  would  thus  be  taking  1-200  of  a 
grain.  At  first,  a  single  dose  should  be  given  at  bedtime;  after  a  few 
days  a  second  dose  may  be  given  three  or  four  hours  earlier;  still 
later  a  dose  may  be  given  at  4  p.  m.,  7  p.  m.,  and  10  p.  m.  To  push  the 
drug  further  than  this  may  cause  much  discomfort  and  is  of  doubtful 
advantage.  After  the  habit  is  under  control,  the  drug  should  be  con- 
tinued for  some  time  and  the  dose  reduced. 

Strychnin  is  sometimes  advantageous  when  there  is  diurnal  as  well  as 
nocturnal  incontinence,  for  under  these  conditions  theje  is  usually  a,  lack 
of  tone  in  the  sphincter,  as  well  as  increased  irritability  in  the  mucous 
membrane  of  the  bladder.  Full  doses  are  necessary;  beginning  with 
1-100  of  a  grain  twice  daily  it  may  be  gradually  increased  to  1-50  of 
a  grain  three  times  a  day  to  a  child  of  five.  Intelligent,  systematic  train- 
ing is  the  most  important  of  all  measures  for  the  relief  of  this  very 
annoying  condition, 


VESICAL  CALCULUS  GG7 


VESICAL  CALCULUS 


Vesical  calculus  is  a  very  rare  condition  in  children  in  New  York. 
The  nucleus  of  the  calculus  is  usually  a  renal  calculus  which  has  passed 
the  ureter,  hut  has  been  prevented  hy  its  size  from  going  farther.  Stone 
in  the  bladder  is  extremely  rare  in  infancy,  probably  owing  to  the  fluid 
diet,  but  it  is  not  infrequent  in  children  from  two  to  ten  years  of  age. 
The  most  common  variety  of  calculus  at  this  time  is  the  uric-acid. 

The  symptoms  in  children  are  somewhat  different  from  those  in 
adults,  and  the  condition  is  often  overlooked.  There  is  frequently  pain 
upon  micturition,  especially  at  the  close  of  the  act,  which  may  be  felt 
at  the  end  of  the  penis  or  in  the  perineum.  There  may  be  a  sudden 
stoppage  in  the  flow  of  urine.  The  straining  often  leads  to  recta!  tenes- 
mus and  even  to  prolapse.  This  complication  is  so  frequent  that,  in  a 
case  of  persistent  prolapse,  stone  should  always  be  suspected.  Incon- 
tinence of  urine  is  a  prominent,  and  often  the  principal  symptom;  in 
many  cases  it  is  noticed  only  during  the  day.  The  urinary  changes  are 
not  generally  marked;  hematuria  is  rare,  and  mucus  and  pus  are  in- 
frequent and  in  small  quantity.  The  genital  irritation  may  lead  to  the 
habit  of  masturbation.  A  stone  of  any  considerable  size  may  often  be 
felt  by  a  bimanual  axamination,  one  finger  being  placed  in  the  rectunr 
and  the  other  hand  above  the  pubes.  This  is  easier  in  males  than  in 
females,  but  it  is  not  very  trustworthy,  and  not  conclusive  when  it  gives 
a  negative  result.  A  positive  diagnosis  is  made  only  by  exploring  the 
bladder  with  a  sound  or  by  the  X-ray. 

The  treatment  of  calculus  is  purely  surgical. 


SECTION    YII 
DISEASES  OF  THE  NEEYOUS  SYSTEM 

CHAPTER    I 


The  Weight  of  the  Brain. — From  ninety-eight  observations  made  in 
the  post-mortem  room  of  the  New  York  Infant  Asyhim,  the  following 
were  the  average  weights  noted: 

At  three  months 21      oz.  (602  grams). 

At  six  months 25 J^    "    (712      "     ), 

At  twelve  months 32^    "    (916      "     ). 

At  two  years 35        "    (990      "     ). 

♦ 

The  following  are  the  figures  given  by  Boyd  and  Schafer. 


Age. 

Males. 

Females. 

Ounces. 

Grams. 

Ounces. 

Grams. 

At  birth  (full  term) 

IIH 

21 

27 
33 
39 
40 
46 
481^ 

330 

500 

602 

776 

941 

1,110 

1,138 

1,.301 

1,.374 

*10 
16 
20 
26 
30 
35 
40 
40^ 
44 

283 

Under  three  months      

450 

From  three  to  six  months 

560 

From  six  to  twelve  months 

From  one  to  two  years. 

727 
843 

From  two  to  four  years 

From  four  to  seven  years 

From  seven  to  fourteen  years 

From  fourteen  to  twenty  years 

990 
1,135 
1,154 
1,244 

At  birth  the  weight  of  the  ])rain  to  that  of  the  body  is  nearly  1 :  8. 
During  infancy  and  childhood  the  following  is  the  ratio,  according  to 
Bischoff :  during  the  first  year,  1 :  G  ;  the  second  year,  1:14;  the  third 
year,  ]  :  18  ;  at  the  fourteenth  year,  1 :  15  to  1 :  25  ;  in  adult  life  it  is  1 :  43. 

The  Spinal  Cord. — Tlie  weight  of  the  cord  to  the  weight  of  the  body 
at  birth  is  1 :  500 ;  in  adult  life  it  is  1 :  1500.  According  to  Kolliker,  the 
spinal  cord  and  the  vertebral  column  are  the  same  length  until  the  end  of 
the  third  month  of  fetal  life,  there  being  at  this  time  no  cauda  equina. 
At  the  ninth  month  the  lower  end  of  the  cord  is  opposite  the  third  lum- 
bar vertebra  ;  in  the  adult  it  is  opposite  tlie  first. 
23  669 


670  DISEASES  OF  THE  XERVOUS  SYSTEM 

Some  Peculiarities  in  the  Diseases  of  the  Nervous  System  in  Infancy 
and  Childhood. — The  relatively  large  size,  the  rapid  growth,  and  the 
immaturity  of  the  brain  and  cord  during  early  life,  explain  much  that  is 
peculiar  to  the  nervous  diseases  of  this  period. 

At  this  time,  apparently  trivial  causes  are  enough  to  produce  quite 
profound  nervous  impressions,  because  of  the  instability  of  the  nervous 
centers  and  the  greater  irritability  of  the  motor,  sensory,  and  vasomotor 
nerves.  These  are  conditions  which  are  very  much  increased  by  all  dis- 
turbances of  nutrition.  These  disturbances  may  be  manifold  in  character, 
but  they  lie  at  the  root  of  very  many  of  the  neuroses  of  early  life,  e.  g., 
extreme  nervousness,  disorders  of  sleep,  stuttering,  chorea,  incontinence 
of  urine,  tetany,  and  convulsions.  The  great  liability  to  convulsions 
depends  not  only  upon  the  greater  irritability  of  the  peripheral  nerves, 
but  upon  the  instability  of  the  nervous  centers  and  the  lack  of  inhibition 
over  the  motor  ganglion  cells  of  the  spinal  cord.  The  nervous  centers  are 
more  easily  exhausted  than  later  in  life. 

Another  peculiarity  is  the  serious  consequences  which  often  follow 
reflex  irritation,  although  this  is  rarely  the  only  factor  in  the  case.  Con- 
ditions which  in  adult  life  produce  almost  no  effect  may  in  infancy  be 
the  cause  of  most  alarming  symptoms. 

As  a  third  point  of  importance  may  be  mentioned  the  grave  per- 
manent results  which  often  follow  relatively  small  organic  lesions.  A 
good  illustration  is  seen  in  the  lesions  which  produce  cerel)ral  birtli-palsy. 
Here  the  damage  is  only  in  small  part  the  immediate  effect  of  the  hemor- 
rhage, for  this  often  is  not  great,  but  it  is  the  interference  with  the  devel- 
opment of  certain  parts  of  the  cortex  that  makes  the  condition  so 
serious. 

From  what  has  been  said,  it  follows  that  the  hygiene  of  the  ner\'ous 
system  is  of  the  utmost  importance  in  infancy  and  childhood.  It  is 
essential  for  the  healthy  development  of  the  nervous  system  that  all  stim- 
ulants should  be  avoided — not  only  tea,  coffee,  and  alcohol,  but  undue 
and  unnatural  excitement,  the  effect  of  which  in  infancy  is  almost  as 
serious.  A  normal  development  can  take  place  only  in  the  midst  of  quiet 
and  peaceful  surroundings,  with  plenty  of  time  for  rest  and  sleep.  The 
conditions  of  modern  life,  especially  in  cities,  are  such  that  these  laws 
are  almost  in^'ariably  violated,  and  the  consequences  of  this  are  seen 
in  the  marked  and  steady  increase  in  nervous  diseases  among  children 
of  all  classes. 


CONVULSIONS  671 

CHAPTEE  II 

GENERAL  AND   FUNCTIONAL  NERVOUS  DISEASES 
CONVULSIONS 

All  young  children,  but  especially  infants,  are  extremely  prone  to 
convulsive  disorders.  In  certain  infants,  especially  those  who  are 
rachitic,  this  susceptibility  is  much  heightened. 

Under  the  head  of  convulsions  are  included  attacks  of  acute  transient 
nervous  disturbance,  characterized  by  involuntary  rhythmical  spasm  of 
the  muscles,  either  of  the  face,  trunk,  or  extremities,  or  all  of  them, 
usually  accompanied  by  loss  of  consciousness.  They  may  be  regarded  as 
"motor  discharges''  from  the  cortex  of  the  brain. 

Etiologically,  e()n^■ulsions  may  be  divided  into  those  of  organic  and 
those  of  functional  origin  according  as  to  whether  a  pathological,  lesion 
is  or  is  not  demonstrable.  It  must  not  be  overlooked,  however,  that  what 
we  now  consider  functional  may,  with  improved  methods,  be  shoAvn  to 
depend  upon  an  actual  change  in  the  tissue  of  the  brain.  Under  the  head 
of  organic,  or  those  due  to  direct  irritation  of  the  cortex  of  the  brain, 
may  be  included  all  convulsions  occurring  with  the  various  forms  of 
cerebral  disease.  The  most  frequent  are  meningitis,  meningeal  or  cere- 
bral hemorrhage,  tumor,  abscess,  hydrocephalus,  embolism,  and  throm- 
bosis. Developmental  defects  of  the  brain,  especially  microcephalus,  arc 
frequently  the  cause  of  repeated  convulsions  that  are  usually  classed 
under  epilepsy.  Convulsions  due  to  organic  disease  may  be  found  at  any 
time  during  infancy  and  childhood.  Because  of  their  dependence  upon 
traumatism  at  birth  they  are  frequent  in  the  first  few  weeks  of  life. 

Convulsions  functional  in  origin  are,  in  the  overwhelming  majority 
of  cases,  dependent  upon  tetany  which  may  be  either  active  or  latent. 
It  is  only  in  the  last  few  years  that  this  has  been  sufficiently  recognized. 
As  will  be  emphasized  under  Tetany,  the  symptoms  of  this  disease  and 
the  irritation  of  the  nervous  system  accompanying  it  are  not  usually 
manifest  before  the  end  of  the  first  half  year.  For  this  reason,  functional 
convulsions  are  much  less  frequent  during  the  early  months  of  life. 

It  has  been  held  that  the  most  important  predisposing  cause  of  con- 
vulsions in  infancy  is  the  instability  of  the  nerve  centers,  which  is 
dependent  upon  a  lack  of  development  of  the  voluntary  centers  of  the 
cortex.  It  should  be  emphasized,  however,  that  while  convulsions  of 
functional  origin  are  exceedingly  common' in  infancy,  they  are.  not  so 
in  the  first  three  or  four  months  of  life  wlien  instal)ility  of  the  centers 
might  be  assumed  to  be  tbe  greatest.    It  is  quite  evident  (hat  the  instabil- 


672  ^      DISEASES  OF  THE  NERVOUS  SYSTEM 

ity  depends  not  upon  the  normal  insufficiency  of  cerebral  development, 
but  upon  the  acquisition  of  tetany,  which  causes  cerebral  instability. 

It  has  long  been  held  that  convulsions  were  caused  by  materials 
absorbed  from  the  gastro-intestinal  tract.  It  is  certainly  true  that  over- 
feeding or  indigestion  may  excite  convulsions.  This  is  usually,  however, 
in  children  suffering  from  tetany  and  it  is  very  likely  that  the  convul- 
sions are  not  due  to  any  specificity  of  the  material  absorbed,  but  that 
any  irritation  to  the  child's  nervous  system  is  likely  to  be  followed  by 
convulsions.  Convulsions  are  sometimes  seen,  it  must  be  admitted,  in 
infants  when  no  evidence  of  organic  disease  can  be  detected,  nor  any 
symptoms  of  tetany  and  no  hyperexcitability  of  the  nervous  system  as 
shown  by  electrical  examination.     The  cause  of  these  is  not  clear. 

Convulsions  are  apparently  at  times  of  toxic  origin.  They  may  result 
from  conditions  like  uremia  and  asphyxia  and  also  at  the  onset  or  in 
the  course  of  various  infectious  diseases.  They  are  more  frequent  in 
children  who  have  or  have  had  tetany,  but  may  be  found  without  any 
evidences  of  this.  They  are  very  frequent  at  the  onset  of  certain  diseases, 
particularly  pneumonia,  scarlet  fever,  malaria  and  acute  indigestion. 
In  pertussis,  which,  of  all  the  infectious  diseases,  is  the  one  in  which 
convulsions  are  most  frequent,  several  factors  may  be  present:  asphyxia, 
due  to  a  severe  paroxysm,  cerebral  congestion  or  hemorrhage  resulting 
from  such  a  paroxysm,  or  simply  a  peculiar  susceptibility  of  the  patient 
brought  about  by  the  disease  itself.  One  attack  of  convulsions,  whatever 
the  cause,  renders  the  patient  more  liable  to  a  second  attack  and  when 
there  have  been  several,  they  occur  from  causes  which  are  less  and  less 
marked. 

An  infrequent  cause  of  convulsions  in  young  children  is  an  encephal- 
opathy due  to  lead  poisoning.  We  have  seen  four  such  cases,  three  of 
which  Avere  fatal.  The  poisoning  was  caused  in  each  instance  by  the 
child's  nibbling  and  swallowing  the  paint  from  his  crib  or  furniture. 

Convulsions  ending  fatally  are  not  infrequently  associated  with  en- 
largement of  the  thymus  gland.  We  have  seen  many  such  where  there 
was  found  at  autopsy  great  enlargement  of  the  thymus,  and  the  lymphatic 
structures.  Some  of  these  infants  were  previously  healthy;  some  were 
rachitic.  The  similarity  of  all  these  cases  indicated  that  the  convulsions 
were  in'  some  way  associated  with  the  enlarged  thymus,  but  the  exact 
explanation. of  such  cases  is  not  understood.  In  infants  who  die  during 
convulsions  the  brain  may  be  the  seat  of  punctate  hemorrhages,  and  some- 
times of  more  extensive  ones.  The  lungs  are  also  deeply  congested,  and 
the  right  heart  is  generally  distended  with  dark  clots.  Tlie  other  lesions 
found  are  accidental. 

Symptoms. — In  soMe  cases  prodromal  symptoms  are  present,  such  as 
extreme  restlessness,  irritability,  slight  twitchings  of  the  muscles  of  the 


CONVULSIONS  673 

face>  hands,  feet,  or  eyelids.  More  frequently,  however,  the  attack  conies 
quite  suddenly  with  little  warning.  Usually  the  first  thing  noticed  is 
that  the  face  is  pale,  the  eyes  fixed,  sometimes  rolled  up  in  their  orbits ;  in 
a  moment  or  two,  convulsive  twitchings  begin  in  the  muscles  of  the 
eye  or  face,  or  in  one  of  the  extremities,  which  usually  rapidly  extend 
until  all  parts  of  the  body  participate.  In  most  cases  the  convulsions 
become  general,  but  they  may  remain  unilateral  even  when  not  due  to 
a  local  cause — a  point  which  is  often  forgotten.  The  contraction  of 
the  facial  muscles  causes  a  succession  of  grimaces;  the  neck  is  thrown 
back;  the  hands  are  clenched;  the  thumbs  buried  in  the  palms;  and  a 
quick  spasmodic  contraction  of  the  extremities  occurs.  There  may  be 
some  frothing  at  the  mouth,  and  in  all  true  convulsions  there  is  loss  of 
consciousness.  Respiration  is  feeble,  shallow,  and  may  be  spasmodic. 
The  pulse  is  weak;  it  may  be  slow  or  rapid;  often  it  is  irregular.  The 
forehead  is  covered  with  cold  perspiration.  The  face  is  first  pale,  then 
becomes  slightly  blue,  especially  about  the  lips.  Unnatural  rattling 
sounds  may  be  produced  in  the  larynx.  The  bladder  and  rectum  may  be 
evacuated.  The  convulsive  movements  consist  in  an  alternation  of  flexion 
and  extension  occurring  rhythmically.  All  varieties  of  tonic  and  clonic 
spasm  may  be  seen,  and  in  all  degrees  of  severity.  The  contractions  of 
the  two  sides  of  the  body  are  usually  synchronous.  Jiiter  a  variable  time, 
from  a  few  moments  to  half  an  hour,  the  convulsive  movements  grad- 
ually become  less  frequent,  and  finally  cease  altogether,  usually  leaving 
the  patient  in  a  condition  of  stupor.  They  may  recur  after  a  short  time 
or  there  may  be  but  one  attack.  A  period  of  general  relaxation  usually 
follows  the  convulsive  seizures,  frequently  accompanied  by  marked  evi- 
dences of  prostration.  Transient  paralysis,  apparently  due  to  exhaus- 
tion of  the  nerve  centers,  is  not  an  uncommon  sequel. 

Death  may  take  place  from  a  single  attack ;  this,  however,  is  rare  ex- 
cept in  very  young  infants,  or  those  with  status  lymphaticus.  There  may 
be  no  sequel  to  the  convulsions  if  the  cause  is  a  temporary  one,  or  they 
may  produce  some  serious  brain  lesion,  particularly  meningeal  hemor- 
rhage. Death  from  convulsions  is  generally  due  to  asphyxia,  or  to  ex- 
haustion from  the  rapidly  recurring  attacks.  Many  cases  recover  in 
which  the  children  for  several  minutes  had  the  appearance  of  being 
moribund. 

One  attack  of  convulsions  is  very  apt  to  be  followed  by  others,  espe- 
cially if  tetany  be  the  cause.  The  longer  the  interval  which  has  passed, 
the  less  likely  is  there  to  be  a  repetition,  especially  if  the  child  has  passed 
his  third  year. 

Biagnosis. — There  can  rarely  be  any  ditficulty  in  recognizing  an 
attack  of  convulsions.  The  difficulty  consists  in  determining  with  which 
of  the  many  possible  exciting  causes  we  have  to  deal  in  the  case  before 


674  DISEASES  OF  THE  NERVOUS  SYSTEM 

US.  If  it  comes  with  acute  symptoms  does  it  depciid  upon  a  cerebral 
lesion,  or  does  it  mark  the  onset  of  some  other  acute  disease?  Is  it  due 
to  tetany?  If  there  are  no  acute  symptoms,  is  it  epilepsy?  To  answer 
these  questions  a  careful  history  must  be  obtained,  and  all  the  circum- 
stances surrounding  the  patient,  the  character  of  the  conviilsions,  and 
all  the  other  symptoms  present  must  be  taken  into  consideration.  Tetany 
is  easy  to  recognize  if  there  is  carpopedaL  spasm,  Chvostek's  sign,  laryn- 
gospasm,  or  Trousseau's  sign.  If  these  are  absent,  it  can  only  be  deter- 
mined by  the  electrical  reactions.  Tetany  is  to  be  considered  the  most 
likely  cause,  however,  in  the  absence  of  the  evidence  of  organic  cerebral 

disease.  «.— *^^^^ 

In  infancy,  epilepsy  is  the  least  probable  diagn||^HPPMRr  children 
the  important  points  indicating  that  disease  areT^inistory  of  previous 
attacks,  a  distinct  aura  preceding  the  seizure,  or  a  sudden  onset  with  a 
cry  or  fall,  biting  of  the  tongue,  a  deep  sleep  following  the  seizure,  and, 
finally,  perfect  recovery^n  the  course  of  a  few  minutes  or  hours.  Convul- 
sions which  come  on  with  high  fever,  even  though  a  patient  may  have 
repeated  attacks,  are  seldom  epileptic.  However,  in  some  cases  only 
prolonged  observation  can  enable  one  to  decide  positively  whether  or 
not  epilepsy  is  present. 

Convulsions  occurring  in  brain  disease,  except  acute  meningitis,  are 
not  as  a  rule  accompanied  by  any  marked  rise  in  temperature.  Focal 
symptoms  are  often  present,  such  as  localized  paralysis  or  rigidity, 
changes  in  the  pupils,  and  strabismus.  The  convulsive  movements  are 
frequently  limited  to  one  side  of  the  body.  It  should,  however,  be  borne 
in  mind  that  unilateral  convulsions,  even  when  repeated,  do  not  always 
mean  a  local  lesion,  as  we  have  seen  proved  by  autopsy  more  than  onco. 
In  hemorrhage  or  meningitis,  convulsions  are  likely  soon  to  recur.  In 
tumor  they  may  recur  after  a  longer  interval. 

Convulsions  may  be  thought  to  indicate  the  onset  of  some  acute  dis- 
ease when  they  occur  in  a  child  over  two  years  old,  and  when  they  come 
on  suddenly  or  with  only  slight  premonition  in  a  child  previously  well ; 
but  the  most  important  point  is  that  they  are  accompanied  by  a  high 
temperature — 104°  to  106°  F.  Acute  meningitis  is  the  only  other  con- 
dition likely  to  produce  these  symptoms,  Whether  the  convulsions  mark 
the  onset  of  lobar  pneumonia,  Scarlet  fever,  or  some  other  disease,  can 
be  determined  only  by  carefully  watching  the  patient's  symptoms  for 
twenty-four  or  thirty-six  hours  or  possibly  longer. 

In  the  first  weeks  of  life  one  may  often  be  in  great  doubt  as  to  the 
cause  of  convulsions.  Such  attacks  may  be  due  to  some  disorder  of  the 
digestive  tract,  to  a  recent  cerebral  lesion  like  hemorrhage,  or  to  a  defec- 
tive brain  development.  Apparently  prolonged  pressure  in  a  difficult 
labor  may  produce  temporary,  perhaps  circulatory,  changes  in  the  brain 


CONVULSIONS  675 

sufficient  to  cause  convulsions  during  the  first  few  days  of  life.  We  have 
seen  them  in  a  number  of  children  whom  we  have  had  an  opportunity 
to  follow  for  several  years.  Their  physical  and  mental  development  has 
progressed  in  a  perfectly  normal  manner. 

Examination  of  the  urine  should  not  be  omitted  in  any  case  of  con- 
vulsions of  doubtful  origin.  Asphyxia  may  be  suspected  in  the  case  of 
convulsions  occurring  in  the  newly  born,  late  in  pneumonia^  in  some  cases 
of  pertussis,  in  spasmodic  or  membranous  laryngitis,  or  with  laryngo- 
spasm.  It  is  altogether  improbable  that  dentition  and  worms  play  any 
part  in  the  causation  of  convulsions  except  perhaps  that  of  the  slight 
irritant  which  is  sufficient  to  excite  convulsions  in  a  child  suffering  from 
tetany. 

Encephalopathy  due  to  lead  should  be  kept  in  mind  as  a  rare  cause 
of  convulsions  in  children.  The  blue  punctate  line  in  the  gums  can 
usually  be  found,  though  not  around  each  tooth.  There  is  also  stippling 
of  the  red  blood-cells.  The  cerebrospinal  fluid  is  under  increased  pres- 
sure, the  cells  are  slightly  increased  in  number  and  there  is  a  positive 
reaction  for  globulin.  There  is  frequently  pallor  of  the  optic  discs  and 
hemorrhages  into  the  retina  may  be  seen. 

In  all  cases  of  convulsions  occurring  in  infants  in  which  the  cause  is 
not  readily  apparent,  tetany  should  be  suspected  as  the  underlying  con-' 
dition. 

Prognosis. — This  depends  upon  the  cause  of  the  convulsions,  and 
differs  with  each  underlying  cause.  In  general  it  may  be  said  that  con- 
vulsions in  themselves  are  seldom  fatal  unless  they  occur  as  a  terminal 
condition.  Espegiglly  fatal  are  the  convulsions  of  pertussis  and  of 
asphyxia  whjen  they  occur  late  in  any  form  of  laryngeal  or  pulmonary 
disease.  The  conditions  during  an  attack  which  should  lead  one  to  make 
a  !)ad  prognosis  are  when  the  convulsions  are  ]irolonged  or  recur  fre- 
quently ;  also  the-  presence  of  very  great  prostration,  a  feeble  pulse  with 
cyanosis,  or  deep  stupor. 

In  the  prognosis  one  must  take  into  account  not  only  the  immediate 
result  of  the  attacks,  but  the  possible  outcome.  In  a  highly  nervous  or 
susceptible  child  a  convulsion  often  means  very  little.  Permanent  injury 
to  the  brain,  simply  as  a  result  of  an  attack,  is  very  rare.  The  possibility 
of  epilepsy  is  to  be  borne  in  mind  in  all  cases  where  children  over  two 
years  old  have  occasional  attacks  of  convulsions.  The  farther  apart  the 
attacks  are  and  the  more  definite  the  exciting  cause,  the  less  likely  is 
this  to  be  the  case. 

Treatment. — ^Summoned  to  a  child  in  convulsions,  a  physician  should 
go  at  once  and  remain  until  the  attack  lias  sul)sided.  He  should  take 
with  him  chloroform,  a  hypodermic  syringe  with  morphin,  a  soft  cath- 
eter or  rectal  tube,  and  a  solution  of  chloral.     In  order  to  treat  convul- 


676  DISEASES  OF  THE  NERVOUS  SYSTEM 

sions  intelligently  one  must  have  in  mind  the  prominent  pathological 
conditions.  These  are  acute  cerebral  hyperemia,  a  more  or  less  severe 
asphyxia  with  pulmonary  congestion,  an  overtaxed  right  heart,  and  a 
tendency  to  congestion  of  all  the  internal  organs.  The  nervous  centers 
are  in  a  condition  of  such  unnatural  excitability  that  the  slightest  irrita- 
tion may  bring  on  convulsive  movements  when  they  have  temporarily 
subsided.  The  patient  should  therefore  be  kept  perfectly  quiet,  and  every 
unnecessary  disturbance  avoided.  Cold  should  be  applied  to  the  head — 
best  by  means  of  an  ice  cap  or  cold  cloths — and  dry  heat  and'  counter- 
irritation  to  the  surface  of  the  body  and  extremities.  The  time-honored 
mustard  bath  causes  so  much  disturbance  of  the  patient  that  it  can  usually 
be  dispensed  with  and  the  mustard  pack  substituted.  The  feet  may  be 
placed  in  mustard  water  while  the  child  lies  in  his  crib.  The  mustard 
pack  and  footbath  should  be  continued  until  the  skin  is  well  reddened. 
The  degree  to  which  counter-irritation  of  the  skin  should  be  carried 
will  depend  upon  the  condition  of  the  pulse  and  the  cyanosis. 

In  controlling  convulsions  the  remedies  which  may  be  depended  upon 
are  the  inhalation  of  chloroform,  chloral  per  rectum,  morphin  and  mag- 
nesium sulphate  hypodermically.  Chloroform  is  undoubtedly  the  most 
reliable  remedy  for  an  immediate  effect,  and  may  be  used  even  in  the 
youngest  infant.  At  the  same  time  that  it  is  being  administered,  chloral 
may  be  given.  The  initial  dose  should  be,  at  six  months,  four  grains; 
at  one  year,  six  grains;  at  two  years,  eight  grains,  dissolved  in  one 
ounce  oiwarm  milk.  It  should  be  injected  high  into  the  bowel  through 
a  catheter,  and  prevented  from  escaping  by  pressing  the  buttocks  to- 
gether. It  may  be  repeated  in  an  hour  if  necessary.  The  effect  of  the 
drug  is  generally  obtained  in  twenty  or  thirty  minutes.  If,  in  spite  of 
the  chloral,  the  convulsions  show  a  marked  tendency  to  continue  as  soon 
as  the  chloroform  is  withdrawn,  or  if  the  enema  of  chloral  has  been 
expelled,  morphin  may  be  given  hypodermically.  When  the  heart's  ac- 
tion is  weak,  this  is  probably  the  best  of  all  remedies.  To  a  well-grown 
child  two  years  old,  y^  grain  may  be  given;  one  year  old,  -gV  grain;  six 
months  old,  ^V  grain.  This  dose  may  be  repeated  in  half  an  hour  if  no 
effect  is  seen.  The  tolerance  of  opium  in  cases  of  convulsions  is  very 
marked,  and  sometimes  double  the  doses  mentioned  may  be  required. 
For  frequently  recurring  convulsions  magnesium  sulphate,  hypodermic- 
ally, is  a  valuable  remedy.  It  has  the  advantage  over  morphin  in  that  it 
does  not  constipate.  Eight  or  ten  grains  of  Epsom  salts  may  be  given  to 
an  average  infant  of  three  or  four  months,  and  from  fifteen  to  twenty 
grains  to  one  of  six  or  eight  months.  It  does  not  act  so  promptly  as  does 
morphin.  The  dose  may  l)o  repeated  in  two  hours  if  necessary.  The 
only  other  agent  of  much  value  is  oxygen.  We  have  occasionally  seen 
convulsions  which  continued  in  spite  of  all  other  treatment  yield  imme- 


TETANY  ■  G77 

diately  to  oxygen.  This  is  most  likely  to  be  valuable  iu  cases  of  convul- 
sions due  to  asphyxia. 

In  infancy  it  is  wise  in  every  case  to  irrigate  the  colon  thoroughly 
with  warm  water,  to  remove  any  possible  source  of  irritation.  If  there 
is  reason  to  suspect  the  presence  of  undigested  food  in  the  stomach,  this 
may  be  washed  out.  Much  more  frequently  it  is  in  the  intestines,  and 
free  purgation  by  calomel  is  advisable.  If  there  is  high  temperature, 
this  should  be  reduced  by  the  cold  bath  or  pack. 

When  once  under  control,  the  recurrence  of  the  convulsions  may  be 
prevented  by  keeping  the  patient  for  two  or  three  days  under  the  influence 
of  chloral  with  bromid  of  sodium,  the  amount  of  chloral  being  gradually 
reduced.  If  it  is  badly  borne  by  the  stomach  and  not  easily  retained  by 
the  rectum,  either  antipyrin  or  pheiwcetin  may  be  used  with  the  bromid. 
As  soon  as  the  convulsions  have  ceased,  the  cause  should  be  sought  and 
treated. 

TETANY 

Several  clinical  conditions,  formerly  described  under  different 
names,  are  now  regarded  as  manifestations  of  tetany :  arthrogryposis  or 
carpopedal  spasm,  laryngismus  stridulus  or  laryngospasm,  holding-breath 
spells,  etc. 

Tetany  is  a  disease  characterized  by  an  extreme  irritability  of  the 
nervous  system  to  mechanical  and  electrical  stimulation.  It  is  frequently 
accompanied  by  more  or  less  prolonged  contractions  of  the  muscles  of  the 
extremities.  Spasm  of  the  glottis  and  also  general  convulsions  are  very 
common.  It  was  formerly  believed  that  tetany  was  rather  infrequent 
and  was  manifested  only  by  muscular  spasm.  Studies  by  electrical 
methods,  however,  have  shown  that  in  infancy  and  childhood  the  disease 
is  exceedingly  frequent  and  that  it  may  exist  without  giving  any  symj)- 
toms,  i.  e.,  in  a  latent  form.  To  the  latent  form  of  the  disease  as  well 
as  to  all  the  manifestations,  the  term  "spasmophilia,"  or  "spasmophilic 
diathesis,'^  has  been  applied  by  many. 

Etiology. — While  tetany  is  found  with  the  greatest  frec|uency  during 
the  latter  half  of  the  first  and  during  the  second  year,  it  is  very  rarely 
seen  in  the  first  three  months  of  life.  It  may  occur  at  any  time  during 
childhood  but  its  frequency  diminishes  rapidly  with  age.  Tetany  is 
rare  in  summer  and  early  autumn,  but  it  is  very  common  in  winter  and 
early  spring.  The  association  of  tetany  with  rickets  is  a  very  close  one. 
Not  only  is  it  found  at  the  time  of  year  when  active  rickets  is  most  com- 
mon, but  almost  all  children  with  tetany  show  some  of  the  symptoms 
of  rickets.  While  cases  are  observed  in  which  no  rachitic  manifestations 
are  present,  rickets  cannot  be  entirely  excluded,  for,  as  has  been  stated 


678  DISEASES  OF  THE  XERVOUS  SYSTEM       , 

elsewhere^  the  first  evidences  of  rickets  in  the  bones  escape  clinical  ob- 
servation. Symptoms  of  both  rickets  and  tetany  begin  to  be  seen  at 
about  the  same  age.  While  tetany  may  occur  in  the  breast-fed,  this  is 
relatively  infrequent.  The  disease  evidently  depends  for  its  development 
largely  upon  artificial  feeding  Imt  occurs  even  when  this  has  l)een  appar- 
ently proper. 

Tetany  seems  to  be  closely  connected  ^^■ith  changes  in  the  calcium  me- 
tabolism, although  these  are  not  yet  entirely  clear.  It  has  been  shown 
in  a  certain  number  of  patients  that  with  active  tetany,  just  as  with 
active  rickets,  there  is  a  negative  calcium  balance — more  calcium  being 
eliminated  than  is  ingested  with  the  food.  There  has  also  been  found 
post  mortem  a  deficiency  in  the  calcium  content  of  the  brain.  Mariott 
and  Howland  have  demonstrated  a  inarked  reduction  of  the  calcium  of 
the  blood  of  infants  with  active  tetany.  MacCallum  and  Voigtlin  have 
shown  a  deficiency  of  calcium  in  the  blood  of  animals  with  experimental 
tetany.  It  is  therefore  clear  that  there  is  some  alteration  of  calcium 
metabolism  in  tetany. 

The  removal  of  the  parathyroids  in  animals  and  the  occasional  acci- 
dental injury  of  these  in  human  surgery  produces  a  condition  closely 
akin  to  tetany.  The  work  of  Erdheim,  Escherich  and  Yanase  indicated 
that  the  parathyroids  might  be  diseased  in  tetany,  the  changes  consisting 
in  hemorrhages  and  their  remains.  Later  observations  have  shown  that 
these  alterations  may  be  found  in  children  who,  during  life,  have  given 
no  evidence  of  tetany  and  also  that  the  glands  may  be  normal  when  defi- 
nite tetany  has  been  j)resent.  It  is  as  yet  impossible  to  say  whether  the 
parathyroids  play  an  important  part  in  the  disease.  There  is,  however, 
sufficient  evidence  to  indicate  that  they  may  have  some  influence  upon  its 
production.  Tetany  is  at  times  hereditary.  There  may  be  a  history  of 
the  disease  in  one  of  the  parents  and  occasionally  families  are  found 
with  several  children  who  have  suffered  from  tetany.  Acute  disease, 
especially  when  accompanied  by  fever,  is  sometimes  the  exciting  cause.  It 
must  be  assumed  that  up  to  the  onset  of  the  acute  disease  tetany  has 
been  latent,  the  new  condition  providing  the  necessary  irritation  to  make 
the  tetany  active.  Thus,  tetany  is  seen  with  acute  diseases  of  the  gastro- 
intestinal tract,  pneumonia  and  the  acute  infectious  diseases. 

There  are  no  characteristic  pathological  changes  other  than  those  of 
the  associated  rickets.  In  a  certain  proportion  of  the  cases  alterations  in 
the  parathyroids  are  found.  One  or  more  of  the  four  glands  may -be 
enlarged  and  red  as  a  result  of  extravasation,  or  the  changes,  may  only 
be  evident  under  the  microscope  and  consist  in  small  hemorrhages,  and 
the  remains  of  hemorrhages. 

Symptoms. — One  of  the  most  characteristic  and  striking  is  carpo- 
pedal  spasm.     It  is,  however,  by  no  means  the  most  common  manifesta- 


TETAXY 


679 


tioii,  and  is  seen  in  only  a  small  percentage  of  the  eases.  The  spasm 
of  the  hands  and  feet  may  develop  abruptly,  or  it  may  be  preceded  by 
sensory  disturbances.  The  upper  extremities  are  usually  first  affected  and 
both  sides  equally.     The  position  is  very  characteristic :     The  fingers  are 


Fig.  86. — Tetany,  showing  the  Characteristic  Position  of  the  Hands  and  Feet. 

In  a  child  two  years  old. 


flexed  at  the  metacarpophalangeal  joints  and  the  phalanges  extended;  the 
thumbs  are  adducted  almost  to  the  little  finger ;  the  wrist  is  flexed  acutely 
and  the  hand  drawn  somewhat  to  the  ulnar  side.  Tf  the  spasm  is  very 
marked  no  motioii  is  allowed  at  the  wi'ist.  The  feet  are  strongly  ex- 
tended;,  sometimes  in  the  position  of  equinovarus.     The  first  phalanges 


680  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  the  toes  are  flexed,  and  the  second  and  third  rows  extended;  the  plantar 
surface  is  strongly  arched  and  the  dorsum  of  the  foot  is  very  prominent, 
standing  out  like  a  cushion.  The  typical  position  of  the  hands  and  feet 
is  well  shown  in  Fig.  86.  Motion  at  the  elbow,  shoulder,  hip  and  knee 
is  generally  free.  The  spasm  in  many  cases  is  limited  to  the  hands  and 
feet;  more  rarely  the  muscles  of  the  thigh,  usually  the  adductors,  may 
be  involved.  In  rare  cases  the  muscles  of  the  trunk  or  the  face  may  be 
affected.  The  spasm  can  be  voluntarily  overcome  to  a  certain  extent; 
thus  a  child  may  open  his  hands  to  grasp  objects  or  feed  himself.  As 
soon  as  active  motion  ceases,  the  hands  resume  their  former  characteristic 
attitude. 

Evidences  of  pain  are  frequent;  it  may  be  so  severe  as  to  cause  chil- 
dren to  cry  out.  Pain  may  be  induced  by  any  attempt  to  overcome  the 
spasm,  and  sometimes  it  is  constant.  There  is  no  loss  of  consciousness 
and  no  fever.  The  duration  of  carpopedal  spasm  may  be  from  a  few 
hours  to  several  days.  Tlie  muscular  contraction  is  generally  continuous, 
although  there  are  often  periods  of  remission.  There  may  be  only  a  single 
short  attack.  Of  this  we  have  seen  several  striking  instances.  One  child 
seven  years  old  who  had  always  been  well  was  operated  upon  for  enlarged 
tonsils.  The  night  following  oiaeration  she  cried  out  with  pain  and  her 
hands  and  feet  were  found  in  the  typical  position  of  tetany.  In  four  or 
five  hours  this  completely  disappeared  and  did  not  return.  This  was  the 
only  symptom  of  tetany  that  she  ever  manifested.  Carpopedal  spasm 
may  come  on  spontaneously  but  is  more  frequently  found  in  the  course 
of  some  febrile  illness.  It  is  found  in  no  other  disease  and  is  diagnostic 
of  tetany. 

Disturbances  of  respiration  are  exceedingly  common  in  tetany.  The 
most  typical  of  these  is  spasm  of  the  glottis  or  laryngospasm.  This  con- 
sists in  a  contraction  of  the  laryngeal  muscles  of  such  intensity  as  par- 
tially to  obstruct  inspiration  or  for  a  time  to  arrest  i1^.  When  the  obstruc- 
tion is  partial  there  is  a  very  characteristic  crowing  sound  with  each 
inspiration,  especially  if  the  child  is  disturbed  or  crying.  There  may  be 
a  succession  of  these  sounds,  followed  by  an  intermission,  or  the  condition 
may  last  in  a  mild  form  for  several  minutes  or  hours.  The  severe  attacks 
of  obstructed  respiration  usually  come  on  suddenly.  The  child  throws 
back  his  head,  the  face  becomes  pale,  then  livid,  and  for  the  time  there 
is  complete  arrest  of  respiration.  This  continues  for  a  few  moments, 
during  which  the  cyanosis  deepens,  and  the  child  seems  in  great  distress, 
making  violent  efforts  to  breathe.  If  the  paroxysm  is  very  severe,  the 
asphyxia  may  be  so  great  as  to  lead  to  loss  of  consciousness,  or  the  attack 
may  terminate  in  general  convulsions.  It  may  even  be  fatal.  In  less 
severe  attacks,  after  fifteen  or  twenty  seconds  the  muscular  spasm  relaxes, 
the  glottis  opens,  and  a  long,  deep  inspiration  occurs,  with  the  production 


TETANY  G81 

of  a  crowing  sound.  Such  forms  of  spasm  often  come  on  without  evident 
cause,  and  may  be  repeated  from  two  to  twenty  times  a  day.  Between 
them  the  condition  of  the  child  may  be  normal  or  carpopedal  spasm  and 
other  evidences  of  tetany  may  be  present.  Not  all  the  paroxysms  are 
equally  severe.  A  child  may  have  in  the  course  of  a  day  a  great  many 
mild  attacks,  but  only  a  few  severe  ones.  General  convulsions  are  seen 
in  over  one-third  of  the  severe  cases.  Laryngospasm  is  most  common 
in  children  from  six  to  fifteen  months  of  age. 

Attacks  closely  related  to  those  which  have  just  been  described  are 
met  with  in  which  respiration  entirely  ceases  for  a  time;  there  are  tem- 
porarily no  attempts  at  inspiration.  It  has  been  assumed  that  the  dia- 
phragm participates  in  the  spasm.  Attacks  with  temporary  arrest  of 
respiration  are  seen  most  frequently  in  the  latter  part  of  the  first  and 
during  the  second  year,  but  beginning  in  infancy  they  may  recur  from 
time  to  time  until  the  age  of  four  or  five  years.  They  affect  children  of 
an  extremely  nervous  type.  Several  attacks  may  occur  in  a  single  day, 
or  they  may  occur  at  intervals  of  several  days  or  weeks.  In  susceptible 
children  almost  any  form  of  excitement  may  precipitate  one.  They  are 
often  known  as  "holding-breath  spells.^'  In  older  children  by  far  the 
most  frequent  exciting  causes  are  temper  and  fright.  If  anything  is 
attempted  to  which  the  child  strongly  objects,  e.  g.,  a  cold  bath,  inspection 
of  the  throat,  or  taking  away  a  toy,  an  attack  may  ensue.  The  child's 
face  becomes  flushed,  then  livid;  there  is  general  rigidity  of  the  trunk 
and  extremities,  but  very  rarely  clonic  spasms.  This  rigidity  is  usually 
followed  by  complete  relaxation  with  loss  of  consciousness.  The  entire 
attack  usually  lasts  about  half  a  minute.  There  may  be  a  crowing  sound 
as  the  child  catches  his  breath  or  there  may  be  none.  After  a  few  minutes 
of  quiet  the  child  gets  up  and  in  a  short  time  is  apparently  as  well  as 
ever.  Many  of  those  who  are  subject  to  attacks  of  this  sort  sooner  or 
later  have  one  or  more  general  convulsions,  but  in  some  only  the  mild 
attacks  are  seen  though  they  may  recur  at  intervals  for  years.  Death 
occasionally  occurs  with  severe  attacks,  there  being  no  renewal  of  respira- 
tion and  all  attempts  at  resuscitation  failing. 

Lederer  has  described  a  complex  of  pulmonary  symptoms  closely 
simulating  asthma.  This  he  has  termed  broncho-tefanie.  It  is  not 
clear  that  the  symptoms  which  he  describes  are  necessarily  dependent 
upon  tetany. 

General  convulsions  are  exceedingly  common  with  tetany  in  infancy. 
After  that  they  are  less  frequently  seen.  They  differ  in  no  respect  from 
those  that  have  been  described  in  the  previous  chapter.  The  more  fre- 
quent the"  convulsions,  the  milder  they  usually  are.  From  the  character 
of  the  convulsions  alone,  it  is  impossible  to  differentiate  them  from 
epiley)sy.    They  may  occur  without  any  exciting  cause  or  the  least  stimu- 


682  DISEASES  OF  THE  NERVOUS  SYSTEM 

lus  may  be  sufficient  to  cause  au  attack.  Thus  we  have  seen  a  child  who 
repeatedly  had  convulsions  whenever  cold  was  applied  to  the  skin.  The 
number  of  attacks  may  be  very  great.  In  one  case  that  we  saw,  an 
infant  during  the  latter  part  of  his  second  year  had,  during  six  months, 
■over  3,500  distinct  attacks  of  convulsions.  For  a  considerable  period  they 
reached  the  almost  incredible  number  of  80  a  day.  After  improvement 
occurs,  the  number  may  gradually  diminish  or  more  frequently  they  may 
cease  almost  at  once.  Death  is  infrequent  during  a  convulsion  Init  occa- 
sionally occurs,  apparently  from  exhaustion,  when  severe  convulsions  are 
frequently  or  uninterruptedly  repeated. 

When  tetany  is  suspected,  three  confirmatory  signs  should  be  sought: 
Chvostek's  sign  or  the  facial  phenomenon,  Trousseau's  sign,  and  Erb's 
sign.  Chvostek's  sign  consists  in  a  momentary  contraction  of  the  muscles 
of  the  face  when  a  branch  of  the  facial  nerve  is  tapped  with  the  per- 
cussion hammer  or  with  the  finger.  The  nerve  may  be  tapped  anywhere, 
but  usually  best  about  the  middle  of  the  check.  The  contraction  may 
affect  only  the  mouth  and  the  alae  nasi,  or  it  may  involve  any  of  the 
muscles  supplied  hj  the  nerve.  This  sign  is  not  found  in  the  first  two 
years  of  life,  except  in  cases  of  tetany.  Later,  it  is  of  more  frequent 
occurrence  and  less  reliance  can  he  placed  upon  it  as  an  evidence  of  tet- 
any, particularly  after  the  fifth  year.  Thiemich,  however,  maintains  that 
it  always  indicates  tetany.  But  it  is  found  in  such  a  large  proportion  of 
older  children  in  whom  no  symptoms  or  history  of  tetany  can  be  obtained 
that  it  is  generally  believed  to  indicate  in  them  only  a  neurotic  con- 
stitution. 

Trousseaus  sign  is  elicited  by  pressure  by  the  hand  or  a  bandage 
upon  the  blood  vessels  of  an  extremity  with  sufficient  force  to  stop  the 
circulation  temporarily.  The  sign  is  most  easily  elicited  in  the  upper 
extremity  when  pressure  is  made  above  the  elbow.  The  radial  pulse 
should  be  obliterated  for  several  minutes.  Then  the  hand  may  assume 
the  typical  position  of  carpopedal  spasm.  The  sign  is  often  absent  in 
well-marked  tetany,  but  when  present  is  to  be  regarded  as  positive  evi- 
dence of  tetany. 

Erh's  sign  or  the  quaiititaiive  reaction  of  the  nerves  to  the  galvanic 
current } — Muscular  contractions  are  produced  by  the  application  of  the 

^  For  the  electrical  determinations  a  galvanic  battery  with  a  milliamperemeter 
graduated  in  fifths  up  to  five  milliamperes  is  necessary.  The  measurements  are 
usually  made  upon  the  peroneal  nerve.  The  large  indifferent  electrode  should  be 
placed  upon  the  abdomen,  the  stimulating  electrode  upon  the  peroneal  ner^^e  in 
the  outer  part  of  the  popliteal  space  near  the  head  of  the  fibida. 

The  cathodal  closure  contraction  is  often  obtained  with  a  current  less  than  5 
milliamperes  in  strength  in  normal  children  under  six  months  of  age,  and  after 
this  time  it  is  regularly  present  with  a  current  of  this  strength  or  a  weaker  one. 
No  evidence  in  regard  to  tetany  may  be  obtained  from  the  C.C.C.    The  anodal 


TETANY  683 

galvanic  current  to  the  nerves.  These  contractions  occur  with  the  making 
or  breaking  of  the  current  and  are  called  "closing"  and  "opening"  con- 
tractions, respectively.  The  nerves  react  differently  to  the  different  poles 
and  also  to  the  making  or  breaking  of  the  current.  Age  also  has  an 
important  influence  in  the  character  of  the  electrical  response.  The 
nerves  of  the  newly  born  and  of  infants  durijig  the  first  year  are  less 
responsive  to  the  current  than  those  of  children  who  are  older.  The 
excitability  increases  with  age  up  to  about  five  years,  after  which  there 
is  little  if  any  difference  between  the  child  and  the  adult.  Closing 
contractions  occur  in  early  childhood  with  a  weaker  current  than  do 
opening  contractions. 

In  the  first  six  months  of  life  any  contraction  with  a  current  of  less 
than  5  milliamperes,  except  that  of  cathodal  closure,  points  to  tetany  ;i 
while  an  opening  contraction,  either  cathodal  or  anodal,  with  a  current 
weaker  than  5  m.  ap.  is  positive  evidence  of  tetany. 

Under  two  years  of  age  an  A.O.C.  with  a  current  of  less  than  5 
m.  ap.  and  weaker  than  one  which  will  cause  an  A.C.C.,  is  presumptive 
but  not  positive  evidence  of  tetany.  C.O.C.  or  C.C.  tetanus  with  a 
current  of  less  than  5  m.  ap.  in  a  child  under  five  may  be  considered 
hyperexcitability  due  to  tetany.  Eepeated  measurements  upon  the  same 
child  often  give  different  results  in  the  course  of  a  few  days.  For  this 
reason  several  electrical  examinations  are  frequently  necessary  to  deter- 
mine or  exclude  tetany. 

closure  usually  requires  more  than  5  m.  ap.  of  current  with  infants  less  than  six 
months  of  age.  From  that  time  up  to  two  years  the  A.C.C.  is  frequently,  and 
after  two  years  regularly,  obtained  with  a  current  less  than  5  m.  ap.  strength. 
An  A.C.C,  therefore,  with  a  current  of  less  than  5  m.  ap.  is  suggestive  of  tetany 
only  in  the  first  six  months. 

The  anodal  opening  contraction  in  the  first  six  months  of  life  occurs  with 
normal  children  only  with  a  current  of  more  than  5  m.  ap.  strength  and  up  to 
two  years  it  almost  always  requires  a  current  of  more  than  this.  It  also  usually 
requires  more  current  to  produce  an  A.O.C.  than  an  A.C.C.  until  the  second  or 
third  year.  After  five  years  of  age  the  A.O.C.  is  regularly  obtained  with  a  cur- 
rent of  less  than  5  m.  ap.,  and  less  than  is  required  to  produce  an  A.C.C. 
An  A.O.C.  therefore  in  the  first  six  months  of  age  obtained  with  a  current  less 
than  5  m.  ap.  is  strong  evidence  of  tetany  and  under  two  years  of  age  is  sug- 
gestive of  tetany,  especially  if  the  A.O.C.  takes  place  with  a  current  less  than 
is  required  to  produce  an  A.C.C.  This  was  called  by  von  Pirquet  "anodal  hyper- 
excitabilit3^"  We  cannot  regard  it  as  more  than  highly  suggestive  of  tetany  after 
six  months  of  age,  for  it  sometimes  occurs  with  children  that  are  apparently 
entirely  normal.  After  two  years  of  age  it  is  often  present  and  after  five  years 
of  age  regularly  so  with  normal  children. 

A  cathodal  opening  contraction  or  cathodal  closing  tetanus,  occurring  with  a 
current  of  less  than  5  m.  ap.  in  children  under  five  years  of  age,  is  positive  evi- 
dence of  tetany.  After  that  time  such  values  may  occasionally  be  found  with 
quite  normal  children. 


684  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  conception  of  "latent"  tetany  was  gradually  reached  when  it  was 
appreciated  that  muscular  spasm  of  the  extremities,  laryngospasm  and 
general  convulsions  were  all  symptoms  of  the  same  basal  disorder.  The 
electrical  reactions  also  were  shown  to  be  in  many  instances  the  same  in 
children  that  had  suffered  from  no  spasmodic  symptoms,  as  in  those 
who  were  the  subjects  of  frank  tetany.  If  the  former  were  followed 
carefully  it  was  often  noticed  that,  sooner  or  later,  convulsions,  laryngo- 
spasm or  carpopedal  spasm  developed.  It  is  therefore  apparent  that  there 
is  an  instability  of  the  nervous  system  that,  without  electrical  measure- 
ments, may  exist  unsuspected  until  suddenly  it  becomes  clinically  evi- 
dent. Electrical  measurements  upon  a  large  number  of  children  in 
hospital  and  out-patient  practice  have  shown  that  latent  tetany  is  a  fre- 
quent condition  and  that  undoubtedly  only  a  small  percentage  of  these 
children  show  symptoms  by  which  the  disease  is  recognizable. 

Various  other  symptoms  have  been  ascribed  by  writers  to  tetany. 
Thus,  Ibrahim  has  emphasized  spasm  of  the  pylorus  producing  vomiting, 
of  the  intestines,  causing  pain  and  meteorism,  and  of  the  anal  sphincter 
leading  to  obstinate  constipation.  The  occasional  retention  of  urine  in, 
tetany  has  been  referred  to  spasm  of  the  vesical  sphincter.  The  fatal 
outcome  in  some  cases  of  general  convulsions  or  those  with  laryngospasm 
it  is  claimed  results  from  tetany  of  the  cardiac  musculature.  The  relation 
of  all  of  these  conditions  to  tetany  is  very  doubtful. 

From  what  has  been  stated  it  is  evident  that  the  variations  in  the 
course  of  the  disease  may  be  extreme.  Tetany  may  entirely  escape 
observation  or  it  may  give  symptoms  for  months  or  even  years.  There 
is  a  surprisingly  close  connection  between  the  condition  of  the  bowels 
and  the  symptoms  of  tetany.  In  most  patients  tetany  is  aggravated  by 
the  existence  of  constipation.  A  sharp  attack  of  diarrhea  or  free  purga- 
tion by  medicine  regularly  causes  a  diminution  and  often  a  complete 
disappearance  of  all  symptoms  including  the  abnormal  electrical  irritabil- 
ity. As  the  result  of  dietetic  treatment,  a  marked  diminution  in  the 
intensity  and  frequency  of  the  attacks  may  be  observed.  They  often 
cease  altogether  in  a  short  time.  Other  cases  are  observed,  however,  in 
which  improvement  is  very  slow.  In  those  children  that  suffer  from 
malnutrition  a  proper  growth  and  gain  in  weight  may  be  difficult  to 
obtain. 

Diagnosis. — ^This  may  be  easy  or  so  difficult  as  to  be  possible  only 
after  prolonged  observation.  Carpopedal  spasm,  laryngospasm.  Trous- 
seau's sign  and  Chvostek's  sign  under  five  years,  are  pathognomonic  symp- 
toms. But  in  perhaps  the  largest  number  of  children  with  tetany  none 
of  them  is  present.  The  electrical  reactions  are  usually  conclusive,  but 
at  times  may  l)e  of  little  assistance.  If  an  infant  with  no  evidences  of 
an  organic  brain  lesion  has  repeated  attacks  of  convulsions  tetany  should 


TETANY  685 

always  be  suspected.  If  there  are  symptoms  of  rickets  and  if  the  attacks 
are  frequent  the  probabilities  of  tetany  are  greatly  increased.  The  chief 
difficulties  in  diagnosis  are  with  older  children  who  suffer  from  occasional 
convulsions.  It  may  be  almost  impossible  without  prolonged  observation 
to  decide  between  epilepsy  and  tetany.  Electrical  reactions  at  this  age 
offer  little  assistance.  The  older  the  child  the  greater  are  the  chances 
in  favor  of  epilepsy. 

Prognosis. — The  prognosis  of  tetany  varies  greatly  with  the  age  of 
the  patient,  the  type  of  the  disease  and  its  severity.  The  prognosis  of 
latent  tetany  is  always  good,  with  proper  treatment.  In  general,  the 
younger  the  patient  the  more  severe  the  manifestations  of  tetany  are 
likely  to  be  and  the  more  difficult  to  control.  After  two  years,  except  in 
markedly  rachitic  children,  the  prognosis  as  to  life  is  always  good.  The 
chances  are  always  in  favor  of  recovery  when  there  are  only  occasional 
attacks  of  general  convulsions.  With  frequently  repeated  convulsions 
there  is  danger  to  life,  not  only  from  the  convulsions  themselves,  but 
from  the  frequent  association  of  severe  attacks  of  laryngospasm.  This 
must  always  be  looked  upon  as  a  dangerous  manifestation  of  tetany  and 
infants  may  die  during  such  attacks. 

Tetany  complicating  gastro-intestinal  or  any  acute  infectious  disease 
makes  its  prognosis  less  favorable.  According  to  Thiemich  and  Birk,  the 
mental  development  of  children  who  have  suffered  from  severe  tetany  is 
often  greatly  retarded  and,  in  many  cases,  permanently  interfered  with. 
The  physical  development  also  suffers.  More  observations  are  required 
definitely  to  settle  this  point.  It  is  apparent,  however,  that  tetany  may 
leave  permanent  effects. 

Treatment. — Prophylaxis  should  be  emphasized.  Tetany  does  not 
often  occur  with  breast  feeding.  Maternal  nursing  is  not  only  the  best 
preventive,  but  feeding  with  woman's  milk  is  also  the  best  means  of 
stopping  the  further  progress  of  tetany  when  it  has  once  developed.  It 
does  not,  however,  rapidly  cure  the  disease.  With  infants  under  eight 
months  of  age  who  give  symptoms  of  tetany  woman's  milk  should  be 
supplied  if  possible.  Treatment  should  be  directed  not  only  against  the 
manifestations  of  tetany  but  also  against  the  fundamental  metabolic  dis- 
turbance upon  which  they  depend.  The  treatment  of  this  basal  con- 
dition is  the  treatment  of  the  associated  rickets.  It  differs  in  no  respect 
even  though  we  recognize  that  the  two  conditions  are  not  similar.  This 
has  been  discussed  in  the  Chapter  on  Eickets.  The  only  exception  to 
this  general  statement  is  that  during  the  presence  of  attacks  of  convul- 
sions and  laryngospasm  or  carpopedal  spasm  it  may  be  advisable  to 
remove  all  cow's  milk  temporarily  from  the  food.  While  it  is  true  that 
overfeeding  with  cow's  milk  apparently  causes  and  certainly  aggravates 
tetany,  in  the  event  that  breast  feeding  is  impossible,  cow's  milk  cannot 


686  DISEASES  OF  THE  XEKVOUS  SYSTEM 

be  altogether  removed  from  the  diet,  except  for  a  short  period.  There 
is  no  advantage  in  excluding  it  for  a  long  period.  The  most  satisfactory 
results  are  generally  obtained  when  feeding  is  carried  on  according  to 
the  indications  afforded  by  the  child's  digestive  symptoms.  There  is  a 
distinct  advantage  in  providing  a  mixed  diet  with  a  minimum  amount 
of  milk  as  soon  as  the  child's  digestion  veill  allow  it. 

The  specific  treatment  of  tetany  by  parathyroid  extract  has  not  been 
followed  by  any  appreciable  benefit,  nor  has  the  administration  of  calcium 
in  our  hands  given  favorable  results.  There  can  be  no  doubt  that  the 
prolonged  administration  of  cod-liver  oil  and  phosphorus  is  beneficial 
in  a  certain  number  of  cases.     They  are  to  be  used  as  in  rickets. 

General  convulsions  are  to  be  treated  according  to  the  methods  given 
in  the  previous  chapter.  Chloroform,  chloral,  morphin  and  magnesium 
sulphate  are  all  useful  and  are  to  be  employed  for  rather  different  indica- 
tions. In  an  average  case  in  an  infant  the  last  mentioned  remedy  is  to 
be  preferred.  It  is  given  subcutaneously  m  doses  mentioned  under  Con- 
vulsions. If  the  convulsions  are  frequent  it  is  advisable  to  withdraw 
cow's  milk  from  the  diet  entirely  for  a  time.  Gruels  ma}^  take  its  place 
for  several  days.  "When  milk  is  again  included  in  the  diet  it  should  be 
added  very  gradually  and  in  minimum  amount. 

Laryngospasm,  if  severe,  recpiires  the  administration  of  calcium  bro- 
mid  by  mouth  or  chloral  by  rectum  until  the  frequency  and  severit}^  of 
the  attacks  are  controlled.  Antipyrin  at  times  seem  to  be  more  effective 
than  bromid  or  chloral.  If  during  attacks  there  are  no  efforts  at  inspira- 
tion, artificial  respiration  should  be  performed  and  possibly  intubation 
may  be  of  value.  The  dietetic  treatment  should  also  be  the  same  as  when 
general  convulsions  are  severe.  Carpopedal  spasm  is  often  relieved  by 
prolonged  warm  baths  or  by  the  application  of  warm  compresses.  Bro- 
mids,  chloral  or  antipyrin  are  also  to  a  certain  extent  useful  in  relaxing 
the  spasm.  Latent  tetany  requires  no  treatment  other  than  the  general 
dietetic  and  hygienic  treatment  directed ,  toward  the  correction  of  the 
basal  disturbance  of  metabolism. 

EPILEPSY 

Epilepsy  cannot  be  considered  a  sharply  limited  disease.  Eather  it 
is  to  be  looked  upon  as  consisting  of  certain  symptom-complexes  that 
are  frequently  repeated  and  arise  as  the  result  of  widely  different  causes, 
some  known  and  some  unknown.  Moreover,  these  symptom-complexes 
are  to  a  certain  extent  interchangeable.  Epilepsy  is  manifested  by  re- 
peated general  or  localized  muscular  spasm  with  or  without  loss  of  con- 
sciousness and  by  peculiar  mental  states,  the  so-called  ^'equivalents." 

A  distinction  must  ])0  made  between  cases  of  so-called  "idiopathic" 


EPILEPSY  687 

epilepsy,  or  those  without  gross  anatomical  basis,  and  those  which  are 
secondary  to  a  definite  lesion  of  the  brain,  such  as  tumor,  sclerosis  or 
abscess.  Convulsions  of  tlie  latter  character  are  designated  as  "symp- 
tomatic" epilepsy,  and  are  discussed  in  connection  with  the  various 
diseases  in  which  they  occur.  The  nature  of  the  attack  may,  liowever, 
be  identical  in  both  varieties,  and  may  not  differ  from  an  ordinary  attack 
of  convulsions  or  eclampsia.  The  proportion  of  idiopathic  cases  in  chil- 
dren is  not  so  large  as  w^as  formerly  supposed ;  many  of  these  have  been 
shown  to  depend  upon  lesions  once  overlooked,  particularly  mild  infantile 
cerebral  paralyses. 

Etiology.— From  a  consideration  of  1,450  cases  of  epilepsy,  Gowers 
states  that  12  per  cent  begin  in  the  first  three  years  of  life,  and  46  per 
cent  between  ten  and  twenty  years.  The  greatest  tendency  to  the  develop- 
ment of  the  disease  is  shown  about  the  time  of  puberty.  Females  are 
rather  more  liable  to  be  affected  than  males,  although  the  difference  in 
sex  is  slight.  Heredity  plays  the  most  important  role  in  the  production 
of  the  disease.  It  is  estimated  by  \arious  authors  that  from  35  to  65 
per  cent  of  epileptics  come  from  epileptic  families.  Echevierra  investi- 
gated the  families  of  135  epileptics  and  found  that  of  their  533  children, 
78  were  epileptic  and  that  126  manifested  various  forms  of  nervous  and 
mental  diseases.  The  influence  of  alcoholism  in  the  parents  upon  the 
production  of  epilepsy  cannot  be  estimated  with  certainty.  It  is  hardly 
to  be  doubted  that  it  is  a  factor  of  importance  in  at  least  a  certain  per- 
centage of  cases.  Syphilis  also  must  be  looked  upon  as  the  cause  of 
some  of  the  cases.  Whether,  in  the  absence  of  definite  anatomical  lesions, 
it  so  affects  the  brain  as  to  lead  to  epileptic  seizures  cannot  be  stated  at 
the  present  time.  Further  studies  with  the  assistance  of  the  Wassermann 
reaction  are  necessary  to  decide  this  question. 

It  was  formerly  believed  that  infantile  convulsions  were  not  infre- 
quently followed  by  epilepsy  in  later  years.  There  are  numerous  causes 
for  convulsions  in  infancy.  By  far  the  greatest  number  not  due  to  or- 
ganic brain  disease  depend  upon  tetany.  Not  sufficient  time  has  elapsed 
nor  sufficient  observations  been  made  since  the  more  recent  knowl- 
edge of  tetany  to  say  whether  it  is  likely  to  induce  epilepsy.  There  is 
no  good  reason,  however,  to  suppose  that  it  does.  Convulsions  in  infancy 
that  are  followed  by  epilepsy  are  probably  epileptic  from  the  beginning. 

An  innumerable  number  of  other  causes  have  been  suggested,  such  as 
autointoxication  from  the  intestinal  tract,  worms,  adenoid  vegetations  of 
the  pharynx,  phimosis,  masturbation,  etc.  That  poisons  absorbed  from 
the  intestinal  tract  can  cause  convulsions  is  probably  true,  but  that  epi- 
lepsy results  in  this  way  is  very  much  to  be  doubted.  The  influence  of 
the  other  factors  suggested  awaits  any  definite  proof. 

Patholo^. — If  one  includes  in  the  pathology  of  epilepsy  the  symp- 


688  DISEASES  OF  THE  NERVOUS  SYSTEM 

tomatic  cases  the  changes  in  the  brain  are  striking  and  of  the  greatest 
variety.  These,  however,  do  not  concern  us  here.  There  has  been  much 
written  and  many  careful  observations  made  upon  the  changes  in  the 
so-called  idiopathic  cases.  While  it  is  perhaps  true  that,  with  improved 
technic  and  new  methods,  more  definite  and  conclusive  alterations  in  the 
brain  will  be  found,  it  must  be  admitted  that  at  tlie  present  time  in  the 
opinion  of  very  competent  authorities  certain  alterations  can  be  demon- 
strated in  the  majority  of  instances.  These  are  chiefly  lesions  in  the 
cortex  that  can  only  be  observed  microscopically.  A  generalized  gliosis 
has  been  described  by  Bleuler,  Alzheimer  and  Chaslin.  Meynert  has 
observed  a  sclerosis  in  the  cornu  ammonis  and  Eedlich  and  others  have 
demonstrated  various  degenerative  changes  in  the  ganglion  cells  as  well. 

It  seems  probable  that  a  great  variety  of  lesions,  many  of  Avhich  are 
apparently  slight,  may  produce  this  disease. 

Symptoms. — Two  distinct  types  of  epileptic  seizures  are  met  with: 
the  major  attacks,  or  grand  mal,  in  which  there  are  severejQpnvulsions 
lasting  from  two  to  ten  minutes,  with  loss  of  consciousness,  etc. ;  and 
minor  attacks,  or  petit  mal,  in  which  the  convulsive  movements  are 
slight  and  may  be  absent,  and  in  which  the  loss  of  consciousness  is  often 
but  momentary.    Between  these  two  extremes  all  gradations  are  seen. 

Grand  Mal. — The  onset  may  be  sudden,  without  premonition,  or  it 
may  be  preceded  by  certain  prodromal  symptoms  known  as  the  aura. 
The  aura  may  be  motor,  such  as  a  local  spasm  of  the  hand,  face,  or  leg ; 
or  sensory,  such  as  numbness  and  tingling  in  any  part  of  the  body,  or 
some  abnormal  sensation  rising  gradually  to  the  head,  at  which  time  loss 
of  consciousness  occurs.  The  variety  of  sensations  described  by  patients 
as  indicating  an  attack  is  endless.  There  may  be  a  sensation  in  one 
finger,  in  the  face,  tongue,  eye,  or  in  any  part  of  the  body ;  or  the  warn- 
ing may  be  of  a  general  character,  like  a  tremor  or  a  shivering  sensation, 
or  a  feeling  of  faintness.  There  has  also  been  described  a  visceral  or 
pneumogastric  aura,  in  which  there  is  epigastric  pain,  sometimes  nausea, 
and  a  sensation  of  a  ball  in  the  throat;  or  there  may  be  palpitation,  or 
cardiac  distress.  There  may  be  general  giddiness  or  vertigo,  or  a  sensa- 
tion of  fulness  in  the  head ;  or  feelings  of  strangeness,  or  a  dreamy,  dazed 
condition ;  and,  finally,  the  aura  may  have  reference  to  any  of  the  special 
senses,  most  frequently  to  sight.  Sparks  may  appear  before  the  eyes, 
or  flashes  of  light  or  color,  or  strange  objects  may  be  seen;  or  there 
may  be  a  momentary  loss  of  hearing;  or  strange  sounds  may  be  heard. 
In  most  cases  the  aura  is  peculiar  to  the  individual. 

At  the  beginning  of  the  seizure  the  face  becomes  pale,  the  pupils 
widely  dilated,  the  eyes  rolled  up  in  their  orbits  and  fixed.  Speedily 
there  is  loss  of  consciousness.  Simultaneously  with  these  symptoms,  or 
immediately  following  them,  there  occurs  a  violent  tonic  muscular  spasm 


EPILEPSY  689 

to  which  are  due  the  characteristic  symptoms  of  the  early  part  of  the 
seizure,  viz.,  the  fall,  cry,  biting  of  the  tongue,  cyanosis,  and  evacuation 
of  the  bladder  or  rectum.  The  fall  is  forcible,  violent;  in  fact  the 
patient  is  precipitated,  usually  forward,  and  frequently  suffers  injury, 
never  sinking  down  as  in  a  faint.  The  head  is  often  strongly  rotated  to 
one  side.  The  position  of  the  hands  is  frequently  that  assumed  in  tetany. 
The  cry  is  a  hoarse,  inarticulate  sound,  not  very  loud,  and  is  due  to 
forcible  expiration,  owing  to  spasm  of  the  muscles  of  respiration  with 
the  glottis  partially  closed.  The  cyanosis  is  the  result  of  tonic  spasm 
of  the  muscles  of  respiration;  it  may  be  quite  intense,  so  that  the  face 
is  livid,  bloated,  and  the  features  distorted.  The  spasm  of  the  muscles 
of  mastication  causes  the  biting  of  the  tongue.  Evacuation  of  the  bladder 
and  rectum  may  result  from  contraction  of  their  walls,  or  from  spasm  of 
the  abdominal  muscles.  The  violence  of  the  muscular  spasm  in  this 
stage  may  be  very  great;  it  has  caused  fracture  of  bones,  rupture  of 
muscles,  and  even  dislocation  of  joints. 

The  stage  of  tonic  spasm  may  be  only  momentary,  the  patient  passing 
almost  at  once  into  the  stage  of  clonic  convulsions.  The  usual  duration 
is  from  ten  seconds  to  half  a  minute.  In  the  stage  of  clonic  spasm 
which  follows,  the  symptoms  are  i;hose  of  an  ordinary  attack  of  con- 
vulsions. The  muscular  contractions  are  violent,  and  there  is  often 
frothing  at  the  mouth.  Gradually  the  muscles  of  respiration  relax,  ^ir 
enters  the  lungs,  and  the  cyanosis  passes  off.  After  the  clonic  spasm 
has  continued  for  a  variable  time — from  two  to  three  minutes  to  half  an 
hour — the  muscular  contractions  become  less  and  less  frequent,  and 
finally  cease  altogether.  In  a  few  minutes  the  patient  may  regain 
consciousness,  look  vacantly  around,  and  in  a  dazed  way  perhaps  ask  what 
has  happened,  he  being  completely  oblivious  to  all  that  has  occurred. 
More  frequently,  however,  he  passes  at  once  into  a  deep  sleep,  which 
continues  for  an  hour  or  more,  but  from  which  he  can  be  aroused.  From 
this  he  usually  wakens  with  a  severe  headache,  which  may  continue  for 
several  hours.  After  this  he  often  feels  better  than  for  several  days 
preceding  the  attack.  During  the  seizure  the  temperature  may  be 
elevated  one  or  two  degrees,  but  rarely  more.  The  attack  may  be  fol- 
lowed by  a  slight  temporary  paresis,  aphasia,  hysterical  phenomena, 
vomiting,  and  intense  hunger.  In  very  rare  cases  the  urine  may  contain 
a  trace  of  sugar. 

Petit  i¥a/.^The  minor  attacks  of  epilepsy  may  present  a  very  great 
variety  of  symptoms,  and  at  times  it  is  almost  impossible  to  decide  that 
these  are  epileptic,  except  from  their  periodical  occurrence.  They  pass 
under  the  names  of  "spells,"  "attacks  of  dizziness,"  "fainting  turns," 
etc.  In  recent  years  the  term  "absences"  has  been  employed  to  designate 
them.     The  most  striking  thing  which  stamps  them  as  epileptic  is  the 


690  DISEASES  OF  THE  NERVOUS  SYSTEM 

loss  of  consciousness,  and  this  may  be  of  short  duration,  sometimes  only 
momentary,  and  so  pass  unnoticed;  in  some  cases  there  is  none.  There 
is  no  fall,  but  there  may  be  a  slight  dropping  of  the  head,  a  fixed  stare 
for  a  moment  or  two,  and  that  is  all.  The  muscles  are  often  firmly  fixed 
so  that  the  child  stands  straight  and  stiff.  Occasionally  there  are  one 
or  two  contractions  of  the  arms  or  a  violent  bending  forward  or  nodding 
movement.  These  attacks  may  or  may  not  be  preceded  by  aura.  After 
such  a  mild  attack  the  patient's  mind  may  be  somewhat  confused  or  he 
may  become  sleepy.  One  of  the  most  striking  things  about  attacks  of 
petit  mal  is  the  frequency  of  their  repetition.  There  may  be  as  many 
as  thirty  or  forty  attacks  a  day.  Petit  mal  is  a  serious  form  of  epilepsy 
and  after  a  time  is  usually  associated  with  grand  mal. 

"'Equivalents"  are  attacks  in  which  only  an  abnormal  mental  state  is 
manifested.  They  may  come  on  after  an  attack  of  grand  mal  or  petit 
mal  or  they  may  occur  with  no  previous  attack,  apparently  taking  the 
place  of  one  of  them.  Sometimes  they  are  the  first  evidence  of  epilepsy. 
There  may  be  for  a  time  a  complete  alteration  in  the  disposition  of  the 
child.  He  may  have  uncontrollable  fits  of  anger,  be  disobedient  or 
destructive,  run  away,  and,  in  rare  instances,  even  acts  of  violence  have 
been  committed.  Upon  recovery  from  such  a  state,  which  is  usually 
sudden,  there  is  generally  no  recollection  of  what  has  occurred. 

The  Mental  Condition  of  Epileptics. — A  careful  distinction  should  be 
made  between  cases  in  which  epilepsy  is  secondary  to  some  organic  brain 
disease,  and  the  mental  disturbances  seen  in  cases  of  idiopathic  epilepsy. 
The  children  who  are  the  subjects  of  the  latter  disease,  and  who  are 
perfectly  normal  mentall}^,  are  certainly  few.  All  degrees  of  disturbance 
may  be  seen,  from  those  who  are  simply  dull,  apathetic,  backward  in 
development,  and  uncontrollable  in  temper,  to  those  who  are  melancholic, 
idiotic,  and  even  maniacal.  The  earlier  in  childhood  epilepsy  develops, 
the  greater  is  usually  the  mental  disturbance  seen,  because  of  the  effect 
upon  the  brain  during  its  period  of  active  growth.  Mental  deterioration 
with  repeated  attacks  of  petit  mal  may  be  rapid. 

Symptomatic  Epilepsy. — This  occurs  most  frequently  in  children  as  a 
sequel  of  cerebral  palsy,  usually  with  hemiplegia,  and  it  may  follow 
either  the  congenital  or  acquired  form.  Epilepsy  may  come  on  at  any 
time  after  the  onset  of  the  paralysis, — from  a  few  months  to  five  or  six 
years.  At  first  the  attacks  may  be  separated  by  long  intervals,  but  they 
gradually  become  more  frequent  as  time  passes.  The  convulsions  in 
posthemiplegic  epilepsy  begin,  as  a  rule,  on  the  paralyzed  side,  and 
for  a  long  time  they  may  be  confined  to  that  side;  but  later  they  may 
become  general,  in  which  case  they  are  indistinguishable  from  attacks 
of  idiopathic  epilepsy.  Severe  seizures  are  more  likely  to  be  seen  than 
are  the  mild  ones.     Children  with  microcephalus  often  regularly  sufEer 


EPILEPSY  09 1 

from  repeated  convulsions  that  differ  in  no  way  from  epileptic  seizures. 

Jacksonian  epilepsy  consists  in  localized  spasms  of  groups  of  muscles 
in  the  face,  arm  or  leg  with,  retention  of  consciousness.  The  most  fre- 
quent lesion  producing  this  form  of  epilepsy  is  a  cerebral  tumor,  but 
almost  any  abnormal  process  involving  the  cortex  may  be  the  cause. 
Jacksonian  epilepsy  is  described  under  the  diseases  in  which  it  may  be 
found. 

Course  of  the  Disease. — In  most  cases  seizures  at  first  occur  at  long 
intervals,  of  perhaps  a  year,  but  later  they  become  more  and  more  fre- 
quent. Either  the  mild  or  the  severe  attacks  may  be  first  seen,  and  may 
remain  throughout  as  the  only  type  present,  or  they  may  be  associated 
in  the  same  case.  There  are  most  frequently  seen  occasional  major 
attacks  with  a  large  number  of  minor  ones.  The  ■  interval  between  the 
epileptic  seizures  in  most  cases  is  from  two  to  four  weeks,  although  they 
may  be  of  daily  occurrence.  Sometimes  three  or  four  seizures  will  follow 
one  another  closely,  and  then  there  will  occur  a  long  interval.  The 
seizures  may  come  on  either  during  sleep  or  in  the  waking  hours,  and 
in  some  cases  for  a  long  time  they  may  occur  only  in  sleep.  Such  cases 
present  peculiar  difficulties  in  diagnosis,  and  are  often  long  unrecognized 
as  epileptic.    The  general  health  of  patients  may  be  quite  normal. 

Death  rarely,  if  ever,  results  from  epilepsy,  except  from  some  accident 
at  the  time  of  the  seizures,  or  from  the  condition  known  as  status  epilep- 
ticus;  in  this  the  attacks  come  on  Math  great  frequency  and  severity,  the 
patient  at  times  passing  rapidly  from  one  convulsion  into  another,  the 
temperature  rising  to  105°  or  106°  F.,  and  death  occurring  either  from 
exhaustion  or  in  coma. 

Diagnosis. — In  most  cases  there  is  little  difficulty  in  recognizing  the 
major  attacks  when  they  occur  by  day.  Nocturnal  attacks  may  be  diag- 
nosticated by  the  cry,  the  biting  of  the  tongue,  blood  upon  the  pillow, 
sub-conjunctival  extravasation,  evacuation  of  the  bladder  or  rectum,  and 
the  severe  headache.  Minor  attacks  present  the  greatest  difficulties,  and 
a  positive  diagnosis  is  often  impossible  until  the  patient  has  been  watched 
for  a  long  time.  The  most  important  points  to  be  noted  are  sudden 
pallor,  dilatation  of  the  pupils,  temporary  loss  of  consciousness,  or  simply 
mental  confusion,  and  sometimes  the  evacuation  of  the  bladder.  Psychic 
equivalents  can  only  be  suspected  unless  there  is  a  history  of  attacks  of 
grand  or  petit  mal. 

It  is  not  always  possible  to  distinguish  between  secondary  or  symp- 
tomatic epilepsy  and  the  idiopathic  or  hereditary  form,  particularly  if 
the  case  comes  under  observation  late  in  the  course  of  the  disease.  The 
points  which  go  to  establish  the  first  form  are :  that  the  convulsive  move- 
ments are  partial,  or  limited  to  one  side;  that  when  they  are  general, 
they  always  begin  in  the  same  part  of  the  body ;  or  that  there  is  a  history 


692  DISEASES  OF  THE  NEEVOUS  SYSTEM 

of  partial  or  unilateral  attacks  for  some  time  before  the  occurrence  of  any 
general  convulsions.  It  is  important  in  all  cases  to  examine  the  patient 
carefully  for  signs  of  an  old  hemiplegia,  the  symptoms  of  which  may 
be  so  slight  as  to  be  readily  overlooked.  A  marked  increase  in  the  reflexes 
of  one  side  is  quite  as  conclusive  evidence  as  is  a  di.stinct  weakness  of  the 
arm  or  leg.  In  idiopathic  epilepsy  some  of  the  stigmata  of  degeneration 
are  usually  present.  The  sudden  development  of  epileptiform  seizures  in 
a  child  previously  healthy,  and  in  whom  there  is  no  hereditary  history  of 
the  disease,  should  always  arouse  the  suspicion  of  some  organic  brain 
disease,  especially  tumor. 

Prognosis. — The  danger  to  life  in  epilepsy  is  very  slight.  Death  is 
generally  due  to  some  accident,  particularly  drowning,  at  the  time  of  a 
seizure.  The  tendency  to  spontaneous  cessation  of  the  attacks  is  small, 
while  the  tendency  to  recurrence  is  very  great.  It  should  be  recognized, 
however,  that  instances  are  not  infrequently  met  with  in  which  appar- 
ently clear  eases  of  epilepsy  recover.  This  may  happen  without  any  treat- 
ment. This  is  more  common  when  the  attacks  have  been  of  the  grand 
mal  type  but  even  petit  mal  may  cease  spontaneously.  The  attacks  may 
gradually  become  less  and  less  frequent  or  may  cease  suddenly  without 
recurrence. 

The  prognosis  in  any  given  ease  depends  upon  the  cause  of  the  dis- 
ease and  the  duration  of  the  symptoms.  When  the  cause  can  be  removed, 
which  is  infrequently  the  case,  and  when  the  symptoms  have  lasted  less 
than  a  year,  the  prospects  of  permanent  cure  are  fairly  good.  If  an 
hereditary  tendency  to  the  disease  is  marked,  if  the  epileptic  seizures 
have  developed  apart  from  any  adequate  exciting  cause,  and  if  they  have 
continued  untreated  or  in  spite  of  treatment  for  two  or  three  years,  the 
symptoms  may  perhaps  be  relieved,  but  there  is  little .  prospect  of  per- 
manent cure.  In  the  cases  also  which  are  due  to  local  irritation,  like 
that  resulting  from  an  old  meningeal  hemorrhage,  the  prognosis  is 
invariably  bad,  and  only  temporary  relief  is  to  be  expected.  A  few  cases 
of  traumatic  epilepsy  have  been  cured  and  many  have  been  greatly  im- 
proved by  a  surgical  operation. 

Treatment. — The  general  hygienic  and  dietetic  measures  are  of  equal 
importance  with  the  use  of  drugs.  The  most  common  mistake  is  to  rely 
only  upon  drugs,  ignoring  the  other  measures  mentioned.  It  not  infre- 
quently happens  that  drugs  are  without  any  effect  when  they  are  the 
only  means  of  treatment  employed,  whereas  in  conjunction  with  other 
measures  marked  improvement  is  seen.  The  general  hygiene  of  the 
patient  must  receive  careful  attention.  He  should  lead  a  simple,  regular 
life,  as  much  as  possible  out  of  doors,  away  from  all  sources  of  excite- 
ment. Particular  attention  should  be  given  to  tlie  digestive  organs. 
Meat  should  be  allowed  once  a  day  and  in  moderate  quantity.     Milk 


EPILEPSY  693 

should  be  given,  also  buttermilk  or  kumyss.  Green  vegetables,  peas  and 
beans,  may  be  given  freely ;  also  all  fresh  fruits.  Tea,  coffee,  and  alcohol 
in  every  form  must  be  absolutely  prohibited.  Under  no  circumstances 
should  a  condition  of  chronic  constipation  be  neglected. 

Evidences  of  syphilis,  in  the  history,  by  physical  examination  and 
by  the  Wassermann  reaction  should  be  carefully  sought.  If  these  are 
present  or  if  there  is  only  a  suspicion  that  syphilis  may  be  the  cause  a 
thorough  trial  of  antisyphilitic  treatment  should  be  made. 

The  bromids  are  unquestionably  the  best  means  of  combating  the 
epileptic  habit.  Either  the  sodium  salt  alone  or  a  combination  of  the 
sodium  and  ammonium  bromid  is  to  be  preferred.  The  purpose  should 
be  to  give  the  smallest  doses  which  will  control  the  seizures.  Children 
require  proportionately  larger  doses  than  adults,  and  in  most  cases  a 
child  of  five  years  will  need  from  twenty-five  to  fifty  grains  a  day.  The 
method  of  administering  the  bromids  is  of  some  importance.  The  larger 
part  of  the  quantity  for  twenty-four  hours  should  be  given  shortly  before 
the  time  when  the  seizures  have  usually  occurred;  in  the  interval  much 
smaller  doses.  In  most  cases  it  is  desirable  to  give  a  full  dose  at  bedtime. 
Bromids  should  always  be  given  largely  diluted — in  from  three  to  four 
ounces  of  water.  It  is  believed  by  -many  that  more  satisfactory  results 
are  obtained  with  the  bromids  and  a  smaller  quantity  required  if  the 
sodium  chlorid  in  the  diet  is  restricted  to  a  minimum.  A  combination  of 
opium  with  the  bromids  is  warmly  recommended  by  some  authors.  The 
opium  must  be  given  in  full  doses  and  preferably  for  some  days  or  weeks 
before  giving  the  bromid. 

Cases  of  petit  mal  are  especially  difficult  to  control.  For  such  there 
is  often  an  advantage  in  combining  belladonna  with  the  bromids.  In  all 
cases  the  treatment  must  be  continued  for  a  long  time  if  anything  is 
accomplished.  The  bromids  should  be  gradually  reduced  after  the  attacks 
are  controlled,  but  must  be  given  in  moderately  large  doses  for  at  least 
two  years  after  the  seizures  have  ceased.  Sometimes  the  combination 
of  chloral  or  antipyrin  with  bromids  is  advantageous,  particularly  if  the 
latter  are  badly  borne  or  cause  an  annoying  amount  of  acne.  Cases 
have  been  reported  of  very  striking  benefit  following  the  use  of  calcium 
lactate.  It  is  deserving  of  trial  and  should  be  given  in  full  doses,  at 
least  thirty  grains  a  day  for  a  considerable  period. 

The  surgical  treatment  of  epilepsy  has  of  late  attracted  much  atten- 
tion. An  operation  is  to  be  considered  in  cases  in  which  the  paroxysms 
are  very  frequent  and  severe,  when  they  are  limited  entirely  or  chiefly  to 
one  side  of  the  body  and  when  there  is  present  a  definite  local  cause, 
such  as  an  old  fracture  of  the  skull,  or  when  epilepsy  has  followed  an 
injury  to  the  head  even  without  fracture.  The  results  of  operation  are, 
in  many  instances,  disappointing.     There  may  be  a  diminution  of  the 


694  DISEASES  OF  THE  NERVOUS  SYSTEM 

attacks  for  a  time,  but  they  usually  recur.  There  are  sufficient  instances 
on  record,  however,  of  permanent  improvement  or  even  definite  cure  to 
warrant  operative  procedure  for  very  frequently  repeated  epileptic  at- 
tacks, especially  if  there  are  any  evidences  of  localization  of  the  lesion. 
Status  epilepticus  requires  prompt  and  active  treatment.  A  high  cleans- 
ing enema  should  be  given  followed  by  chloral  and  bromid  by  rectum  in 
full  doses.  Morphin  hypodermically,  or  veronal  in  full  doses,  trional  or 
amylene  hydrate  by  mouth  may  be  given  in  addition. 

The  education  of  epileptic  children  is  a  subject  of  great  difficulty 
and  is  often  neglected.  There  are  many  reasons  why  it  is  impracticable 
to  send  them  to  ordinary  schools,  and  it  is  therefore  very  desirable  that 
special  schools  and  colonies  for  them  should  be  established. 

The  Management  of  the  Attack. — Abortive  measures  are  sometimes 
successful  in  cases  with  a  distinct  aura,  the  most  reliable  being  the  in- 
halation of  nitrite  of  amyl.  While  the  seizure  lasts,  the  patient  should 
be  prevented  from  injuring  himself.  The  clothing  should  be  loosened, 
a  spool  or  cork  should  be  placed  between  his  teeth  to  protect  the  tongue, 
but  no  effort  made  to  restrain  his  movements  unless  he  is  likely  to  do 
violence  to  himself.  An  epileptic  child  should  never  be  without  some 
companion. 

CHOREA 
{Saint  Vitus' s  Dance) 

Chorea  is  a  functional  nervous  disease  characterized  by  aimless, 
irregular  movements  of  any  or  all  the  voluntary  muscles.  Choreic  move- 
ments are  of  a  somewhat  spasmodic  character,  often  accompanied  by  an 
apparent  or  real  loss  of  power  in  the  groups  of  muscles  affected,  and 
by  a  mental  condition  of  extreme  irritability. 

Etiolo^. — Chorea  is  most  frequently  seen  between  the  ages  of  seven 
and  fourteen  years.  Of  146  cases,  6  were  under  five  years,  72  between 
■  five  and  nine  years,  and  68  between  ten  and  fourteen  years.  The  young- 
est case -of  which  we  have  records  was  that  of  a  child  four  years  old. 
It  is  extremely  rare  before  the  third  year,  although  it  may  occur  even  in 
infancy.  Our  own  ol^servations  coincide  with  those  of  nearly  all  writers, 
that  the  disease  is  more  than  twice  as  frequent  in  females  as  in  males. 
While  chorea  may  be  seen  at  all  seasons,  it  is  much  more  frequent  in  the 
spring  months.  Of  717  attacks  studied  by  Lewis  (Philadelphia),  the 
largest  number  began  in  March,  and  the  next  largest  number  in  May; 
in  our  own  cases  May  stands  first. 

The  relation  of  chorea  to  rheuniatisiu  is  of  nmch  importauce.  The 
investigations  of  different  writers  have  given  results  which  are  somewhat 


.     CHOREA  695 

contradictory.  Some  have  found  evidences  of  rheumatism  in  but  a  small 
proportion  of  the  cases — in  not  more  than  five  or  ten  per  cent— while 
the  statistics  of  others  have  placed  the  percentage  with  rheumatism  as 
high  as  fifty  or  even  sixty  per  cent.  The  question  hinges  largely  upon 
what  is  to  be  admitted  as  evidence  of  rheumatism  in  a  child ;  if  cases  of 
acute  articular  inflammation  only,  then  the  number  will  be  very  small ;  if 
subacute  cases  with  joint  swellings  are  included,  the  proportion  will  be 
considerably  larger;  while  if  we  admit  cases  of  acute  endocarditis  without 
articular  symptoms,  and  those  of  articular  pains  and  joint  stiffness  but 
without  swelling,  the  proportion  will  be  very  much  increased.  Our  own 
belief  is  that  there  is  a  very  close  connection  between  chorea  and  the 
rheumatic  diathesis  as  manifested  by  all  the  symptoms  above  noted,  and 
accompanied  by  a  family  history  of  rheumatism.  There  seems  to  be  a 
large  group  of  cases,  therefore,  which  may  be  classed  distinctly  as  rheu- 
matic. There  are,  however,  a  few  others  in  which  no  such  element  can 
be  found. 

Crandall  has  analyzed  146  cases  of  chorea  treated  in  an  out-patient 
clinic  and  in  private  practice,  with  the  following  results:  Of  111  cases 
in  which  the  question  of  rheumatism  was  investigated  there  was  a  definite 
history  of  it  in  63.  In  41,  articular  symptoms  occurred  before  the  chorea; 
in  13,  the  first  evidence  of  rheumatism  was  coincident  with  the  chorea ; 
and  in  9  it  first  occurred  subsequent  to  the  chorea,  usually  within  three 
months.  In  about  one-third  of  the  cases,  attacks  of  rheumatism  occurred 
(luring  or  subsequent  to  the  chorea  as  well  as  before  it.  It  may  then  be 
stated  that  previous  rheumatism  was  evident  in  37  per  cent,  concurrent 
rheumatism  in  24  per  cent,  and  subsequent  rheumatism  in  15  per  cent 
of  the  cases.  Excluding  cases  mentioned  twice,  and  also  all  those  in 
which  there  was  a  history  only  of  "growing  pains,"  there  was  evidence 
of  articular  rheumatism  in  56.7  per  cent  of  the  cases.  Many  of  these 
patients  were  under  observation  for  several  years,  and  it  was  interesting 
to  see,  as  time  passed,  how  the  evidences  of  rheumatism  multiplied  the 
longer  the  cases  were  followed. 

In  the  above  statistics  only  articular  symptoms  have  been  accepted 
as  evidence  of  rheumatism.  If  the  cases  of  endocarditis  without  articular 
symptoms  were  included,  as  they  might  fairly  be,  it  would  raise  the 
proportion  of  rheumatic  cases  still  higher.  The  great  proportion  of 
constant  cardiac  murmurs  persisting  after  chorea,  if  not  all  of  them, 
should  be  classed  as  rheumatic,  even  if  no  articular  symptoms  have  been 
present. 

Overpressure  in  school  is  often  an  important  element  in  the  produc- 
tion of  chorea.  Anemia,  if  not  an  essential  factor,  is  certainly  a  very 
important  one,  and  the  great  proportion  of  cases  present  very  distinct 
evidences  of  it.    Chorea  may  develop  as  a  sequel  of  any  of  the  infectious 


696  DISEASES  OF  THE  NERVOUS  SYSTEM 

diseases,  more  particularly  scarlet  and  typhoid  fevers.  Among  the  reflex 
causes  that  have  been  suggested,  but  whose  influence  is  doubtful,  may  be 
mentioned  phimosis,  either  lumbricoids  or  pinworms,  delayed  menstrua- 
tion, and  ocular  defects.  The  latter  frequently  cause  a  local  spasm  of 
the  muscles  of  the  eyes,  which  can  hardly  be  considered  choreic.  Hered- 
itary influence  is  of  considerable  importance  in  the  production  of  chorea. 
It  is  much  more  frequent  in  children  of  neurotic  families,  and  very 
often  several  successive  generations,  or  several  children  in  the  same  fam- 
ily, may  suffer  from  the  disease. 

The  exciting  cause  of  chorea  in  a  certain  proportion  of  cases  is  fright ; 
occasionally  it  arises  from  imitation,  and  the  disease  has  been  known  to 
occur  epidemically  in  institutions. 

The  role  of  bacteria  in  the  production  of  rheumatic  chorea  is  still 
unsettled.  The  organism  which  Poynton  and  Paine  have  described  as 
the  cause  of  acute  articular  rheumatism  has  been  found  in  the  meninges 
of  the  brain  in  a  few  fatal  cases  of  chorea,  but  in  tlirae  of  our  own  it  was 
impossible  to  obtain  any  growth  from  the  brain  or  other  organs. 

Patholo^* — The  exact  pathology  of  chorea  is  at  the  present  time  not 
settled.  The  seat  of  the  morbid  process  is  undoubtedly  the  central 
nervous  system,  probably  the  motor  areas  of  the  cortex.  The  cases  asso- 
ciated with  rheumatism  are  now  generally  regarded  as  of  infectious 
origin.  In  some  severe  cases  which  v/ere  fatal,  owing  to  association  with 
acute  endocarditis,  capillary  emboli  have  been  found  in  the  brain.  How- 
ever, it  is  by  no  means  established  that  this  is  the  condition  present  in 
most  of  the  rheumatic  cases.  The  fact  that  in  the  great  majority  of  such 
cases  complete  recovery  occurs  in  the  course  of  a  few  weeks  or  months, 
speaks  strongly  against  any  important  structural  change  in  the  nervous 
centers. 

Symptoms. — An  attack  of  chorea  generally  comes  on  gradually.  At 
first  the  child  may  be  considered  simply  as  unusually  nervous;  if  at 
school,  there  may  be  noticed  a  difficulty  in  writing,  drawing,  or  in  using 
the  hands  for  other  delicate  operations.  At  home,  the  child  is  con- 
tinually dropping  things,  has  difficulty  in  feeding  himself,  sometimes  in 
buttoning  his  clothes,  and  very  frequently  he  is  not  brought  to  the 
physician  until  the  symptoms  have  lasted  a  week  or  two.  Sometimes  the 
legs  are  first  affected,  and  a  history  is  given  of  frequent  falls,  a  stumbling 
gait,  difficulty  in  going  upstairs,  etc.  At  other  times  the  spasm  is  first 
seen  in  the  facial  muscles,  with  disturbance  of  articulation,  twitchings  of 
the  eye  muscles,  and  the  child  may  be  punished  for  making  grimaces.  In 
most  cases  the  spasmodic  movements  soon  extend  to  all  parts  of  the  body. 
They  remain  limited  to  one  side  of  the  body  (hemichorea)  in  about  one- 
third  of  the  cases.  When  fully  developed,  the  movements  of  chorea  are 
quite   unmistakable.      They    are   irregular,    jerking,    spasmodic,    never 


CHOREA  697 

rhythmical,  rarely  symmetrical,  and  vary  in  intensity  from  an  occasional 
muscular  contraction  to  almost  constant  motion.  The  movements  are 
not  under  the  control  of  the  patient's  will,  and  are  usually  intensified  by 
efforts  to  repress  them.  They  are  increased  by  excitement,  embarrass- 
ment, or  fatigue,  but  do  not  continue  during  sleep. 

Very  often  there  is  weakness  of  the  affected  muscles,  which  may  be 
so  great  as  to  lead  to  the  suspicion  that  actual  paralysis  exists.  Not 
infrequently  we  have  had  patients  brought  to  the  clinic  for  supposed 
paralysis,  either  of  one  extremity  or  of  one  side  of  the  body,  where  the 
choreic  movements  have  not  been  severe  enough  to  attract  the  attention 
of  the  mother.  This  paralysis  usually  disappears  in  the  course  of.  a  few 
weeks. 

In  severe  forms  of  chorea  the  patient  may  be  unable  to  walk,  to  speak 
intelligibly  or  even  to  sii  up  in  bed.  The  movements  may  l)e  so  violent 
that  it  is  necessary  to  pad  the  bed  and  to  wrap  the  child's  extremities 
in  cotton.  Control  of  the  bladder  or  rectum  may  also  be  lost.  The  symp- 
toms may  be  so  intense  as  even  to  threaten  life.  Such  cases,  however,  are 
usually  dangerous,  not  from  the  choreic  movements,  but  from  the  acute 
endocarditis  with  which  they  are  frequently  associated.  We  have  seen 
fatal  cases,  however,  in  which  the  outcome  was  not  determined  by  the 
endocarditis.  The  temperature  usually  rises  to  103°  F.  or  more  and 
remains  constantly  high.  The  choreiform  movements  are  almost 
impossible  to  control  even  with  sedatives  in  enormous  doses,  and 
death  takes  place  after  several  days,  apparently  as  the  result  of  exhaus- 
tion. 

The  mental  condition  of  choreic  patients  is  one  of  marked  irritability. 
They  are  fretful,  emotional,  easily  provoked  to  tears  or  laughter,  and 
difficult  to  control.  In  extreme  cases  a  mental  disturbance  bordering 
upon  acute  mania  has  been  observed.  In  other  cases  the  facial  expression 
and  manner  of  speech  strongly  suggest  beginning  imbecility.  All  degrees 
of  speech  disturbances  are  seen  from  the  slight  difficulty  in  articulation 
due  to  inability  properly  to  control  the  movements  of  the  tongue  and 
lips,  to  a  condition  in  which  speech  is  almost  impossible.  In  severe  cases 
speech  may  be  temporarily  lost. 

Cardiac  murmurs  are  frequent  in  chorea.  Some  of  these  are  of 
anemic  origin,  but  a  large  number,  probably  the  majority,  are  due  to 
concurrent  endocarditis,  as  is  shown  l>y  the  fact  that  they  are  permanent, 
and  are  followed  by  all  the  signs  of  orgairic  heart  disease.  During  every 
attack  the  heart  should  be  closely  watched,  especially  in  children  in  whom 
there  is  a  strong  predisposition  to  rheumatism. 

The  general  condition  of  choreic  patients  is  usually  much  below  nor- 
mal. They  are  anemic ;  the  appetite  is  poor,  often  capricious ;  they  sleep 
very  badly;  they  suffer  frequently  from  headaches;  they  are  easily  fa- 


698  DISEASES  OF  THE  NERVOUS  SYSTEM 

tigued  by  slight  muscular  exertion ;  and  in  short  they  have  all  the  symp- 
toms of  a  greatly  disturbed  nutrition. 

Course  and  Duration. — The  ordinary  form  of  chorea  tends  to  spon- 
taneous recovery  in  from  six  to  ten  weeks.  Exceptionally  it  may  last  for 
three  or  four  months.  In  a  small  number  of  cases  the  disease  may 
continue  for  a  much  longer  period  with  remissions  and  exacerbations. 
Certain  forms  of  local  spasm,  particularly  choreiform  movements  of  the 
muscles  of  the  face,  eyes,  or  neck,  may  be  permanent.  In  any  case  of- 
chorea  which  lasts  longer  than  the  usual  time,  the  patient  should  be 
carefully  examined  for  some  cause  of  peripheral  irritation.  The  tendency 
to  relapses  and  second  attacks  is  very  marked.  Later  attacks  are  likely 
to  occur  in  the  spring  succeeding  the  first  illness,  and  in  a  small  number 
of  patients  attacks  may  come  every  year  for  four  or  five  years. 

Diagnosis. — There  is  little  difficulty  in  recognizing  chorea  from  the 
sudden,  irregular,  spasmodic  contraction  of  the  muscles  coming  on  under 
other  circumstances.  No  other  movements  of  childhood  are  likely  to  be 
confounded  with  it.  The  form  of  chorea  following  hemiplegia  is  usually . 
more  athetoid  than  choreic,  yet  at  times  it  closely  simulates  ordinary 
chorea.  The  difficulty  in  distinguishing  between  the  two  is  often  in- 
creased by  the  fact  that  the  weakness  of  simple  chorea  may,  if  unilateral, 
closely  simulate  hemiplegia.  The  existence  of  rigidity,  contractions,  and 
increased  reflexes  belongs  exclusively  to  hemiplegic  cases,  and  these  will 
usually  suffice  to  clear  up  all  doubt  with  reference  to  the  diagnosis. 

Prognosis. — As  a  rule,  this  is  favorable,  and  complete  recovery  can 
usually  be  predicted,  the  exceptions  being  few  in  number.  Parents  should 
always  be  warned  of  the  tendency  of  the  disease  to  return  in  succeeding 
years,  and  the  fact  should  be  stated  that  in  a  certain  proportion  of  cases 
the  disease  may  be  of  exceptional  duration.  The  prognosis  of  the  cardiac 
murmurs  occurring  in  chorea  should  always  be  guarded,  although  some 
of  these  are  functional  and  disappear  with  recovery  from  the  chorea; 
but  the  number  of  those  which  do  not  disappear  is  very  large  and  suffi- 
cient to  make  one  always  apprehensive  as  to  the  ultimate  result.  Acute 
chorea  may  be  fatal  from  the  accompanying  endocarditis  and  much  more 
rarely  from  the  severity  of  the  disease  itself. 

Treatment. — The  general  management  of  the  case  is  equally  im- 
portant with  the  administration  of  drugs.  A  child  with  chorea  should  at 
once  be  taken  from  school,  and  should  never  be  subjected  to  punishment 
or  to  ridicule  on  account  of  the  movements.  Special  attention  should 
be"  given  to  the  patient's  diet  and  general  nutrition.  Tonics,  especially 
iron,  are  indicated  in  most  cases.  The  food  should  be  simple  and  nutri- 
tious, and  all  stimulants,  particularly  tea  and  coffee,  should  be  absolutely 
prohibited.  Wliile  fresh  air  is  desira1)lc,  exercise  should  be  prescribed 
with  great  caution  and  its  efl'ect  should  be  carefully  watched.     A   -ertain 


CHOREA  609 

amount  of  moral  restraint  is  iiulispen sable;  thus  it  often  happens  that 
choreic  patients  do  very  badly  at  home  where  they  are  indulged  and 
receive  sympathy,  while  in  a  hospital,  where  they  are  under  restraint  and 
made  to  control  themselves,  they  begin  to  improve  immediately.  In  all 
severe  cases  the  rest  treatment  should  be  employed.  It  is  equally  bene- 
ficial in  the  milder  ones ;  the  patient  is  put  to  bed,  and  complete  mental 
and  physical  rest  secured.  This  may  be  combined  with  gentle  massage 
for  fifteen  or  twenty  minutes  a  day.  The  daily  use  of  prolonged  warm 
baths,  either  alone  or  in  conjunction  with  massage,  is  at  times  decidedly 
beneficial.  In  other  cases  the  regular  use  of  cold  douches  is  of  value. 
;  In  estimating  the  value  of  drugs  in  the  treatment  of  chorea,  the 
natural  course  of  the  disease  should  be  kept  in  mind,  since  those  drugs 
which  are  taken  after  the  third  or  fourth  week  are  much  more  likely  to 
be  thought  beneficial  than  those  used  in  the  early  period  of  the  attack. 
On  account  of  the  cloje  association  of  chorea  with  rheumatism,  anti- 
rheumatic remedies  (sodium  salicylate,  aspirin,  etc.)  have  very  frequently 
been  tried,  especially  in  cases  with  fever  and  endocarditis  and  when  joint 
symptoms  supervene  in  the  course  of  an  attack.  Our  experience  has 
been  that  they  rarely  have  very  much  effect  upon  the  course  of  the 
disease.  They  may  alleviate  the  pain  of  acute  arthritis  somewhat  and 
in  large  doses  may  reduce  the  temperature,  but  they  exert  little  influence 
ujDon  the  severity  or  duration  of  the  symptoms  of  chorea. 

Arsenic  was  long,  and  still  is,  regarded  by  some  as  a  specific  for 
the  disease.  The  usual  method  of  administration  is  to  begin  with  four 
drops  of  Fowler's  solution  three  times  a  day  for  a  child  of  eight  years, 
and  to  increase  the  daily  quantity  by  one  drop  every  two  or  three  days 
until  eight  drops  are  given  at  each  dose.  One  should  stoj)  short  of  this 
if  digestion  is  disturbed,  or  there  is  puffiness  of  the  face  or  albumin  in 
the  urine.  Arsenic  should  always  be  given  after  meals,  and  largely 
diluted.  The  possibility  of  arsenical  poisoning  should  be  remembered, 
although  it  is  rare.  We  have  known  of  several  cases  in  which  multiple 
neuritis  developed  after  a  few  weeks'  administration  of  the  drug.  In 
our  hands  arsenic  has  not  been  very  effective  against  chorea. 

Severe  chorea  requires  sedatives.  Not  only  do  they  relieve  the  symp- 
toms but  in  many  instances  apparently  have  a  distinct  influence  in 
shortening  the  duration  of  an  attack.  They  must  be  given  in  quantities 
sufficient  to  produce  an  effect  and  the  amount  required  is  often  enor- 
mous. The  bromids,  chloral,  opium  or  morphin  and  veronal  will  be 
found  the  most  efficacious.  The  bromids  not  infrequently  must  be  sus- 
pended on  account  of  eruptions.  Morphin,  hypodermically,  is  at  times 
the  most  satisfactory  drug.  Improvement  is  shown  by  a  diminution  of 
the  amount  required  to  produce  quiet  but  the  above  drugs  must  some- 
times be  continued  for  many  weeks. 


700  DISEASES  OF  THE  NERVOUS  SYSTEM 

Chorea  has  a  strong  tendency  to  recur,  especially  in  the  spring 
mouths.  Children  who  have  had  one  attack  should  be  closely  watchedj 
particularly  with  reference  to  their  work  in  school.  They  should  not  be 
crowded  in  their  studies,  they  should  have  long  vacations,  and  the  nervous 
system  should  not  be  put  upon  any  severe  tension  for  a  long  time. 


OTHER   SPASMODIC    AFFECTIONS 

Habit  Spasm.— This  term  is  used  to  describe  certain  spasmodic  mus- 
cular movements  which  at  first  are  only  occasionally  noticed,  but  which 
may  persist  until  they  become  habitual  and  almost  entirely  involuntary. 
The  movements  usually  affect  the  muscles  of  the  face,  but  they  may  be 
seen  in  almost  any  part  of  the  body.  The  most  frequent  varieties  consist 
of  blinking  or  sudden  frowning,  raising  the  eyebrows,  grinding  of  the 
teeth,  or  some  peculiar  grimace.  At  other  times  there  is  sudden  twisting 
of  the  head,  shrugging  of  the  shoulders,  or  Jerking  of  the  hands.  Habit 
spasm  is  not  often  seen  in  the  lower  extremities,  but  the  muscles  of 
respiration  are  quite  frequently  affected.  There  may  be  a  half-sigh,  a 
sort  of  sob,  or  a  peculiar  dry,  pharyngeal  cough>    • 

These  movements  are  at  first  infrequent;  but  as  the  habit  becomes 
more  firmly  fixed  the  spasm  recurs  every  few  minutes,  and  in  severe 
cases  it  may  be  almost  continuous.  The  form  of  spasm  is  not  always 
the  same;  one  may  disappear  and  another  take  its  place.  The  condition 
may  last  for  months  or  years,  and  it  may  even  be  permanent. 

Habit  spasm  is  really  little  more  than  exaggerated  nervousness  con- 
tinuing in  some  definite  form  until  by  repetition  a  fixed  habit  is  estab- 
lished. It  is  different  in  cause,  course,  prognosis,  and  treatment  from 
chorea,  with  which,  however,  it  is  often  confounded. 

The  causes  are  those  of  neuroses  in  general.  In  the  beginning,  at 
least,  the  general  health  is  usually  below  the  normal.  The  patients  are 
nervous  children  of  neurotic  antecedents.  There  may  be  a  history  of 
some  definite  exciting  cause,  such  as  illness  or  overwork  in  school. 
There  is  frequently  some  local  cause  of  which  the  spasm  is  merely  a 
reflex. 

Habit  spasm  is  to  be  differentiated  from  chorea ;  this  is  usually  easy, 
from  the  limitation  of  the  movements  to  one  part  or  group  of  muscles 
and  from  the  duration  of  the  disease. 

Treatment  is  quite  unsatisfactory  after  the  habit  has  become  fixed, 
hence  it  is  of  very  great  importance  that  it  should  be  arrested  at  the 
earliest  possible  age.  Punishments  are  of  no  avail,  and  usually  aggravate 
the  condition.  Eewards  are  much  more  effectual.  The  child's  surround- 
ings, work  and  study  should  be  carefully  investigated.     Any  local  cause 


SPASMODIC  AFFECTIONS  701 

which  can  be  discovered  should  be  removed.  Especially  should  the  gen- 
eral health  receive  attention. 

Athetosis  and  Athetoid  Movements. — These  terms,  introduced  by 
Hammond,  are  used  to  describe  a  chronic  form  of  spasm  usually  seen  in 
the  hand,  but  sometimes  also  in  the  foot,  and  even  the  face.  It  may  affect 
both  sides,  but  in  most  cases  it  is  unilateral.  The  movement  is  slow, 
irregular,  and  incoordinate — a  sort  of  "mobile  spasm,"  it  has  been  called 
— and  there  may  be  associated  a  certain  amount  of  muscular  rigidity. 
Such  movements  rarely  occur  in  persons  apparently  healthy,  but  are 
usually  seen  as  a  sequel  of  cerebral  palsies,  generally  hemiplegia.  Eecov- 
ery  from  the  paralysis  may  be  so  nearly  complete  that  the  athetoid 
movements  are  looked  upon  as  primary.  In  some  cases  the  movements 
are  more  rapid  and  somewhat  resemble  those  of  chorea,  the  condition 
being  sometimes  classed  as  post-hemiplegic  chorea.  Athetosis  is  not  in- 
fluenced by  treatment. 

Rotary  and  Nodding  Spasm  of  the  Head. — These  are  rare  forms  of 
irregular  movements  usually  observed  in  infancy.  The  condition  was 
described  long  ago  by  Henoch,  The  most  frequent  is  tlie  rotary  spasm, 
which  consists  in  a  side-to-side  oscillation  of  the  head,  which  may  be 
slow  or  rapid,  and  in  some  cases  is  almost  continuous.  Some  children 
have  at  times  the  nodding  spasm  also,  and  in  others  this  is  the  only 
movement  seen.  Nystagmus  is  frequently  associated,  and  may  affect  one 
or  both  eyes.  In  a  few  of  the  reported  cases  convergent  strabismus  was 
present. 

The  causes  of  the  condition  are  extremely  obscure.  It  is  usually  seen 
in  infancy  between  the  third  and  eighteenth  months.  It  is  believed  by 
Eaudnitz  to  be  often  the  result  of  living  in  poorly  lighted  rooms,  it  being 
necessary  for  the  infant  to  assume  an  unnatural  position  of  the  head  in 
order  to  see  things  held  before  him.  The  nystagmus  is  regarded  as  anal- 
ogous to  that  which  develops  in  miners.  While  this  explanation  is  satis- 
factory for  some  cases  that  are  cured  by  being  placed  in  well-lighted 
rooms,  it  is  not  applicable  to  all. 

As  a  rule,  the  condition  lasts  for  several  months  and  improves, 
recovery  almost  always  taking  place.  The  prognosis  is  therefore  fa- 
vorable. 

Nystagmus. — This  term  is  applied  to  rhythmical,  involuntary,  oscil- 
latory movements  usually  of  both  eyes.  They  are  caused  by  the  alter- 
nate contraction  of  opposing  muscles.  Nystagmus  may  be  either  vertical 
or  lateral.  It  is  most  often  seen  in  infants  a  few  months  old.  In 
some  cases  the  movement  is  almost  continuous,  occurring  even  in  sleep; 
in  others,  it  is  only  noticed  at  times  of  special  excitement. 

The  etiology  of  nystagmus  is  obscure,  and  it  may  occur  in  quite  a 
variety  of  conditions — sometimes  referable  to  the  eye,  at  other  times  to 
24 


702  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  central  nervous  system.  On  the  part  of  the  eye,  nystagmus  may  be 
due  to  blindness  from  any  cause,  to  congenital  cataract,  corneal  opacity, 
disease  of  the  choroid  or  retina,  or  to  errors  of  refraction.  It  may  be 
seen  in  almost  any  organic  disease  of  the  nervous  system,  both  with  focal 
and  diffuse  lesions,  especially  in  chronic  hydrocephalus,  insular  sclerosis, 
tuberculous  meningitis,  and  in  diseases  in  which  sight  is  impaired. 
While  it  is  of  no  importance  as  a  localizing  symptom,  nystagmus  often 
indicates  something  more  than  functional  disturbance.  An  exception  to 
this  may  perhaps  be  made  when  it  follows  cerebral  concussion.  In  such 
cases  it  is  usually  temporary,  disappearing  in  a  few  days  or  weeks.  Under 
other  conditions  it  may  continue  indefinitely. 

The  condition  of  the  eyes  should  be  investigated  in  every  case  of 
nystagmus;  it  is  only  when  the  cause  is  here,  and  can  be  removed,  that 
habitual  nystagmus  is  amenable  to  treatment. 

Hiccough  (Singultus). — This  is  a  spasm  of  the  diaphragm  which  is 
usually  seen  in  young  infants.  In  them  it  is  in  most  cases  due  to  some 
irritation  in  the  stomach,  but  is  found  in  perfectly  healthy  infants  with 
no  digestive  disturbance.  It  is  seen  after  eating,  and  may  depend  upon 
overfilling  of  the  stomach  with  food,  swallowing  of  air,  etc.  In  other 
cases  it  has  no  relation  to  the  taking  of  food.  In  cases  like  the  above, 
hiccough,  though  sometimes  annoying,  is  of  little  importance.  It  may 
be  associated  with  indigestion,  with  intestinal  flatulence  or  inflammation, 
with  peritonitis  or  with  intestinal  obstruction.  With  the  last  two  condi- 
tions it  is  always  an  unfavorable  symptom.  In  older  children  hiccougli 
sometimes  occurs  as  a  pure  neurosis. 

The  object  of  treatment  is  to  remove  the  cause.  In  infants  this  is  to 
aid  in  the  expulsion  of  the  gas  from  the  stomach  by  manipulation  or 
position.  When  it  is  a  nervous  symptom  only,  it  may  be  arrested  in 
older  children  by  holding  the  breath,  or  by  prolonged  forced  expiration, 
as  in  blowing  a  trumpet. 

Thomsen's  Disease  (Congenital  Myotonia). — This  rare  disease  is 
usually  congenital.  It  may  occur  in  several  members  of  the  same  family, 
and  is  almost  always  hereditary.  The  characteristic  symptoms  are  a 
peculiar  rigidity  of  the  muscles  which  is  observed  when  they  are  first 
brought  into  action  after  repose.  This  rigidity  is  spasmodic,  and  usually 
continues  but  a  few  moments.  It  may  recur  when  voluntary  movements 
are  again  attempted.  If,  however,  muscular  effort  is  persisted  in,  it 
soon  passes  off.  It  is  increased  by  apprehension,  excitement,  or  cold,  and 
l)y  observation.  The  legs  are  most  frequently  affected,  the  condition 
being  often  noticed  when  the  patient  starts  to  walk ;  any  of  the  voluntary 
muscles,  however,  may  be  involved,  even  the  tongue.  It  may  be  greater 
upon  one  side  of  the  body  than  upon  the  other.  The  tendon  reflexes  are 
not  increased  but  there  is  a  marked  and  very  prolonged  contraction  of  the 


SPASMODIC  AFFECTIONS  703 

muscles  as  a  result  of  direct  mechanical  stimulation.  The  electrical 
stimulation  of  the  nerves  causes  generally  normal  or  diminished  contrac- 
tions; that  of  the  muscles  directly,  either  with  the  faradic  or  galvanic 
current,  causes  a  contraction  that  remains  for  from  ten  to  twenty  sec- 
onds. The  disease  may  be  noticed  very  early  in  life  and  it  generally 
increases  in  severity  about  the  time  of  puberty.  Thereafter  it  remains 
stationary,  or  nearly  so.  It  never  causes  death  but  is  incurable,  al- 
though the  symptoms  may  be  improved  somewhat  by  active  muscular 
exercise. 

The  muscle  fibers  are  increased  in  size  and  the  nuclei  much  increased 
in  number.  There  are  no  evidences  of  degeneration,  but  in  the  sarco- 
plasm  may  be  seen  a  large  number  of  small,  round,  colorless  or  yellowish 
dots  that  seem  to  indicate  actual  disease  of  this  substance.  Something 
can  be  accomplished  by  massage  and  muscular  exercises  to  diminish 
the  tendency  to  muscular  rigidity,  but  nothing  approaching  a  normal 
condition  can  be  brought  about. 

Torticollis — Wry-Neck. — Torticollis  may  be  congenital  or  acquired. 
Regarding  the  cause  of  congenital  torticollis  there  is  some  dispute.  Such 
cases  have  often  been  attributed  to  the  contraction  resulting  from  hema- 
toma of  the  sternomastoid.  It  is  out  belief  that  this  is  rarely,  if  ever, 
the  case.  While  it  is  possible  that  the  deformity  is  sometimes  the  con- 
sequence of  injury  received  during  delivery,  the  cause  of  most  of  the  con- 
genital cases  goes  back  to  conditions  existing  before  birth.  It  may  be 
compared  to  club-foot,  and  may  be  due  to  a  faulty  position  of  the  child 
in  utero.  There  may  be  a  congenital  shortening  of  the  sternomastoid 
muscle  alone  or  of  several  muscles,  or  of  all  the  tissues  on  one  side  of  the 
neck.  Very  rarely  congenital  torticollis  is  the  result  of  anomalies  of  one 
or  more  cervical  vertebrae.  The  most  frequent  cause  in  the  acquired 
cases  is  inflammations  of  the  neck,  the  result  of  tonsillitis  and  pharyn- 
gitis. Such  is  the  usual  etiology  of  torticollis  following  scarlet  fever, 
measles,  or  diphtheria.  The  exciting  cause  of  the  spasm  is  irritation  of 
the  cervical  nerves,  usually  the  spinal  accessory,  though  others  also  may 
be  involved. 

Torticollis  is  seen  with  cervical  adenitis,  acute  or  tuberculous,  and 
with  cellulitis  of  the  neck.  Indeed,  it  may  be  the  result  of  anything 
causing  irritation  of  the  trunk  or  branches  of  the  spinal  accessory  nerve, 
either  in  the  spinal  canal,  the  cranium,  or  along  the  course  of  the  nerve 
trunk  or  of  any  of  its  peripheral  fibers.  Most  of  the  cases  that  have 
been  described  as  the  result  of  rheumatism  and  cold  are  probably  due  to 
infections  occurring  through  the  tonsils  and  pharynx.  A  cause  which 
the  physician  should  always  have  in  mind  is  cervical  Pott's  disease;  tor- 
ticollis may  be  the  earliest,  and  for  several  weeks  sometimes  almost 
the  only  objective  symptom  of  this  disease.     Infrequent  causes  of  tor- 


704  DISEASES  OF  THE  NERVOUS  SYSTEM 

ticollis  are  acute  inflammation  of  the  suboccipital  articulations,  uni- 
lateral dislocation,  osteo-arthritis  of  the  cervical  spine  and  cervical 
rib. 

The  onset  may  be  acute  and  accompanied  by  fever,  or  what  is  more 
frequent  is  that  the  torticollis  gradually  develops,  it  being  several  days 
or  weeks  before  it  is  marked  and  permanent.  The  deformity  varies  some- 
what, according  as  the  sternomastoid  muscle  is  alone  affected,  or  the 
posterior  muscles  also,  and  as  to  which  predominates.  In  simple  sterno- 
mastoid spasm  the  head  is  inclined  to  the  affected  side  and  rotated  toward 
the  opposite  side ;  the  chin  is  raised,  and  the  ear  approaches  the  clavicle. 
When  other  muscles  are  involved  the  deformity  is  modified.  If  the 
trapezius  is  affected  there  is  less  rotation  of  the  head,  but  it  is  drawn  to 
the  affected  side  and  somewhat  backward,  while  the  shoulder  is  raised 
and  the  spine  curved.  Both  of  these  symptoms  may  be  seen  to  a  slight 
degree  in  almost  any  marked  case  of  sternomastoid  spasm.  Sometimes 
the  spasm  of  the  posterior  muscles  affects  both  sides;  the  head  is  then 
drawn  backward  and  held  rigidly,  but  without  rotation.  In  recent  cases 
the  deformity  can  be  partially  or  entirely  overcome  by  passive  force; 
but  after  a  time  this  is  impossible,  owing  to  muscular  shortening. 
Atrophy  may  take  place  in  the  affected  muscle.  In  recent  cases  local- 
ized pain  and  tenderness  are  also  frequently  present,  and  sometimes 
they  are  severe.  Attempts  to  reduce  the  deformity  may  produce  great 
pain. 

Prognosis. — The  result  in  a  case  of  torticollis  depends  upon  the  cause, 
the  severity  and  the  duration  of  the  deformity.  Eecovery  in  most  of  the 
acute  cases  is  complete  in  the  course  of  a  few  days  or  weeks.  In  others, 
after  the  subsidence  of  the  symptoms  of  local  inflammation  there  may 
be  no  tendency  to  a  reduction  of  the  deformity.  This,  if  untreated,  may 
be  permanent,  owing  to  shortening  of  the  muscles  and  fascia.  The  con- 
genital cases  with  slight  deformity  are  usually  amenable  to  mechanical 
or  postural  treatment  if  begun  early.  There  is  in  most  of  the  other 
varieties  a  disposition  for  the  deformity,  if  untreated,  to  persist,  and 
even  increase.  If  it  has  lasted  several  months  the  probabilities  of  spon- 
taneous recovery  or  even  of  improvement  are  small. 

Treatment. — The  first  indication  is  to  remove  or  treat  the  cause  when 
one  can  be  found.  Acute  cases  are  to  be  treated  by  rest  in  bed,  hot  appli- 
cations, counterirritation  and  friction,  unless  the  pain  is  too  severe. 
Cases  which  have  lasted  a  month  usually  require  some  orthopedic  head- 
support,  and  those  which  have  lasted  six  months  or  more  are  rarely  cured 
without  a  surgical  operation.  This  may  be  either  a  subcutaneous 
tenotomy  or  myotomy  of  the  sternomastoid,  or  an  open  incision.  An  old 
case  of  torticollis  is  a  serious  matter  and  radical  measures  should  bo 
resorted  to  early  in  the  disease, 


HYSTERIA  705 


HYSTERIA 


This  is  not  a  disease  of  childhood,  but  one  which  is  occasionally 
seen  in  early  life.  All  that  will  be  attempted  in  this  chapter  is  to  point 
out  the  most  common  manifestations  of  hysteria  when  it  occurs  in  chil- 
dren.   After  puberty  it  is  essentially  the  same  as  in  adults. 

Etiology. — Hysteria  is  very  rare  before  the  seventh  or  eighth  year, 
and  most  cases  seen  in  children  occur  after  the  tenth  year.  As  to 
sex,  there  is  no  such  predominance  of  females  as  in  later  life,  although 
even  in  childhood  they  are  more  frequently  affected  than  males.  Hered- 
itary influences  play  an  important  part  in  the  production  of  this  disease. 
It  is  seen  in  children  who  inherit  a  nervous  constitution,  or  in  whose 
parents  nervous  diseases,  such  as  insanity,  or  hysteria,  or  neurasthenia, 
have  been  present.  Of  the  other  etiological  factors  the  most  important  are 
a  disordered  nutrition,  frequently  with  anemia  or  chlorosis,  and  over- 
pressure in  schools.  Masturbation  may  act  as  an  exciting  cause,  or, 
indeed,  anything  which  leads  to  an  exalted  nervous  irritability  and  depre- 
ciation of  the  general  health.  It  may  follow  any  of  the  acute  infectious 
diseases;  or  it  may  be  excited  by  injury,  fright,  or  imitation. 

Symptoms. — There  is  scarcely  any  disease  in  which  the  clinical  pic- 
ture presented  is  so  varied  as  in  hysteria.  It  may  simulate  almost  any 
form  of  organic  disease  of  the  brain,  lungs,  digestive  organs,  bones,  or 
joints.    The  symptoms  are  seen  in  almost  every  conceivable  combination. 

Psychical  symptoms  frequently  predominate.  There  may  be  seen 
periods  of  mental  depression  of  longer  or  shorter  duration,  a  change 
in  disposition,  an  indifference  to  surroundings,  a  capricious  humor,  or  a 
nervous  condition  of  extreme  irritability  with  irregular  paroxysms  of 
laughter  or  weeping  without  cause.  There  may  be  great  excitability  of 
temper,  and  fits  of  passion  almost  maniacal  in  their  severity.  There 
may  be  various  hallucinations.  Sleep  is  frequently  disturbed,  some- 
times by  attacks  resembling  ordinary  night-terrors;  sometimes  somnam- 
bulism is  present.  There  is  often  a  disposition  to  deception  about  the 
most  trivial  matters,  which  may  last  for  weeks.  There  is  a  tendency  to 
imitate  the  symptoms  of  various  diseases,  which  the  patients  may  have 
witnessed  in  others  or  about  which  they  have  read.  Sometimes  the 
special  senses  are  affected,  giving  rise  to  hysterical  blindness  or  deafness, 
usually  of  short  duration. 

Sensory  symptoms  are  the  most  frequent  manifestations  of  hysteria 
in  early  life.  There  is  often  general  or  local  hyperesthesia,  which  may  be 
so  great  as  to  simulate  inflammation  of  the  various  internal  organs. 
Anesthesia  is  much  less  common,  although  it  may  be  seen  in  children  as 
young  as  eight  or  nine.     Anesthesia  is  very  frequently  associated  with 


70G  DISEASES  OF  THE  KErvVOUS  SYSTEM 

paralyses.  In  such  circumstances  it  is  apt  to  involve  the  whole  of 
one  or  more  extremities  and  in  such  a  way  as  to  be  inexplicable  by  any 
organic  lesion.  Paralysis  is  an  infrequent  but  striking  symptom.  There 
may  be  monoplegia  or  paraplegia,  more  rarely  hemiplegia  or  paralysis 
of  all  four  extremities.  There  may  even  be  edema  and  a  certain  degree 
of  atrophy  of  the  affected  extremity  from  disuse.  The  inability  to  stand 
or  walk,  though  the  legs  can  be  moved  perfectly  in  the  recumbent  posi- 
tion, is  observed  at  times.  Headache  is  an  occasional  symptom,  and  is 
sometimes  associated  with  great  tenderness  of  the  scalp.  There  may  be 
neuralgias  in  the  different  parts  of  the  body,  or  sharp  pain,  sometimes 
accompanied  by  vomiting. 

Joint  symptoms  are  really  a  variety  of  sensory  disturbances.  They 
are  not  uncommon,  and  are  often  most  puzzling.  All  forms  of  organic 
disease  of  these  joints  may  be  simulated.  Joint  symptoms  are  usually 
seen  between  the  ages  of  ten  and  fourteen  years,  and  occur  in  both  sexes. 
There  may  be  lameness  referred  to  one  of  the  large  joints,  curvature  of 
the  spine,  or  torticollis.  The  symptoms  are  most  frequently  referred  to 
the  hip,  and  next  to  the  knee,  the  ankle,  or  the  spine.  The  pain  is  acute. 
It  is  increased  by  motion,  and  by  attempts  at  overcoming  the  deformity, 
if  any  is  present.  There  is  a  marked  hyperesthesia  of  the  whole  limb, 
and  sometimes  of  the  body.  The  resistance  and  pain  caused  by  passive 
motion  are  often  greater  than  in  most  joints,  which  are  the  seat  of  or- 
ganic disease.  In  nearly  every  case  there  is  marked  tenderness  of  the 
spine  upon  pressure,  especially  in  the  dorsal  region.  The  deformity 
may  be  very  slight  from  spasm  of  the  flexors  only,  or  it  may  l)e  severe, 
and  followed  by  contracture,  so  that  the  thighs  may  be  flexed  tightly 
against  the  abdomen  with  the  heels  against  the  buttocks.  Such  de- 
formities may  last  for  months.  There  may  be  considerable  muscular 
atrophy,  but  only  that  which  comes  from  disuse.  A  special  difficulty  in 
diagnosis  arises  from  the  circumstance  that  these  symptoms  occasionally 
follow  an  injury. 

Organic  disease  of  bones  and  joints  may  usually  be  excluded  by 
attention  to  the  following  points:  The  mode  of  onset  is  more  abrupt 
than  is  seen  in  bone  disease,  and  the  course  of  the  disease  is  quite  ir- 
regular. The  degree  of  deformity  is  greater  than  is  seen  in  bone  dis- 
ease of  the  same  duration.  There  is  general  hyperesthesia  of  the  limb, 
acute  tenderness  of  the  spine  upon  pressure,  and  undue  sensitiveness  to 
heat  or  cold.  The  deformity  varies  from  time  to  time,  being  always  more 
marked  when  examination  is  attempted.  If  the  patients  are  closely 
watched,  other  evidences  of  hysteria  may  be  seen.  Under  complete  anes-. 
thesia  the  contractures  disappear  entirely.  There  is  no  enlargement 
of  the  articular  ends  of  the  bones,  no  swelling  of  the  soft  parts,  and  no 
evidence  of  active  inflammation  or  of  suppuration.     All  the  symptoms 


HYSTERIA  707 

except  the  deformity  are  subjective.  Under  proper  treatment  there  is 
in  most  cases  perfect  recovery,  often  in  a  surprisingly  short  time. 

Digestive  symptoms  are  quite  frequent.  There  may  be  loss  of 
appetite,  at  times  so  extreme  as  to  lead  to  great  emaciation.  There  may 
be  dysphagia  from  spasm  of  the  esophagus,  or  regurgitation  of  food  on 
attempts  at  swallowing.  There  may  be  troublesome  hiccough.  Vomiting 
is  a  frequent  symptom.  It  is  seldom  severe.  A  very  frequent  form  met 
with  is  that  which  occurs  in  school  children  before  starting  for  school. 
Throughout  the  rest  of  the  day  nothing  is  vomited  and  the  appetite  may 
])e  good.  Persistent  diarrhea,  constipation,  meteorism,  and  incontinence 
of  feces  may  be  met  with. 

In  the  milder  forms  of  hysteria  there  are  seen  many  varieties  of  tonic 
or  clonic  spasm.  There  may  be  local  spasm  of  the  eyes,  face,  or  mouth, 
spasm  of  the  muscles  of  the  neck  producing  torticollis,  of  the  muscles 
of  respiration  causing  dyspnea,  which  may  be  constant  or  paroxysmal. 
Disturbances  of  speech  are  quite  common  especially  in  older  children. 
There  may  be  inability  to  speak  above  a  whisper  while  the  voice  is 
retained  in  singing  or  after  the  application  of  the  faradic  current  to 
the  neck.  Stuttering  and  stammering  may  be  due  to  hysteria.  Very 
rarely  no  attempt  at  phonation  can  be  made.  A  very  common  symptom 
is  hysterical  cough,  which  may  be  so  frequent  and  so  severe  that  grave 
disease  of  the  lungs  is  suspected;  the  chest,  however,  is  free  from  the 
physical  signs  of  disease.  In  more  severe  cases  we  may  have  the  symp- 
toms of  chorea  major  and  attacks  of  hystero-epilepsy.  The  latter  are 
rare  in  children  and  do  not  differ  essentially  from  such  attacks  in  older 
patients.  There  are  usually  prodromal  symptoms.  The  convulsive  move- 
ments are  exceedingly  varied  in  type.  There  are  painful  sensations  and 
sensitive  areas,  by  pressure  upon  which  hysterical  symptoms  may  be 
increased  or  even  convulsions  excited.  The  respiration  may  be  rapid 
or  irregular.  All  variations  in  tonic  and  clonic  spasms  may  be 
seen.  Opisthotonus  is  frequent.  Consciousness  is  not  fully  lost,  but 
is  disturbed,  and  hallucinations  are  present.  The  temperature  is  nor- 
mal. 

Other  symptoms  occasionally  seen  in  hysteria  are  polyuria,  very  fre- 
quent urination,  sometimes  incontinence  of  urine,  and  disturbance  of 
the  secretion  of  saliva  or  perspiration. 

The  general  condition  of  hysterical  patients  is  usually  below  the  nor- 
mal. They  are  poorly  nourished  and  anemic;  they  sleep  badly;  they 
have  capricious  appetites  and  feeble  digestion. 

Diagnosis. — Hysteria  is  apt  to  be  overlooked  because  its  occurrence 
in  children  is  not  considered  as  often  as  it  should  be.  In  most  cases  the 
diagnosis  is  easy  if  hysteria  is  suspected.  A  combination  of  vague  dis- 
connected symptoms  is  usually  present  which  admits  of  no  other  ex- 


708  DISEASES  OF  THE  NERVOUS  SYSTEM 

planation.  Organic  disease  can  be  excluded  only  by  careful  and  repeated 
examinations.  It  is  to  be  borne  in  mind,  however,  that  hysteria  not 
infrequently  complicates  organic  or  constitutional  disease.  Much  im- 
portance is  to  be  attached  to  a  family  history  of  hysteria  or  of  other 
neuroses. 

Prognosia. — This  is  better  than  in  adults,  especially  if  the  cases  are 
taken  in  hand  early,  before  the  disease  has  become  deeply  seated.  Very 
much  depends  upon  how  well  the  directions  for  treatment  can  be  carried 
out.  The  prognosis  is  less  favorable  when  the  hereditary  tendency  is 
strongly  marked.    In  many  cases  there  are  relapses  later  in  life. 

Treatment. — Prophylaxis  is  of  much  importance.  When  an  hereditary 
tendency  to  nervous  diseases  exists  in  a  family,  or  whenever  very 
nervous  children  are  placed  under  the  physician's  care,  every  means 
should  be  taken  to  further  muscular  development,  keeping  the  nervous 
system  in  the  background.  Such  children  should  lead  an  outdoor  life 
as  much  as  possible,  preferably  in  the  country.  They  should  keep  early 
hours,  have  regular  exercise,  and  their  education  should  be  directed  with . 
moderation  and  judgment,  special  attention  being  paid  to  regularity  of 
work  and  the  prevention  of  overpressure  in  schools.  Theaters  and  ex- 
citing books  should  be  avoided.  All  stimulants,  including  tea  and 
coffee,  should  be  absolutely  forbidden.  The  diet  should  be  plain  and 
nutritious.  It  is  highly  important  that  such  children  should  be  re- 
moved from  association  Avith  an  hysterical  mother,  when  this  is  possible. 
The  best  results  are  usually  obtained  when  the  child  is  taken  from  his 
home  surroundings  and  placed  in  some  quiet  retreat  in  charge  of  an 
intelligent  nurse.    Isolation  is  absolutely  essential  in  many  cases. 

In  the  general  management  of  a  case  of  hysteria,  it  is  of  the  first 
importance  that  the  child  should  be  cared  for  by  a  person  of  firmness, 
who  can  exercise  proper  control.  The  general  health  should  be  carefully 
looked  after,  and  arsenic,  iron,  cod-liver  oil,  and  other  tonics  given  ac- 
cording to  indications.  Outdoor  sports  should  be  encouraged,  and  every 
means  taken  to  interest  the  child  in  something  which  requires  physical 
exercise.  In  cases  of  simulated  disease,  the  child  should  be  put  to  bed, 
no  books  or  toys  allowed,  and  no  effort  made  toward  his  amusement.  No 
sympathy  should  be  exhibited,  but  the  child  should  be  treated  with  kind- 
ness and  firmness.  This  moral  treatment  is  quite  as  important  as  any 
other  part  of  the  therapeutics.  In  cases  with  hysterical  joint  symptoms 
mild  counterirritation  to  the  spine,  preferably  by  the  Paquelin  cautery, 
is  sometimes  of  distinct  benefit.  In  no  circumstances  should  mechanical 
force  be  used  to  overcome  deformity.  Many  eases  of  hysteria  improve 
under  hydrotherapy;  the  cold  douche,  the  cold  pack,  or  the  shower  balli 
may  be  used.  This  is  valuable  in  conjunction  with  massage  and  the 
rest  treatment. 


HEADACHES  709 


HEADACHES 


Headaches  are  not  common  in  little  children  except  in  connection 
with  disease  of  the  brain  or  meninges ;  in  older  children  they  occur  from 
causes  similar  to  those  seen  in  adult  life.  The  most  frequent  headaches 
may  be  grouped  in  the  following  classes : 

1.  Toxic  Headaches. — Such  are  the  headaches  resulting  from  uremia, 
from  malaria,  and  those  seen  in  many  acute  infectious  diseases.  But 
the  largest  number  are  associated  with  disturbances  of  digestion. 

2.  Headaches  from  Anemia,  Malnutrition,  and  Nervous  Exhaustion. — 
These  are  most  frequently  seen  in  girls  from  ten  to  fourteen  years  old. 
Some  are  intellectually  bright^  and  have  been  crowded  in  their  school 
work;  others  are  dull  and  learn  only  with  difficulty^  and  in  consequence 
worry  over  their  work  until  their  health  becomes  undermined.  They 
sleep  badly,  lose  appetite,  and  often  become  choreic.  The  anemia  may 
be  either  the  cause  or  the  result  of  these  symptoms. 

3.  Headaches  of  Nervous  Origin. — These  may  occur  in  children  who 
are  highly  neurotic,  either  from  their  inheritance  or  surroundings,  and 
in  those  who  are  the  subjects  of  epilepsy  or  hysteria,  and  they  may  be 
symptomatic  of  organic  disease  of  the  brain,  such  as  tumor  or  tuber- 
culous or  syphilitic  meningitis.  True  facial  neuralgia  is  rare  in  child- 
hood except  from  carious  teeth ;  from  this  cause,  however,  it  is  not  in- 
frequent. 

4.  Headaches  due  to  Disease  of  some  of  the  Organs  of  Special  Sense. 
— In  connection  with  the  eyes  there  may  be  conjunctivitis,  keratitis, 
iritis,  errors  of  refraction,  or  strabismus;  connected  with  the  nose  there 
may  be  polypi,  hypertrophic  rhinitis,  or  adenoid  vegetations  of  the 
pharynx;  connected  with  the  ears  there  may  be  otitis  or  foreign 
bodies  in  the  canal.  Each  one  of  these  conditions  requires  special  treat- 
ment. 

5.  Headaches  due  to  Inherited  Gout  or  Rheumatism. — These  are  not 
very  frequent,  but  they  may  be  severe,  and  may  at  times  simulate  the 
onset  of  meningitis.  They  are  often  accompanied  by  pains  in  the  joints, 
muscles,  or  nerve  trunks. 

6.  Disturbances  of  the  genital  tract  are  rarely  a  cause  of  headaches  in 
children,  although  this  may  be  the  case  in  girls  about  the  time  of  pu- 
berty, especially  when  menstruation  is  delayed  or  difficult. 

Diagnosis. — The  diagnosis  of  headaches  includes  the  discovery  of  the 
cause,  and  this  is  often  difficult.  In  an  infant  or  a  young  child,  organic 
disease  of  the  nervous  system  should  always  be  suspected  as  a  cause  of 
severe  headaches.  In  older  children  the  important  things  to  be  con- 
sidered, because  the  most  frequent,  are  digestive  disturbances,  nervous 


710  DISEASES  OF  THE  NERVOUS  SYSTEM 

exhaustion,  malnutrition,  and  visual  disorders.  An  absolute  diagnosis 
in  a  case  of  persistent  headache  can  be  made  only  by  a  careful  physical 
examination,  not  omitting  a  study  of  the  urine;  often  there  must  be  a 
close  observation  of  the  patient  for  some  time. 

Treatment. — The  only  successful  treatment  is  that  which  is  directed 
toward  a  removal  of  the  cause.  Each  one  of  the  different  groups  above 
mentioned  is  to  be  managed  differenth^,  according  to  the  principles  else- 
where laid  down  regarding  the  treatment  of  these  conditions.  For  the 
relief  of  the  symptoms,  cold  to  the  head,  a  hot  foot-bath,  and  phenacetin 
in  moderate  doses  are  perhaps  the  most  certain  of  all  remedies. 


DISORDERS  OF  SPEECH 

In  this  chapter  will  be  discussed  only  functional  speech  defects,  those 
depending  upon  organic  conditions  being  considered  in  connection  with 
diseases  of  the  brain.  The  most  common  varieties  are  stuttering,  stam- 
mering, lisping,  alalia,  backwardness,  and  functional  aphasia.  All  forms 
are  much  more  frequent  in  boys  than  in  girls,  the  proportion  being  more 
than  four  to  one. 

Stuttering. — This  is  the  most  common  form  of  speech  disturbance. 
Articulation  is  distinct  and  the  separate  sounds  are  properly  produced, 
but  there  is  a  difficulty  in  connecting  the  consonant  with  the  succeeding 
vowel ;  this  seems  like  an  obstacle  to  be  overcome.  Occasional  stuttering 
is  seen  in  very  many  children.  It  is  more  frequent  in  the  third  and 
fourth  years,  before  speech  is  thoroughly  mastered.  At  this  age  it  is 
aggravated  or  produced  by  disturbances  of  nutrition,  but  is  usually 
a  temporary  condition,  lasting  for  a  few  weeks  or  months.  Eecently 
a  little  boy  of  four  was  under  our  care,  who  became  very  anemic,  slept 
poorly,  and  suffered  from  malnutrition  as  a  result  of  the  confinement 
incident  to  a  home  in  the  city.  He  soon  began  to  stutter,  and  in  a  short 
time  it  became  painfully  marked.  After  a  few  weeks  in  the  country  he 
improved  very  much  in  his  general  condition,  gained  four  or  five  pounds 
in  weight,  and  his  stuttering  completely  disappeared.  In  other  cases 
stuttering  follows  some  acute  illness,  and  under  such  conditions  also  it 
is  usually  of  short  duration. 

Most  children  who  become  habitual  stutterers  do  not  begin  until  they 
are  six  or  seven  years  old,  and  sometimes  even  later.  Stuttering  may 
arise  from  imitation,  and  inheritance  is  an  important  etiological  factor. 
It  is  frequently  a  mark  of  degeneration. 

It  is  important  that  all  such  cases  receive  early  treatment  before 
the  habit  becomes  firmly  fixed.  The  prognosis  is  good  for  spontaneous 
recovery  in  nearly  all  the  cases  seen  in  very  ymiug  cbildren.  and  also  in 


DISORDERS  OF  SPEECH  711 

those  coming  on  after  acute  illness.  Other  cases  in  which  the  condition 
has  become  habitual  should  have  the  benefit  of  systematic  training  under 
si  competent  teacher  in  breathing  and  vocal  gymnastics. 

Stammering. — This  term  is  sometimes  used  synonymously  with  stut- 
tering. Kussmaul  makes  the  distinction  between  them  that,  in  stam- 
mering, individual  sounds  are  difficult  of  production,  while  in  stuttering 
it  is  syllabic  combinations.  Stammering  is  often  accompanied  by  some 
defect  in  the  organs  of  articulation — the  teeth,  lips,  tongue,  or  palate — 
which  is  not  present  in  stuttering. 

The  treatment  consists  in  careful  training  and  in  the  correction  of 
whatever  abnormal  local  conditions  may  exist. 

Lisping. — In  this  there  is  an  imperfect  production  of  certain  sounds, 
owing  usually  to  a  faulty  position  of  the  organs  of  articulation.  The 
sounds  may  be  so  indistinct  that  they  can  not  be  understood.  In  this 
condition  also  there  may  be  defective  formation  of  some  of  the  organs 
of  articulation,  although  in  the  milder  forms  this  is  not  the  case.  The 
treatment  is  similar  to  that  of  stammering. 

Alalia. — This  consists  in  a  total  inability  to  articulate.  It  is  seen  in 
all  young  infants  during  their  earliest  attempts  at  talking.  In  older 
children  it  is  not  a  very  rare  condition,  being  usually  associated  with 
some  mental  defect. 

Backwardness.— Backwardness  is  carefully  to  be  distinguished  from 
a  late  development  of  speech  due  to  mental  defects.  At  two  years  old 
children  not  deaf  are  almost  invariably  able  to  speak.  Speech  may  be 
late  in  consequence  of  prolonged  or  very  severe  illness,  and  when  it  has 
once  been  acquired  it  may  be  lost  from  similar  causes. 

Functional  Aphasia. — The  term  has  been  applied  to  a  temporary  loss 
(^f  speech  which  sometimes  occurs  in  chorea,  and  sometimes  from  severe 
fright  or  anything  else  which  has  produced  a  marked  nervous  impression. 
West  records  an  instance  in  a  girl  of  eight  years,  who  was  suffering  from 
an  attack  of  chorea  induced  by  fright.  Speech  first  became  difficult  and 
then  was  lost  altogether.  For  a  month  the  child  could  say  only  "yes" 
and  "no."  The  child  improved  very  slowly,  but  at  the  end  of  nine  weeks 
had  recovered  completely.  Loss  of  speech  sometimes  follows  the  acute 
infectious  diseases,  especially  typhoid  fever. 

In  all  disorders  of  speech,  the  functional  cases  are  to  be  distinguished 
from  those  which  depend  upon  deafness  and  mental  deficiency.  The 
frequency  with  which  these  disorders  are  due  to  disturbances  of  general 
nutrition,  and  to  local  causes  in  the  mouth  and  throat,  should  be  borne 
in  mind,  and  these  conditions  should  receive  their  appropriate  treatment 
early,  before  the  habit  of  defective  speech  becomes  firmly  established. 
For  the  latter  class  of  unfortunates,  special  training  at  the  hands  of  a 
competent  teacher  should  be  advised,  preferably  in  an  institution. 


712  DISEASES  OF  THE  NERVOUS  SYSTEM 


DISORDERS   OF   SLEEP 

Disturbed  Sleep,  Sleeplessness.— Disturbed  or  restless  sleep  is  much 
more  common  in  infancy  and  childhood  than  is  true  insomnia,  although 
the  causes  of  the  two  conditions  may  be  the  same. 

Etiology. — In  infancy  these  symptoms  are  most  frequently  due  to 
hunger  or  to  indigestion  resulting  from  overfeeding  or  improper  feeding. 
Very  often  disturbed  sleep  is  the  result  of  bad  habits,  such  as  rocking 
during  sleep  or  night-feeding.  Sometimes  it  arises  from  the  pain  of  colic 
or  otitis,  rarely  from  dentition;  at  other  times  it  may  be  simply  the 
expression  of  a  condition  of  extreme  nervous  irritability,  the  result  of 
inheritance  or  of  the  child's  surroundings.  It  is  often  caused  by  the 
persistent  activities  of  a  fussy  nurse  or  mother. 

In  later  childhood  the  first  thing  to  be  suspected  when  sleep  is  much 
disturbed  is  some  derangement  of  the  digestive  organs;  in  this  will  be 
found  the  explanation  of  fully  half  the  cases.  The  most  frequent  type, 
when  the  symptom  is  of  long  duration,  is  chronic  intestinal  indigestion, 
often  associated  with  distention,  a  condition  in  which  formerly  the 
usual  diagnosis  was  intestinal  worms.  Other  cases  are  due  to  obstructed 
respiration  from  adenoid  growths  of  the  pharynx  or  enlarged  tonsils, 
sometimes  to  nocturnal  attacks  of  asthma.  A  lack  of  fresh  air  in  the 
sleeping  room,  excessive  or  insuflficient  bedclothing,  and  cold  feet,  are 
other  frequent  causes.  Disturbed  sleep  with  "starting  pains"  is  one  of 
the  earliest  symptoms  of  hip-joint  disease.  In  the  nervous  exhaustion 
resulting  from  overpressure  in  schools,  and  in  malnutrition  and  anemia, 
disturbances  of  sleep  are  well-nigh  constant.  They  are  also  seen  in 
organic  cardiac  disease  and  in  all  pulmonary  conditions  accompanied  by 
dyspnea  or  cough.  Sleep  may  be  disturbed  in  consequence  of  bad  dreams 
which  have  their  origin  in  exciting  stories  heard  or  read  just  before 
bedtime,  or  in  too  violent  or  exciting  play.  To  discover  the  cause  in 
almost  any  case  it  is  necessary  to  investigate  carefully  the  whole  routine 
of  the  child's  life. 

Symptoms. — The  condition  may  be  one  of  real  insomnia  which  may 
last  for  weeks  or  months ;  or  the  sleep  may  be  simply  disturbed  and  rest- 
less, .the  child  waking  many  times  during  the  night,  and  when  asleep 
will  not  lie  quietly,  but  constantly  changes  his  position.  Sometimes 
children  wake  suddenly  with  a  scream,  but  immediately  drop  off  to  sleep 
again. 

Treatment. — The  essential  treatment  consists  in  the  discovery  and 
removal  of  the  cause  of  the  disturbance.  This  will  often  involve  a  radical 
change  in  the  manner  of  feeding,  in  the  hygiene  of  the  nursery,  and  in 
all  the  surroundings  of  tiie  child.     A  change  of  niirses  sometimes  results 


DISORDERS  OF  SLEEP  713 

in  a  speedy  cure.  In  no  circumstances  should  the  physician  counte- 
nance the  use  of  drugs  to  promote  sleep  in  children,  except  in  the  case 
of  severe  acute  disease.  Soothing  syrups  and  all  nostrums  for  "teeth- 
ing" should  be  absolutely  forbidden ;  also  the  sucking  of  "pacifiers." 
Many  mothers  and  nurses  fall  into  the  habit  of  using  them,  because  the 
injurious  effects  are  not  appreciated.  When  the  cause  of  sleeplessness  is 
found  and  removed  the  child  will  sleep,  but  compulsory  sleep  obtained 
under  other  conditions  is  usually  productive  of  more  harm  than  good. 
If  food,  diet,  and  all  bad  habits  have  been  corrected,  nervous  causes 
should  be  investigated.  When  no  cause  can  be  discovered  the  treatment 
should  consist  in  putting  the  child  upon  the  simplest  possible  diet,  and 
in  attention  to  such  general  conditions  as  anemia,  malnutrition,  and 
neurasthenia,  some  of  which  are  almost  certain  to  be  present.  In  many 
cases  a  warm  bath  at  bedtime  will  be  found  beneficial.  A  quiet,  darkened 
room,  plenty  of  fresh  air,  and  the  stopping  of  both  eating  and  drinking 
during  the  night,  are  essential  to  a  cure  in  most  cases.  When  the  con- 
dition accompanies  some  acute  disease,  the  drugs  which  are  most  useful 
are  codein  and  trional.  A  child  of  two  years  may  take  gr.  sV  of  codein 
or  two  grains  of  trional  as  an  initiaLdose,  to  be  increased  if  necessary. 

Night  Terrors — Pavor  Noctumus. — Two  classes  of  cases  have  been 
grouped  under  this  head,  both  having  this  in  common,  that  sleep  is  dis- 
turbed by  fright. 

The  condition  in  the  first  group  partakes  of  the  nature  of  nightmare. 
It  may  be  due  to  partial  asphyxia  from  adenoid  growths  of  the  pharynx, 
or  to  other  causes  mentioned  under  disturbed  sleep,  or  it  may  be  gastric 
or  intestinal  in  its  origin.  These  cases  are  quite  frequent.  Sleep  may 
be  disturbed  from  the  outset,  and  the  attack  may  be  merely  the  culmina- 
tion of  such  disturbance.  The  child  wakes  in  a  state  of  fright  and  ex- 
citement, and  often  says  he  has  had  a  bad  dream.  His  mind  is  clear,  he 
recognizes  those  about  him,  but  it  may  be  a  long  time  before  he  is  suffi- 
ciently calm  to  sleep  again.  The  attack  may  be  remembered  perfectly 
the  next  day.  Cases  like  this  are  to  be  managed  in  the  same  general  way 
as  those  of  disturbed  sleep  above  mentioned. 

In  the  second  group  are  the  only  cases  to  which  the  term  "night  ter- 
rors" should  really  be  applied.  These  are  relatively  rare,  but  the  condi- 
tion is  a  much  more  serious  one.  The  symptom  is  generally  due  to  some 
disturbance  of  the  central  nervous  system.  It  occurs  especially  in  those 
of  neurotic  antecedents,  or  those  who  have  previously  suffered  from 
infantile  convulsions,  and  it  is  often  the  precursor  of  other  nervous  at- 
tacks— migraine,  hysteria,  epilepsy,  and  even  insanity.  The  attack  usu- 
ally comes  suddenly  where  a  child  has  previously  been  sleeping  quietly, 
and  more  frequently  in  the  early  part  of  the  night  than  later.  He  is 
generally  found  sitting  upright  in  his  bed  in  a  bewilderment  of  terror. 


714  DISEASES  OF  THE  NERVOUS  SYSTEM 

being  "afraid  of  the  dog,"  or  "the  bear,"  or  there  is  some  other  vision 
or  hallucination  which  has  produced  the  fright.  Often  this  is  associated 
with  something  of  a  red  color.  The  child  does  not  recognize  those 
about  him,  does  not  know  where  he  is,  and  may  go  to  sleep  again  with- 
out coming  to  full  consciousness.  The  next  day  there  is  no  recollection 
of  what  has  happened.  Usually  no  after-effects  are  seen,  but  sometimes 
a  large  amount  of  pale  urine  is  passed.  The  attacks  may  be  repeated 
at  intervals  of  a  few  months,  or  they  may  occur  every  few  nights;  but 
whatever  the  peculiar  nature  of  the  vision,  it  is  likely  to  be  repeated  in 
nearly  the  same  form.  Such  attacks  have  something  in  common  with 
epileptic  seizures,  and  the  diagnosis  between  them  may  at  times  be  dif- 
ficult. They  are  to  be  regarded  seriously,  not  only  on  account  of  what 
they  are  in  themselves,  but  on  account  of  what  may  follow. 

Treatment. — All  mental  and  nervous  strain  should  be  most  carefully 
avoided,  and  when  the  attacks  are  frequent  the  bromids  should  be  given 
at  bedtime.  Some  person  should  sleep  in  the  same  room  with  the  child, 
or  in  an  adjoining  one  with  the  door  open. 

Excessive  Sleep. — It  is  rare  that  either  infants  or  children  sleep  an 
unnatural  amount  of  the  time  unless  one  of  two  causes  is  present — or- 
ganic brain  disease,  most  frequently  tuberculous  meningitis,  or  the  use 
of  drugs.  The  latter  is  always  to  be  suspected  if  with  the  sleep  there  is 
associated  obstinate  constipation.  Opium  in  the  form  of  "soothing 
syrup"  or  paregoric  is  the  drug  which  has  nsually  been  given. 


INJURIOUS   HABITS  OF  INFANCY  AND  CHILDHOOD 

On  account  of  the  close  connection  of  such  habits  with  disturbances 
of  the  nervous  system,  they  may  be  properly  considered  with  the  func- 
tional nervous  diseases.  Although  some  of  these  habits  may  not  be  of 
serious  importance,  yet  as  a  group  they  usually  receive  too  little  atten- 
tion at  the  hands  of  the  physician.  The  list  is  very  long,  and  only  the 
most  important  ones  will  be  discussed. 

Sucking. — This  is  a  very  common  habit  in  infants,  and  during  the 
first  few  months  it  is  seen  to  some  degree  in  most  of  them.  If  they  are 
carefully  watched  the  habit  is  easily  stopped;  otherwise  it  may  continue 
indefinitely.  Young  infants  usually  suck  the  fingers  when  hungry,  and 
this  can  scarcely  be  considered  abnormal,  but  an  effort  should  always  be 
made  to  stop  it,  lest  the  habit  become  fixed.  Lindner  distinguishes  be- 
tween simple  sucking  and  sucking  with  combinations.  In  the  former, 
the  child  sucks  some  part  of  the  body,  such  as  the  thumb,  fingers,  toes, 
tongue,  lips,  back  of  the  hand  or  arm,  or  it  may  be  some  foreign  sub- 
stance, .siich  as  part  of  the  clothing,  the  blanket,  a  rubber  nipple,  or  the 


INJURIOUS  HABITS  OF  INFANCY  AND  CHILDHOOD  715 

"pacifier."  'J'liis  is  the  most  common  form  that  is  seen.  In  the  second 
variety  the  sucking  is  accompanied  by  the  rubbing  of  some  other  parts, 
which  seems  to  afford  a  pleasurable  excitement ;  this  may  be  the  ear,  the 
genital  organs,  or  any  other  portion  of  the  body.  Sometimes  sucking  is 
accompanied  by  some  practice  which  produces  actual  pain,  such  as  pulling 
of  the  hair  or  scratching  the  body.  Habits  of  sucking  often  persist 
throughout  infancy,  and  not  infrequently  throughout  childhood;  they 
have  often  been  known  to  continue  up  to  puberty.  The  longer  the  habit 
has  lasted  the  more  difficult  is  it  to  break. 

The  results  of  sucking  may  be  serious.  Deformities  of  the  thumb  or 
finger,  of  the  lips  and  teeth,  and  even  of  the  jaws,  are  sometimes  pro- 
duced. We  knew  a  woman  whose  thumbs  to  advanced  age  showed  a  de- 
formity resulting  from  the  habit  of  thumb-svicking  while  a  child.  In 
her  case  the  habit  was  not  broken  until  she  was  eight  or  nine  years  old. 
Probably  the  most  pernicious  result  of  sucking  is  its  tendency  to  develop 
the  habit  of  masturbation.  Habitual  sucking  of  one  hand  or  finger  may 
lead  to  spinal  curvature. 

Treatment. — In  the  management  of  these  cases  the  most  important 
thing  is  to  arrest  the  habit  early,  before  it  becomes  fixed.  Too  often  the 
habit  of  thumb-sucking,  or  of  sucking  a  rubber  nipple,  is  encouraged  by 
mothers,  nurses,  and  sometimes  even  by  physicians  because  of  the  tem- 
porary quiet  which  is  thereby  produced.  In  no  circumstances  should 
it  be  resorted  to  as  a  means  of  putting  children  to  sleep  or  otherwise 
quieting  the  nervous  system.  With  infants,  the  only  treatment  which 
is  at  all  successful  is  mechanical  restraint.  It  is  of  no  use  to  cover  the 
part  which  is  sucked  with  bitter  solutions.  The  hands  of  young  infants 
may  be  covered  with  mittens,  or  with  the  long  sleeves  of  a  night-gown 
which  is  pinned  to  the  bed,  so  that  it  is  impossible  for  the  child  to  get 
the  part  to  the  mouth ;  or,  still  better,  cuffs  or  splints  of  pasteboard  may 
be  applied  at  the  elbow,  so  as  to  prevent  flexion  of  the  arms.  In  the 
milder  cases  the  habit  is  often  discontinued  spontaneously;  but  when 
it  has  been  indulged  in  until  a  child  is  four  or  five  years  old,  it  is  broken 
only  with  the  gi'eatest  difficulty.  Punishments  are  of  little  avail,  but 
rewards  are  often  successful. 

Masturbation. — This  is  not  uncommon  even  in  infancy.  Many  cases 
have  been  observed  during  the  first  year,  and  some  as  early  as  the  sev- 
enth or  eighth  month.  It  is  seen  in  children  of  all  ages  and  in  both 
sexes;  but  in  infants  and  very  young  children  it  is,  in  our  experience, 
much  more  common  in  girls  than  in  boys. 

Etiology. — Local  causes  are  present  in  many  cases;  they  are  usually 
something  which  produces  undue  irritation.  The  most  frequent  are, 
long  or  adherent  prepuce,  phimosis,  balanitis,  vulvovaginitis,  eczema 
of    the    labia,    threadworms,    and    tight    clothing.      A    urine    which    is 


716  DISEASES  OF  THE  NERVOUS  SYSTEM 

irritating  because  of  excessive  acidity  or  the  presence  of  crystals  of  uric 
acid  may  be  a  cause.  Any  irritation  may  lead  the  child  to  rub  the  parts 
in  some  way,  and  a  pleasurable  sensation  being  excited,  this  action  is 
repeated  until  a  habit  is  formed.  Other  causes  are  exercises  in  which 
the  legs  are  rubbed  together,  or  the  body  against  a  pole,  as  in  climbing. 
To  these  causes  must  be  added,  in  infants  at  least,  the  habit  of  sucking. 
After  infancy  the  habit  of  masturbation  is  usually  acquired  from  other 
children,  but  sometimes  taught  by  vicious  nurses. 

General  causes  are  also  important  as  predisposing  factors.  These 
are  the  same  as  underlie  most  of  the  neuroses  of  childhood — viz.,  anemia, 
general  malnutrition,  and  a  highly  neurotic  constitution  or  nervous  in- 
stability, which  is  often  an  inheritance,  and  is  always  aggravated  by  sur- 
roundings which  tend  to  unnatural  stimulation  of  the  nervous  system. 
When  masturbation  develops  in  a  young  child  without  any  local  cause, 
it  may  be  an  early  sign  of  either  mental  deficiency  or  moral  delinquency ; 
it  looked  for,  other  stigmata  of  degeneration  will  often  be  found,  and 
in  many  cases  other  vicious  traits  will  appear  later. 

Symptoms. — In  infants  and  very  young  children  masturbation  is 
usually  accomplished  by  thigh  friction  or  by  rubbing  the  body  against  a 
pillow,  a  chair,  or  some  other  object.  The  variety  of  ways  is  almost  end- 
less. Frequently  the  child  will  simply  lie  upon  the  floor  with  the  thighs 
crossed  and  rigidly  held,  and  sway  the  body  backward  and  forward.  This 
lasts  for  a  few  moments,  is  accompanied  by  flushing  of  the  face  and 
some  appearance  of  excitement,  followed  by  relaxation,  and  often  by 
perspiration.  It  frequently  happens  with  little  children  that  these 
"queer  tricks,"  as  they  are  often  regarded,  have  been  continued  for 
months  before  their  true  nature  is  suspected. 

A  consciousness  that  they  are  doing  something  wrong,  early  leads 
even  young  children  to  seek  seclusion  when  they  repeat  the  habit.  It 
is  especially  likely  to  be  practiced  when  children  lie  long  awake  alone 
after  they  go  to  bed,  or  if  they  wake  early.  The  habit  is  always 
made  worse  by  any  deterioration  of  the  general  health.  We  have  known 
many  children,  who  were  thought  to  be  entirely  cured,  to  relapse  under 
such  conditions. 

It  is  somewhat  difiicult  to  separate  the  general  symptoms  with  which 
masturbation  is  associated,  and  upon  which  it  largely  depends,  from 
those  which  are  the  direct  result  of  the  habit.  There  are  some  children 
in  whom  the  condition  is  chiefly  or  entirely  dependent  upon  a  local  cause, 
or  when  it  is  only  occasionally  practiced,  in  whom  no  general  symptoms 
are  seen,  or  at  most  only  an  unnatural  shyness  and  a  disposition  to  seek 
seclusion.  Others  are  precocious  and  excitable,  with  an  excessive  amount 
of  nervous  sensibility.  Tliere  are  others  in  whom  more  marked  nervous 
symptoms  are  present;  the  most  striking  are  absent-mindedness,  loss  of 


INJURIOUS  HABITS  OF  INFANCY  AND  CHILDHOOD  717 

power  of  concentration,  loss  of  interest  in  all  amusements,  and  mental 
depression.  Some  girls  of  only  seven  or  eight  years  may  have  fairly 
regular  periods  in  which  masturbation  is  practiced.  In  one  of  our  pa- 
tients such  periods  for  a  considerable  time  occurred  monthly.  During 
them  even  very  little  girls  may  lose  all  sense  of  modesty  or  decency. 
Every  particle  of  self-control  is  gone.  They  become  passionate,  excitable, 
apparently  possessed  by  the  one  uncontrollable  desire  to  practice  the 
habit.  In  the  intervals  such  children  may  be  quiet,  modest,  sweet-tem- 
pered, and  perfectly  normal.  In  some  older  subjects  nymphomania,  or 
even  insanity,  may  be  the  ultimate  result.  Epilepsy,  chorea,  or  hysteria 
may  develop,  particularly  where  a  strong  predisposition  to  them  already 
exists  in  the  family.  The  effect  of  masturbation  upon  the  physical  and 
mental  development  of  the  child  may  be  serious  when  it  is  begun  at  an 
early  age  or  is  frequently  practiced.  But  more  striking  is  the  change 
sometimes  brought  about  in  a  child's  moral  nature.  Even  little  chil- 
dren of  eight  or  nine  years  may  become  centers  of  moral  infection, 
which  may  involve  a  group  of  playmates  or  even  a  whole  school. 

Local  symptoms  of  masturbation  are  not  always  present;  in  the  male 
there  may  be  redness  and  slight  swelling  of  the  prepuce ;  the  organs  may 
be  abnormally  large  or  simply  mucli  relaxed.  The  frequent  occurrence 
of  erections  in  young  boys  is  always  a  suspicious  symptom.  In  the 
female  there  is  sometimes  seen  an  abnormal  development  of  the  genital 
organs  for  the  age,  with  an  early  appearance  of  pubic  hair.  Little  im- 
portance is  to  be  attached  to  adhesions  of  the  clitoris.  Sometimes  there 
is  vaginitis. 

Prognosis. — Masturbation  in  children  is  at  all  times  a  most  difficult 
condition  to  deal  with.  The  outlook  is  better  in  infants  and  young  chil- 
dren than  in  those  who  are  older,  because  the  latter  are  more  difficult  to 
watch  and  control;  besides,  in  them  the  habit  has  usually  become  more 
firmly  fixed.  In  young  children  local  causes  are  frequently  found  to  be 
at  the  root  of  the  trouble;  in  those  who  are  older  general  causes  are 
more  often  present,  and  these  it  may  be  impossible  to  remove.  In  almost 
any  case  in  which  the  habit  has  become  firmly  developed,  many  months 
and  usually  several  years  are  necessary  for  complete  cure.  The  tendency 
to  relapse  is  very  strong.  When  masturbation  is  a  symptom  of  degener- 
acy it  is  usually  hopeless. 

Treatment. — The  most  important  thing  is  an  early  recognition  of 
the  condition.  The  physician  should  put  parents  and  nurses  on  their 
guard,  and  the  first  suspicions  should  be  reported  and  the  child  care- 
fully watched  until  all  doul)t  is  removed.  In  young  infants  mu^ch  may 
be  accomplished  by  mechanical  restraint.  The  kind  of  restraint  which 
is  iiecessary  will  depend  upon  the  manner  of  masturbating.  If  by  the 
hands,  they  should  be  tied  during  sleep,  so  that  the  child  can  not  reach 


718     •  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  genitals;  if  by  the  thigh-frietion,  the  thighs  should  be  separated  by- 
tying  one  to  either  side  of  the  crib.  In  inveterate  cases,  a  double  side- 
splint,  such  as  is  used  in  fracture  of  the  femur,  may  be  applied.  In 
children  that  are  over  three  years  old,  all  such  contrivances  are  almost 
invariably  imsuccessful.  It  is  of  the  utmost  importance  in  every  case  to 
have  the  child  under  the  close  surveillance  of  a  competent  and  trust- 
worthy person.  He  should  be  especially  watched  just  after  being  put 
to  bed  and  immediately  after  waking.  Corporal  punishment  is  often 
useful  in  very  young  children,  but  of  little  or  no  benefit  in  those  who  are 
over  three  years  old.  In  fact,  in  such  cases  it  may  do  positive  harm,  for 
deception  and  lying  are  soon  added  to  the  previous  vice.  The  mother 
should  secure  the  child's  confidence,  and  in  every  way  possible  seek  to 
strengthen  his  will  and  stimulate  his  self-control,  using  her  influence  to 
help  him  break  the  habit.  In  fact,  in  older  children  this  psychic  treat- 
ment is  much  more  important  than  all  other  measures.  Often  absence 
from  home  under  the  care  of  a  trustworthy  companion  is  essential  to  suc- 
cessful treatment.  Local  causes,  too,  must  be  sought  and  removed  when- 
ever found.  Circumcision  should  be  done  if  phimosis  exists;  and  even 
when  it  does  not,  the  moral  effect  of  the  operation  is  sometimes  of  very 
great  benefit.  In  girls  improvement  sometimes  follows  a  separation 
under  anesthesia  of  the  preputial  hood  from  the  clitoris.  But  unless 
this  is  frequently  repeated,  the  adhesions  soon  recur.  Complete  circum- 
cision is  sometimes  done  with  advantage,  and  in  very  obstinate  cases 
the  clitoris  may  be  cauterized.  Blistering  the  inside  of  the  thighs,  the 
vulva,  or  the  prepuce  is  sometimes  useful.  But  as  a  rule  none  of  these 
measures  accomplishes  anything  permanent.  Care  should  be  taken  that 
the  clothing  does  not  irritate  the  parts.  The  child  should  be  removed 
from  all  vicious  companions ;  but  it  is  quite  as  important  that  the  great- 
est vigilance  should  be  exercised  in  the  home  and  at  school,  so  that 
the  child  should  have  no  opportunity  to  teach  other  children  the  habit. 
In  the  most  serious  cases  the  child  should  be  sent  away  from  home  and 
kept  from  other  children.  The  cooperation  of  a  trustworthy  nurse  or 
companion  is  indispensable. 

General  treatment  should  be  directed  to  the  child's  condition;  it  is 
required  in  most  of  the  cases.  ■  A  child  suffering  from  malnutrition  and 
anemia  should  be  sent  to  the  country,  kept  out  of  doors  and  away  from 
books,  studies,  and  from  everything  which  stimulates  or  excites  the  nerv- 
ous system.  Almost  all  active  exercises  except  horseback  may  be  recom- 
mended. Every  means  should  be  employed  to  build  up  the  general 
health.  These  cases  are  most  difficult  and  most  discouraging  ones  for 
the  physician.  A  cure  results  only  by  using  all  these  measures  and  for 
a  long  time. 

Nail-biting  and  tongue-sucking  are  two  forms  of  habit  which  are  less 


MALFORMATIONS  7 1  n 

frequent  and  less  important  than  those  already  mentioned.  The  former 
is  best  remedied  by  wearing  gloves  and  by  keeping  the  nails  cut  very 
short.  Tongue-sucking  seldom  becomes  a  fixed  habit,  and  the  child  usu- 
ally ceases  it  of  his  own  accord  as  he  grows  older. 

Pica  or  perverted  appetite  is  an  inordinate  desire  to  eat  various  sub- 
stances, such  as  dirt,  sand,  mortar,  coal,  or  hair.  It  is  most  frequently 
seen  in  infants  but  may  occur  in  older  children.  This  habit  is  met  with 
in  those  who  are  mentally  defective,  but  not  rarely  in  other  children. 
These  patients  are  usually  highly  neurotic  and  exhibit  some  of  the  other 
habits  common  to  this  class.  In  some  children  gastric  derangements 
seem  to  play  the  part  of  an  exciting  cause.  Pica  is  a  common  symptom 
of  infection  with  hook-worm.  The  habit  may  continue  for  years  unless 
corrected.  The  general  health  often  becomes  seriously  undermined  as 
a  consequence  of  the  disturbed  digestion  resulting  from  the  presence 
of  abnormal  substances  in  the  stomach.  Children  in  whom  such  a  habit 
is  present  should  in  the  first  place  be  watched  and  prevented  from  in- 
dulging in  their  abnormal  craving.  Secondly,  the  digestion  and  general 
health  should  be  improved  according  to  indications  afforded  by  the 
individual  case. 

Head-banging  is  an  expression  of  extreme  nervous  irritability  most 
frequently  seen  in  infants  or  in  very  young  children.  It  is  not  indicative 
of  any  special  form  of  nervous  derangement,  but  is  caused  by  the  same 
morbid  impulse  which  leads  other  nervous  children  to  scratch  their  faces, 
pull  their  hair,  etc.  While  in  some  children  head-banging  occurs  only 
occasionally,  we  have  seen  patients  in  whom  it  existed  for  a  long  time. 
It  may  be  repeated  almost  every  night,  and  continue  at  intervals  for  two 
or  three  hours,  and  that  without  temper  or  excitement,  but  Avitli  such 
force  as  to  produce  contusions  of  the  scalp  and  necessitate  padding  the 
sides  of  the  crib.  It  is  rarely  a  symptom  of  organic  brain  disease. 
Eickets  is  often  associated  and  the  nutrition  of  most  of  the  patients  is 
much  below  the  normal.     The  treatment  is  general. 


CHAPTER    III 

DISEASES  OF  THE  BRAIN  AND  MENINGES 

MALFORMATIONS 

The  malformations  of  the  brain  are  of  great  variety,  and  many  of 
them  are  solely  of  anatomical  interest,  as  the  conditions  are  incompatible 
with  life.  Only  the  most  frequent  and  the  best-known  types  will  be  men- 
tioned, and  those  which  are  of  interest  from  a  clinical  point  of  view. 


720 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Meningocele,  Encephalocele,  and  Hydrencephalocele. — These  three 
conditions  have  in  common  a  protrusion  of  some  part  of  the  cranial  con- 
tents through  an  opening  in  the  skull.  In  Meningocele  (Figs.  87,  90) 
there  is  protrusion  of  the  membranes  alone.     These  form  a  sac,  which 


Fig.  87. — Meningocele.  Fig. 


-Encephalocele.        Fig.  89. — Hydrenceph- 
alocele. 


is  usually,  but  not  invariably,  distended  by  fluid.    In  encephalocele  (Fig. 

88)  there  is  a  protrusion  of  a  portion  of  the  brain  substance;  this  is 
connected  Math  the  rest  of  the  brain  by  a  constricted  neck  or  pedicle. 
The  tumor  may  or  may  not  contain  fluid.     In  hydrencephalocele  (Fig. 

89)  there  is  a  protrusion  of  a  portion  of  the  brain   substance  which 

contains  within  it  a  cavity  filled 
with  fluid,  this  cavity  communicat- 
ing with  the  distended  lateral  ven- 
tricles. 

In  all  these  conditions  there  is  a 
tumor,  usually  pedunculated,  of  a 
round    or    pyriform    shape,    with    a 


smooth  or  lobulated  surface.  The 
ordinary  size  is  that  of  a  mandarin 
orange ;  it  may  be  as  small  as  a  wal- 
nut, or  as  large  as  the  patient's 
head.  It  is  generally  covered  by  the 
scalp,  which  is  often  denuded  of 
hair;  but  it  may  be  covered  only  by 
granulation-tissue,  or  it  may  show  a 
central  cicatrix,  like  that  of  spina 
bifida.  Other  deformities,  such  as 
spina  bifida,  club-foot,  and  hare-lip  are  frequently  present. 

All  these  conditions  are  rare,  but  the  most  frequent  and  most  serious 
one  is  hydrencephalocele,  this  being  usually  associated  with  hydroceph- 
alus. The  next  in  frequency  is  encephalocele,  which  has  the  best  prog- 
nosis. This  is  frequently  termed  hernia  cerebri.  If  fluid  is  present,  it 
is  external  to  the  brain.     In  meningocele  there  is  simply  an  accumula- 


Fig.  90. 


-Meningocele.     Infant  one 
Month  old. 


MALFORMATIONS 


721 


Fig.     91. —  Frontal 

Meningocele. 

Infant  Three  Months 

Old, 


tion  of  fluid,  which  communicates  by  a  small  opening  with  the  general 
arachnoid  cavity  of  the  brain. 

Of  105  cases  collected  by  Schatz,  59  occupied  the  occipital  region 
and  46  were  frontal.  The  aperture  through  which  the  occipital  pro- 
trusion takes  place  is  usually  in  the  median  line.  It  may  communicate 
with  the  posterior  fontanel,  with  the  foramen  mag- 
num, or  with  the  cleft  of  a  spina  bifida.  The  occip- 
ital bone  may  be  divided  in  the  median  line,  or  rarely 
it  may  be  absent. 

In  the  nasofrontal  form  (Fig.  92)  the  tumor  is 
usually  at  the  root  of  the  nose,  a  little  to  one  side  of 
the  median  line.  The  aperture  is  most  frequently 
between  the  cribriform  plate  of  tlie  etlimoid  and  the 
frontal  bones.  It  may  be  between  the  lateral  halves 
of  the  frontal  bone,  causing  a  median  tumor.  The 
point  of  protrusion  may  also  be  the  lateral  region  of 
the  skull,  generally  about  the  lateral  fontanel,  or 
along  the  line  of  the  sutures ;  it  may  project  into  the 
mouth  or  the  pharynx.  These  anterior  tumors  are  usually  small,  al- 
though large  ones  containing  the  aliterior  lobes  of  the  brain  have  been 
seen. 

The  theory  of  the  origin  of  these  malformations  which  is  most  widely 
accepted  is  that  they  are  primarily  cases  of  intra-uterine  hydrocephalus, 
and  as  the  cranial  cavity  is  gradually  closed  by  the  development  of  the 
bones,  a  certain  portion  of  the  brain  is  left  outside. 

Symptoms. — The  tumor  is  always  congen- 
ital, although  after  birth  it  frequently  increases 
very  much  in  size.  A  typical  tumor  is  round 
and  elastic,  usually  giving  evidence  of  fluid ;  it 
usually  pulsates  synchronously  with  the  heart; 
during  screaming  or  forced  inspiration,  it  in- 
creases in  size;  partial  and  in  some  cases  com- 
plete reduction  is  possible,  but  this  is  usually 
followed  by  marked  cerebral  symptoms,  even  by 
convulsions.  After  partial  reduction,  an  open- 
ing in  the  skull  may  often  be  made  out.  Micro- 
cephalus  may  be  present,  or  there  may  be  unequal  development  of  the 
two  sides  of  the  head. 

The  following  differential  points  indicate  the  most  characteristic 
features  of  the  three  varieties:  In  meningocele,  the  tumor  is  at  first 
small,  but  increases ;  it  has  a  smooth  surface ;  it  is  pedunculated ;  there 
is  distinct  fluctuation,  perfect  translucency,  rarely  pulsation;  often  it 
is  completely  reducible;  compression  of  the  tumor  causes  cerebral  symp- 


FiG.  92. — Nasofrontal 
Meningocele.  Infant 
one  week  old. 


722  DISEASES  OF  THE  NERVOUS  SYSTEM 

toms;  the  skull  is  normal.  In  encephalocele,  the  tumor  is  small  and 
smooth ;  it  is  rarely  pedunculated ;  fluctuation  is  absent ;  it  is  not  trans- 
lucent; there  is  distinct  pulsation;  it  is  usually  reducible;  pressure 
causes  cerebral  symptoms;  the  skull  is  normal.  In  hydrencephalocele, 
there  is  a  large  pendulous  tumor  with  an  irregular  or  lobulated  sur- 
face; it  is  pedunculated;  translucency  is  rarely  complete;  fluctuation  is 
distinct ;  it  is  irreducible ;  pressure  rarely  causes  symptoms ;  microcepha- 
lus  and  other  deformities  are  often  associated. 

The  occipital  tumors  are  usually  more  serious  than  the  frontal  ones. 
The  majority  of  cases  die  in  the  course  of  the  first  few  weeks  of  life, 
death  resulting  from  meningitis,  convulsions,  or  rupture.  In  menin- 
gocele the  tumor  usually  grows  slowly,  and  ultimately  may  be  shut  off 
from  the  cranial  cavity ;  but  gradual  thinning  of  tlie  membrane  may  take 
place,  and  spontaneous  or  accidental  rupture  occur.  In  encephalocele 
the  tumor  grows  slightly,  or  not  at  all.  Most  of  these  patients  ex- 
hibit signs  of  mental  impairment  or  other  evidences  of  organic  brain 
disease. 

Treatment. — According  to  Treves,  operation  is  justifiable  only  in 
case  of  impending  rupture.  The  conditions  present  are  essentially  the 
same  as  in  spina  bifida.  Meningocele  may  be  aspirated  or  the  sac  may 
be  laid  open  and  a  plastic  operation  performed  for  the  closure  of  the 
communication  with  the  cranial  cavity ;  or  the  skin  may  be  divided,  and 
a  ligature  or  clamp  applied  to  shut  ofE  the  communication  with  the 
brain.  All  these  methods  have  been  at  times  successful,  but  recovery 
in  many  instances  is  followed  by  the  development  of  hydrocephalus. 
Encephalocele  is  to  be  treated  by  protection  and  compression.  Aspiration 
may  be  resorted  to  if  fluid  is  present.  In  hydrencephalocele  the  prog- 
nosis is  absolutely  bad  under  all  circumstances.  Schatz  gives  the  fol- 
lowing statistics,  showing  the  results  with  and  without  operation,  all 
varieties  being  included :  Of  twenty-four  occipital  tumors  not  operated 
on,  three  recovered;  of  thirty-flve  operated  on  by  excision,  ligation,  or 
injection,  six  recovered.  Of  forty-six  frontal  tumors,  there  were  six 
recoveries  in  thirty-two  cases  without  operation,  and  two  recoveries  in 
fourteen  cases  with  operation. 

Microcephalus,. — This  is  often  regarded  as  due  to  premature  ossifi- 
cation of  the  skull ;  but  the  hypothesis  is  certainly  inadequate  to  explain 
most,  if  any,  of  the  cases.  In  many  children  suffering  from  marasmus, 
the  sutures  ossify  and  the  fontanels  close  much  earlier  than  in  healthy 
infants  of  the  same  age,  chiefly  because,  with  the  rest  of  the  body,  the 
brain  also  has  almost  ceased  to  grow.  In  microcephalus  the  early  ossifica- 
tion of  the  skull  is  usually  due  to  arrested  growth  of  the  brain,  and  not 
the  reverse.  The  reasons  for  the  developmental  arrest  in  the  brain 
are  for  the  most  part  unknown. 


PACHYMENINGITIS  723 

It  is  well  known  that  there  is  not  an  invariable  relation  between  the 
size  of  the  head  and  the  size  of  the  brain^  although  generally  the  two 
correspond.  If  the  circumference  of  the  head  is  much  below  the  average 
for  the  age  (see  introductory  chapters),  and  relatively  much  less  than 
the  measurements  of  the  rest  of  the  body,  microcephalus  may  be  assumed 
to  exist.  Sachs  calls  attention  to  the  fact  that  the  circumference  of  the 
head  may  be  nearly  normal  and  yet  the  essential  conditions  of  micro- 
cephalus exist,  owing  to  imperfect  development  of  the  anterior  part  of 
the  brain. 

The  symptoms  of  microcephalus  are  those  of  mental  deficiency  and 
cerebral  paralysis,  existing  in  all  possible  combinations  and  with  variable 
degrees  of  severity. 

The  essential  condition  in  microcephalus  being  an  arrest  in  the  devel- 
opment of  the  brain,  it  is  not  difficult  to  understand  why  the  operation 
of  craniectomy  once  thought  promising  has  been  generally  abandoned. 
The  results  do  not  justify  any  operative  measures  yet  proposed  for  the 
relief  of  these  cases. 

Congenital  Hydrocephalus. — These  cases  may  fairly  be  considered  as 
belonging  in  this  group,  although  they  are  discussed  elsewhere. 

Porencephalus  (literally,  a  hole  in  the  brain)  is  a  condition  in  which 
there  is  a  large  depression  in  some  part  of  the  brain,  but  with  surround- 
ing parts  well  developed.  Such  depressions  may  involve  a  whole  lobe, 
and  they  may  be  deep  enough  to  reach  the  lateral  ventricles. ' 

Porencephalus  is  described  as  congenital  or  acquired.  In  the  con- 
genital form,  the  defect  is  usually  found  in  the  anterior  or  middle  part 
of  the  brain.  The  origin  of  these  conditions  is  still  a  disputed  question. 
They  are  probably  due  to  early  vascular  changes.  Children  sometimes 
live  several  years  with  very  large  defects,  the  symptoms  depending  upon 
the  seat  of  the  lesion.  The  acquired  form  of  porencephalus  is  usually 
one  of  the  late  results  of  meningeal  hemorrhage.  It  may  aifect  one  or 
both  sides.  Such  cases  present  the  symptoms  of  spastic  paralysis — 
usually  diplegia.  In  all  cases  with  large  brain  defects,  the  space  is  filled 
with  fluid. 

PACHYMENINGITIS 

Pachymeningitis,  or  inflammation  of  the  dura  mater,  occurs  both  as 
an  acute  and  a  chronic  disease. 

Acute  Pachymeningitis. — ^This  is  very  rare  in  children.  Only  pachy- 
meningitis externa  is  generally  included  under  this  term,  as  acute  pachy- 
meningitis interna  does  not  occur  alone,  but  usually  with  inflammatio]i 
of  the  pia  mater  (leptomeningitis).  It  may  be  associated  with  disease 
or  injury  of  the  bones  of  the  skull,  but  is  most  frequently  seen  in  con- 


724  DISEASES  OF  THE  NERVOUS  SYSTEM 

nectiou  with  middle-ear  disease.  It  generally  begins  as  a  localized  proc- 
ess, but  the  inflammation  may  extend  to  the  inner  layer  of  the  dura, 
and  to  the  pia  mater;  or  it  may  remain  circumscribed,  and  termi- 
nate in  the  formation  of  an  abscess  between  the  dura  mater  and  the 
bone. 

The  symptoms  of  acute  pachymeningitis  are  distinctive  only  when 
the  process  is  localized.  They  are  then  usually  associated  with  middle- 
ear  disease,  and  are  indistinguishable  from  those  of  cerebral  abscess. 
The  treatment  is  surgical. 

Chronic  Pachymeningitis. — This,  in  children,  almost  invariably  af- 
fects the  inner  layer  of  the  dura  mater  (pachymeningitis  interna.)  :  it  is 
also  known  as  pseudo-membranous  and  as  hemorrhagic  pachymeningitis 
or  hematoma  of  the  dura  mater.  Its  causes  are  for  the  most  part  un- 
known. It  is  a  rather  rare  condition,  being  usually  discovered  at 
autopsy  in  children,  chiefly  cachectic  infants,  who  have  died  of  other 
diseases. 

Two  classes  of  cases  are  to  l)e  distinguished — those  with,  and  those 
without  extensive  hemorrhages.  In  the  latter  group  there  is  found  a 
thin,  translucent,  vascular  membrane  lining  the  inner  surface  of  the 
dura.  It  may  be  only  a  delicate  film  which  can  be  scraped  ofE ;  it  may  be 
as  thick  as  ordinary  blotting-paper,  or  even  twice  that  thickness.  The 
membrane  is  often  edematous ;  it  is  exceedingly  vascular,  and  the  vessels 
have  very  thin  walls.  There  are  usually  scattered  punctate  hemor- 
rhages, and  there  may  be  a  few  of  larger  size.  This  membrane  may  cover 
the  whole  inner  surface  of  the  dura,  but  in  most  cases  it  is  principally 
over  the  convexity  and  may  be  found  only  here;  it  is  apt  to  be  more 
upon  one  side  than  upon  the  other.  In  cases  of  long  standing  there  may 
be  adhesions  between  the  dura  and  the  pia.  When  large  hemorrhages 
have  taken  place,  quite  a.  difEerent  pathological  appearance  is  presented. 
The  lesions  found  in  one  of  our  cases  are  fairly  typical :  The  infant  was 
six  months  old,  and  the  symptoms  had  existed  for  six  days.  The  fontanel 
was  bulging  to  a  marked  degree,  and  the  sagittal  and  coronal  sutures 
were  separated.  A  thin  recent  clot  from  one-eighth  to  one-fourth  of 
an  inch  in  thickness  covered  nearly  the  whole  of  the  right  hemisphere 
and  part  of  the  convexity  of  the  left.  The  entire  dura  was  lined  both 
at  its  convexity  and  base  by  a  pseudo-membrane  of  grayish  color,  about 
one-sixteenth  of  an  inch  in  thickness.     The  brain  was  anemic. 

In  cases  of  longer  standing  partial  organization  of  the  clot  may  be 
seen ;  in  more  recent  ones  the  blood  is  partly  or  entirely  fluid.  We  once 
saw  acute  leptomeningitis  with  a  purulent  exudation,  associated  with 
hemorrhagic  pachymeningitis.  In  cases  where  life  is  prolonged  for 
years,  there  may  be  partial  or  even  complete  absorption  of  the  clot,  fol- 
lowed 1)y  the  formation  of  cysts,  considerable  inflammatory  thickening 


PACHYMENINGITIS  725 

of  the  pia  with  deposits  of  blood  pigment,  and  finall}^  atrophy  and 
sclerosis  of  the  cortex.  The  source  of  the  hemorrhage  may  be  the  rup- 
ture of  a  single  large  vessel,  but  more  frequently  the  blood  comes  from 
many  small  vessels. 

Symptoms. — These  are  due  to  the  hemorrhage,  and  not  to  the  inflam- 
matory process.  Until  hemorrhage  occurs  there  are  no  symptoms  by 
which  the  disease  can  be  recognized.  Thus  in  many  of  the  cases  in  which 
pachymeningitis  is  found  at  autopsy,  its  existence  is  not  suspected  dur- 
ing life.  The  occurrence  of  hemorrhage  is  sometimes  marked  by  vomit- 
ing or  convulsions,  and  usually  there  is  loss  of  consciousness.  It  may 
be  a  question  whether  the  convulsions  are  the  cause  or  the  result  of 
the  hemorrhage.  In  most  cases  they  seem  to  be  the  result.  They  are 
usually  general  and  repeated.  If  the  hemorrhage  occurs  slowly,  there 
may  be  stupor  without  convulsions  until  nearly  the  end.  In  the  fatal 
cases  the  symptoms  generally  continue  from  two  days  to  a  week.  There 
are  dulness,  stupor,  and  finally  coma,  death  occurring  in  coma  or  con- 
vulsions. If  the"  hemorrhage  is  diffuse — and  this  is  apt  to  be  the 
case — there  is  rigidity  of  all  the  extremities;  if  it  is  of  one  side  only, 
the  rigidity  affects  only  one  arm  and  leg.  The  pupils  are  more  fre- 
quently contracted,  but  may  be  dilated  or  unequal.  There  is  diplegia, 
liemiplegia,  or  monoplegia,  according  to  the  seat  and  extent  of  the 
hemorrhage.  The  respiration  is  slow  and  irregular  and  may  be  of  the 
C'heyne-Stokes  variety.  The  pulse  is  slow,  irregular,  and  sometimes 
intermittent.  The  temperature  is  at  first  normal,  but  rises  slowly  until 
death  occurs,  when  it  is  from  100°  to  103°  F.  Generally  the  cranial 
nerves  are  not  affected,  and  opisthotonus  is  absent.  The  knee-jerk  is 
often  exaggerated.  In  cases  which  do  not  prove  fatal — these  being  chiefly 
in  older  children — we  have  a  similar  onset,  but  after  a  few  days  con- 
sciousness is  regained,  and  only  hemiplegia  or  monoplegia  remains. 
The  course  of  the  paralysis  is  that  seen  after  meningeal  hemorrhage 
due  to  other  causes.  Wagner  has  reported  a  case  in  which  recurring 
hemorrliages  took  place  at  intervals  of  several  months,  the  autopsy 
showing  distinct  evidences  of  both  old  and  recent  lesions. 

Pachymeningitis,  we  are  inclined  to  Ijelieve,  plays  a  more  important 
role  in  the  production  of  meningeal  hemorrhages  in  children  than  has 
generally  been  accorded  to  it.  From  the  frequency  with  which  this  lesion 
is  found  as  a  cause  of  sudden  meningeal  hemorrhages  which  are  fatal,  it 
is  not  unlikely  that  some  of  the  cases  which  recover  with  hemiplegia  or 
monoplegia,  may  be  due  to  the  same  cause. 

The  prognosis  depends  upon  the  age  of  the  patient  and  the  extent  of 
the  hemorrhage.  Extensive  hemorrhages  are  usually  fatal  in  infancy, 
but  small  ones  are  seldom  so,  for  they  are  rarely  at  the  base.  The  prog- 
nosis of  the  paralysis  in  cases  not  terminating  fatally  is  the  same  as 


726  DISEASES  OF  THE  NERVOUS  SYSTEM 

after  meningeal  hemorrhage  due  to  other  causes,  with  perhaps  an  added 
liability  to  recurrent  attacks. 

Without  large  hemorrhages,  pachymeningitis  interna  can  not  be 
diagnosticated;  and  it  is  impossible  to  differentiate  the  hemorrhagic 
cases  from  other  varieties  of  meningeal  hemorrhage.  It  is  important  to 
make  a  diagnosis  between  pachymeningitis  with  hemorrhage,  and  acute 
meningitis.  In  the  former  there  is  a  sudden  onset;  stupor  occur- 
ring early,  usually  on  the  first  day,  gradually  diminishing  in  cases  of 
recovery,  or  deepening  into  coma  in  fatal  cases;  localized  or  general 
paralysis,  also  occurring  early;  there  is  no  fever  in  the  beginning,  and 
only  moderate  fever  at  the  close.  In  acute  meningitis  there  is  usually 
a  higher  temperature,  especially  early  in  the  disease;  coma  develops 
later,  and  rigidity  of  the  extremities  is  less  pronounced.  However,  when 
the  hemorrhage  occurs  in  the  course  of  some  other  disease,  a  differential 
diagnosis  may  be  impossible  without  lumbar  puncture. 

Treatment. — The  treatment  of  hemorrhagic  pachymeningitis  is 
symptomatic.  The  indications  are,  to  relieve  cerebral  "congestion  by  ap- 
plying ice  to  the  head,  to  allay  irritative  symptoms  by  the  use  of  bromids, 
and  to  keep  the  patient  perfectly  quiet. 


ACUTE  MENINGITIS 

Several  different  varieties  of  acute  meningitis  are  met  with  in  chil- 
dren. Cerebrospinal  meningitis  is  the  only  form  which  occurs  epidem- 
ically; but  this  is  also  seen  as  a  sporadic  disease.  It  is  due  to  a  specific 
organism,  the  meningococcus.  There  are  several  other  forms  of  acute 
meningitis  which  more  or  less  closely  resemble  cerebrospinal  meningitis 
clinically,  and  which  were  for  a  long  time  confoimded  with  it.  Pneu- 
mococcus  and  influenza  meningitis  are  usually  secondary  inflammations, 
but  sometimes  are  apparently  primary.  The  typhoid  bacillus  and  the 
gonococcus  may  cause  acute  meningitis,  but  very  rarely  in  children. 
Acute  meningitis  may  be  due  to  any  of  the  pyogenic  organisms.  This 
is  sometimes  spoken  of  as  "septic"  meningitis,  and  is  almost  invariably 
secondary.  Tiually,  there  is  tuberculous  meningitis,  altogether  the  most 
common  variety  in  young  children  except  during  epidemics  of  cerebro- 
spinal meningitis. 

Some  idea  of  the  relative  frequency  of  the  different  forms  of  acute 
meningitis  as  seen  apart  from  epidemics,  may  be  gained  from  the  fol- 
lowing figures  which  give  the  number  of  cases  occurring  in  the  Babies' 
Hospital  for  a  series  of  years,  the  diagnosis  in  every  case  being  made  by 
lumbar  puncture  or  by  autopsy.  The  patients  were  nearly  all  luider 
three  years  of  age.     The  organism  found  was  as  follows : 


CEllEP.noSPTXAL  :\[EXTXriPlTS 

Tubercle    bacillus    157  cases 

Pneumococcus 23 

Meningococcus    (sporadic)    24  " 

Staphylococcus  or  streptococcus  11  " 

Influenza   bacillus    5  " 

Colon   bacillus 1  " 


'27 


CEREBROSPINAL    MENINGITIS 

(Epidemic   Mi'itlngitis ;   Cerebrospinal   Fever) 

Epidemics  of  cerebrospinal  meningitis  are  separated  by  quite  long 
intervals  and  occur  without  any  assignable  cause.  The  following  chart 
(Fig.  93)  represents  the  prevalence  of  the  disease  in  Ncav  York  City 
during  forty  years.  But  little  was  seen  of  cerebrospinal  meningitis  until 
the  epidemic  of  1872.  Since  that  time  a  certain  numl)er  of  deatlis  from 
this  cause  have  occurred  each  year;  but  there  have  been  seen  al)out  once 


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Fig.  93. — Chart  showing  Deaths  from  Cerebrospinal  Meningitis  in  New  York 
City,  for  Forty  Years,  per  100,000  of  Population. 


in  ten  years  epidemics  of  greater  or  less  severity.  Tlie  most  important 
one  was  that  of  1904-5.  After  each  epidemic,  for  two  or  three  years, 
the  disease  is  prevalent,  but  it  occurs  with  gradually  lessening  frequency 
until  the  average  incidence  is  reached.  What  has  heen  said  of  'New 
York  is  true  of  almost  every  large  city.  In  remote  country  towns, 
epidemics  are  occasionally  witnessed,  and  after  prevailing  a  few  months 
tlie  disease  disappears  as  mysteriously  as  it  came.  Epidemics  are  usually 
seen  in  the  winter  and  early  spring,  lasting  for  several  months,  gen- 
erally reaching  their  height  in  March  or  April  and  slowly  subsiding  as 
warm  weather  approaches. 

With  reference  to  the  cause  of  epidemics  very  little  is  known.  When 
the  disease  prevails  in  cities  it  occurs  especially  in  crowded  tenements, 
being  relatively  infrequent  in  private  houses. 


728  DISEASES  OF  THE  KERVOUS  SYSTEM 

Cerebrospinal  meningitis  has  only  recently  been  included  among 
the  communicable  diseases.  In  a  series  of  observations  made  by  the 
New  York  Health  Department  the  meningococcus  was  found  in  the 
nasal  secretion  of  fifty  per  cent  of  the  cases  of  meningitis  examined 
during'  the  first  two  weeks  of  the  disease.  It  was  found  in  the  nasal 
mucus  in  ten  per  cent  of  the  persons  in  close  contact  with  cases.  In 
Flexner's  experiments  upon  nionkevs  he  found  the  organism  in  the  nasal 
mucus  after  animals  had  been  inoculated  by  way  of  the  spinal  canal. 
These  observations  indicate  that  the  nasal  mucosa  is  a  common  avenue  of 
infection  and  probably  also  a  channel  of  elimination.  The  degree  of 
communicability  when  compared  with  the  common  contagious  diseases 
seems  very  slight.  In  fully  seventy  per  cent  of  the  cases  investigated 
in  the  iS^ew  York  epidemic  of  1904-5,  but  one  person  in  a  household  was 
affected,  although  no  effort  at  isolation  was  made.  We  have  never  known 
the  disease  to  originate  in  a  hospital  patient,  although  in  Xew  York 
cases  of  cerebrospinal  meningitis  have  been  until  recently  received  mto 
the  general  wards  with  other  patients.  Sporadic  cases  of  meningitis 
occur  after  epidemics,  and  quite  apart  from  them  without  apparent 
cause,  and  it  is  very  exceptional  that  any  connection  with  a  previous 
case  can  be  established.  About  fifty  per  cent  of  the  cases  of  cerebro- 
spinal meningitis  occur  in  children  under  five  years,  and  about  twelve 
per  cent  in  those  under  one  year.  The  youngest  case  we  have  seen  was 
in  an  infant  six  weeks  old. 

The  specific  organism  of  cerebrospinal  meningitis  is  the  diplococcus 
intracellularis  of  Weicliselbaum  or,  as  it  is  now  generally  designated, 
the  meningococcus.  It  is  present  in  the  meningeal  exudate,  in  the 
cerebrospinal  fluid  obtained  l)y  lumbar  puncture,  and  in  some  cases  can 
be  demonstrated  in  the  blood,  the  lungs  and  other  organs,  sometimes 
in  the  large  joints.  It  is  almost  invariably  found  in  pairs  or  tetrads 
within  the  leucocytes.  It  is  decolorized  when  stained  by  Gram's  method. 
Outside  the  body  the  organism  is  unknown. 

Lesions. — In  epidemic  meningitis  death  may  take  place  so  early  that 
the  changes  found  at  autopsy  are  slight.  There  may  be  only  a  serous 
exudation  and  intense  hyperemia,  which  is  doubtless  nmch  less  marked 
after  death  than  during  life.  The  cerebrospinal  fluid  is  turbid  and 
much  increased  in  amount.  The  microscope,  however,  may  show,  even 
in  these  early  cases,  an  abundant  exudation  of  leucocytes  in  the  pia 
mater.  After  the  third  day  the  lesions  are  quite  uniform.  The  con- 
volutions appear  somewhat  flattened  from  pressure  due  to  distention  of 
the  ventricles.  The  inner  surface  of  the  dura  is  usually  normal  or  only 
congested.  There  may  be  thrombi  in  any  of  the  cerebral  sinuses,  or  in 
the  meningeal  veins  of  the  convexity.  There  is  an  exudation  of  greenish- 
yellow  fibrin,  which  is  sometimes  very  abundant.     It  is  generally  widely 


CEREBROSPINAL  MENINGITIS  729 

distributed,  but  is  usually  most  marked  over  the  anterior  half  of  the 
brain  and  at  the  base.  In  some  cases  it  is  limited  to  the  base,  but  very 
rarely  limited  to  the  convexity.  There  is  an  increase  in  the  quantity  of 
cerebrospinal  fluid.  The  ventricles  are  moderately  distended  with  serum 
or  sero-pus,  and  their  walls  may  be  slightly  softened.  The  brain  sub- 
stance of  the  cortex  may  be  reddened  or  may  appear  normal.  In  the  men- 
inges of  the  cord,  lesions  similar  to  those  of  the  brain  are  usually  seen. 
The  exudation  is  principally  upon  the  posterior  surface,  and  may  extend 
throughout  the  entire  length  of  the  cord,  or  be  limited  to  its  upper  or 
to  its  lower  portion. 

Microscopical  examination  shows  the  exudation  to  consist  of  fibrin 
and  pus  cells,  which  infiltrate  the  pia  mater.  The  superficial  layers  of 
the  cortex  in  the  inflamed  areas  often  show  minute  hemorrhages  and 
very  marked  cell-infiltration.  ]\Iinute  abscesses  may  be  present.  Very 
marked  degenerative  changes  can  usually  be  demonstrated  in  the  nerve 
cells  themselves.  The  cells  of  the  neuroglia  are  also  affected;  they  are 
swollen  and  increased  in  number;  and  there  may  be  proliferation  of  the 
connective  tissue  about  the  blood  vessels.  Changes  similar  to  those  just 
described  may  be  found  in  the  cord,  but  these  are  less  frequent  and  as 
a  rule  much  less  severe  than  those  in  the  brain.  Inflammatory  products 
are  sometimes  present  in  the  central  canal  of  the  cord  and  in  the  walls 
of  the  lateral  ventricles  of  the  brain.  The  inflammatory  process  fre- 
quently extends  along  the  cranial  nerves,  especially  the  auditory  and 
optic,  and  this  may  result  in  otitis  or  choroiditis ;  from  the  cord,  it  may 
extend  along  either  the  anterior  or  posterior  nerve  roots.  Descending 
degeneration  is  found  in  the  nerves  both  of  the  brain  and  the  cord. 

In  patients  that  die  after  the  disease  has  lasted  two  or  three  months, 
the  later  results  of  these  lesions  may  be  seen.  There  is  usually  present  a 
chronic  meningo-encephalitis,  sometimes  diffuse,  sometimes  localized. 
The  pia  mater  is  cloudy,  thickened,  and  frequently  adherent  to  the 
brain.  Here  and  there  are  seen  small,  yellow,  opaque  patches  which  are 
the  result  of  fatty  changes  in  the  cells  and  fibrin  of  the  exudate,  with 
some  proliferation  of  connective  tissue.  The  lesions  are  usually  most 
marked  at  the  base,  where  the  thickening  of  the  meninges  and  the  ad- 
hesions may  lead  to  the  development  of  a  secondary  hydrocephalus. 

In  cases  which  have  lasted  a  much  longer  time  very  marked  changes 
are  found  in  the  brain  substance.  There  may  be  generalized  menin- 
geal adhesions,  with  a  diffuse  cortical  atrophy,  but  more  frequently  there 
are  areas  of  sclerosis,  especially  over  the  frontal  and  temporosphenoidal 
lobes,  with  which  there  are  almost  always  associated  marked  descending 
degenerative  changes  in  the  cord.  Such  lesions  are,  of  course,  perma- 
nent, and  seriously  interfere  not  only  with  the  functions,  but  also  witli 
the  growth  and  development  of  the  brain, 


730  DISEASES  OF  THE  BRAIN  AND  MENINGES 

The  lesions  and  their  effects  are  well  illustrated  by  one  of  our  patients 
who  died  six  months  after  an  attack.  She  was  a  bright  little  girl  of 
four  and  a  half  years,  and  had  a  typical  attack  of  meningitis  of  moderate 
severity.  Convalescence  was  slow,  but  at  the  end  of  two  months  recovery 
was  perfect  in  everything  but  her  mental  condition.  She  remembered 
nothing  which  she  had  previously  learned  in  the  kindergarten,  where  she 
had  been  an  exceptionally  bright  pupil.  Her  mind  was  a  blank.  She 
was  dull,  listless,  and  her  face  had  a  vacant,  idiotic  expression.  The 
special  senses  seemed  unaffected,  and  her  speech  was  retained.  She  died 
during  an  attack  of  convulsions.  At  the  autopsy  the  pia  was  everywhere 
thickened  and  adherent,  while  in  the  cortex  were  present  the  earlier 
changes  of  a  general  encephalitis. 

The  visceral  lesions  most  frequently  found  in  epidemic  meningitis 
are  pulmouar}^  There  may  be  loljar  or  bronchopneumonia,  and  in  the 
lungs  may  be  found  the  same  organism  as  in  the  brain.  Acute  degen- 
eration of  the  liver  and  kidneys  is  also  frequent.  The  other  viscera  are  sel- 
dom affected.   Occasionally  suppurative  inflammation  of  the  joints  occurs. 

Symptoms. — The  symptoms  of  cerebrospinal  meningitis  do  not  differ 
essentially  in  the  sporadic  and  epidemic  cases,  except  that  the  most 
severe  forms  of  the  disease  are  seen  in  the  latter.  They  may  be  divided 
into  several  quite  distinct  groups : 

1.  Hyper-acute  Form. — Cases  of  this  kind  are  rarely  seen  except  in 
an  epidemic,  and  usually  occur  at  its  height.  The  onset  is  very  abrupt, 
the  course  short  and  intense,  and  death  may  take  jDlace  in  from  twelve 
to  thirty-six  hours.  The  following  case  illustrates  this  type :  A  little 
girl  of  ten  years  was  well  enough  at  2  p.m.  to  carry  a  bundle  of  clothes 
a  dozen  city  blocks.  Eeturning  home,  she  complained  of  intense  head- 
ache, vomited  frequently,  and  was  so  weak  that  she  was  obliged  to  go  to 
bed.  In  a  few  hours  she  passed  into  deep  coma,  with  very  high  fever, 
and  died  at  11  p.m. 

The  earliest  symptoms  are  usually  intense  headache,  repeated  attacks 
of  vomiting,  and  very  high  fever.  There  is  great  prostration  and  the 
nervous  s^anptoms  increase  so  rapidly  that  in  a  few  hours  the  patient 
may  become  comatose  and  death  occur  in  a  short  period.  The  tempera- 
ture rises  rapidly  to  103°  or  10-1°,  sometimes  to  106°  F.  A  few  petechial 
spots  may  be  discovered  over  the  face,  chest,  or  extremities.  There  is 
usually  no  rigidity,  but  rather  general  relaxation.  The  pulse  is  weak, 
in  most  cases  rapid,  but  sometimes  slow  and  irregular.  The  respiration 
is  usually  irregular  both  in  frequency  and  depth. 

The  symptoms  appear  to  be  due  to  two  factors :  the  intensity  of  the 
infection,  and  the  rapid  accumulation  of  cerebrosi^inal  fluid,  causing 
coma  with  eventual  respiratory  paralysis.  T'sually  both  these  factors 
are  present,  but  the  second  one  seems  the  more  important.     In  support 


CEREBROSPIXAL  MENJNaiTIS 


7ol 


of  this  view  is  the  striking  infreqiiency  of  cases  of  this  type  iu  in- 
fants with  an  open  fontanel.  Should  the  patient  snrvive  the  violence 
of  the  onset,  a  period  of  reaction  occurs,  and  after  a  day  or  two  the  dis- 
ease follows  the  regular  course. 

2.  Usual  Form. — In  this  also  the  onset  is  generally  ahrupt,  but  not 
so  violent  as  in  the  cases  just  described.  It  may  be  marked  by  intense 
headache,  vomiting,  convulsions,  delirium,  chills,  and  fever  with  general 
hyperesthesia  and  rigidity.  The  initial  temperature  is  from  101°  to 
101°  F.  Opisthotonus,  with  severe  pains  in  the  back  of  the  neck  and 
along  the  spine,  and  general  muscular  rigidity  are  usually  present. 
There  is  often  active  delirium,  but  rarely  stupor  or  coma.     The  pulse 


Fia.  94. — Posture  in  Cerebrospinal  Meningitis.     (Smith.) 


is  generally  rapid,  120  to  150,  and  sometimes  irregular.  The  respira- 
tion is  often  slightly  irregular,  and  it  may  be  rapid  or  slow.  The  erup- 
tion is  not  so  frequently  seen  as  in  the  very  acute  cases. 

As  the  disease  progresses,  the  Jiervous  symptoms  often  change  but 
little  from  day  to  day  for  two  or  three  weeks.  They  are  mainly  of  the 
irritative  type — moderate  delirium,  extreme  hyperesthesia,  tremor  and 
muscular  rigidity.  The  posture  is  quite  characteristic  (Fig.  91).  Ow- 
ing to  the  opisthotonus  the  child  can  not  lie  upon  the  back,  but  rests 
upon  the  side,  with  arched  spine  and  neck,  and  general  flexion  of  the 
extremities.  There  is  a  rather  rapid  loss  in  weight,  steadily  increasing 
prostration,  and  a  weak,  rapid  pulse.  The  bowels  are  usually  constipated. 
From  time  to  time  attacks  of  vomiting  occur.  In  many  cases  there  is 
considerable  difficulty  in  feeding.  The  duration  of  this  form  of  the  dis- 
ease without  specific  treatment  is  from  three  to  six  weeks.  The  course 
is  often  marked  by  periods  of  remission  and  exacerbation.    If  recoverv  is 


732  DISEASES  OF  THE  NERVOUS  SYSTEM 

to  take  place,  the  temperature  gradually  falls  to  normal  aud  often  at 
times  it  is  subnormal.  The  mind  becomes  clear,  and  one  by  one  the 
nervous  symptoms  disappear,  the  muscular  rigidity  being  usually  the 
last  to  go.    Convalescence  is  always  protracted. 

In  cases  ending  fatally,  the  patient  usually  passes  into  a  deep  stupor 
or  coma,  with  extreme  prostration,  a  slow,  weak,  irregular  pulse,  shallow 
respiration  of  the  Cheyne-Stokes  variety,  sunken  abdomen,  general  re- 
laxation, and  death  occurs  from  exhaustion  or  from  bronchopneumonia. 

Occasionally  the  attack  is  much  prolonged,  the  fever  and  all  the 
active  symptoms  continuing  from  eight  to  twelve  weeks.  Emaciation 
sometimes  becomes  extreme,  and  with  a  few  nervous  symptoms  may  con- 
tinue long  after  the  fever  ceases.  In  infants,  death  is  often  due  to 
marasmus.  While  a  fatal  outcome  is  more  frequent  in  these  prolonged 
cases,  a  few  recover  completely,  even  when  marked  symptoms  have  lasted 
for  eight  or  ten  weeks. 

3.  Mild  Form. — Especially  toward  the  end  of  an  epidemic,  and  some- 
times occurring  sporadically,  there  are  seen  cases  which  in  their  onset 
and  for  the  first  two  or  three  days  resemble  those  just  described;  but 
instead  of  running  the  usual  course,  the  fever  and  the  nervous  symptoms 
subside  rapidly  and  convalescence  is  established  early. 

4.  Chronic  Form. — Owing  sometimes  to  the  extent,  sometimes  to  the 
position  of  the  lesions,  the  disease  does  not  subside  at  the  usual  time, 
but  nervous  symptoms  continue  after  the  temperature  and  most  of  the 
other  constitutional  symptoms  have  passed  away.  These  cases  are  chiefly 
of  the  basilar  type,  and  often  lead  to  the  development  of  chronic  basilar 
meningitis  with  secondary  hydrocephalus.  They  are  more  fully  con- 
sidered in  a  later  chapter. 

Onset. — One  of  the  most  striking  features  of  this  disease  is  the  ab- 
ruptness with  which  it  develops.  Occasionally  there  are  indefinite  symp- 
toms for  a  day  or  two  before  active  symptoms  begin;  but  in  the  great 
majority  not  only  the  day,  but  the  hour  of  the  onset  is  definitely  marked. 
The  most  frequent  initial  symptoms  are  the  simultaneous  occurrence  of 
severe  headache  and  vomiting,  followed  by  high  fever  and  marked  pros- 
tration. The  vomiting  is  usually  repeated,  projectile,  and  has  no  relation 
to  meals.  Convulsions  occurred  in  the  beginning  of  thirty  per  cent  of 
our  cases.  Occasionally  a  decided  chill  is  seen.  After  twenty-four  hours 
acute  general  pains  and  hyperesthesia  are  usually  present,  together  with 
rigidity  of  the  muscles  of  the  neck  and  extremities,  giving  rise  to  opis- 
thotonus and  muscular  contractions. 

Skin. — Eruptions  upon  the  skin  vary  much  in  frequency  in  different 
cases  and  in  different  epidemics.  The  most  characteristic  one  is  the 
appearance  of  small  punctate  hemorrhages,  resembling  flea  bites ;  they 
are  not  numerous,  but  may  l)e  found  on  almost  any  part  of  the  body^ 


CEREBROSPINAL  MENINGITIS  733 

most  frequently  upon  the  extremities,  the  upper  part  of  the  chest,  and 
neck.  In  our  experience  they  have  been  present  in  about  fourteen  per 
cent  of  the  eases.  Sometimes  larger  hemorrhages  are  present.  We  have 
twice  seen  a  very  extensive  purpuric  eruption  with  hemorrhagic  areas 
from  half  an  inch  to  three  inches  in  diameter  over  the  face,  buttocks,  and 
extremities.  This  eruption  belongs  to  the  early  stage  of  the  disease 
and  is  rarely  visible  after  the  third  or  fourth  day  unless  unusually 
extensive.  In  some  cases  a  general  erythema  is  present;  in  others,  an 
eruption  closely  resembling  measles.  Herpes  upon  the  lips  and  face  is 
common  in  older  children,  but  is  rare  in  infants.  Bed-sores  are  very 
common  in  protracted  cases.  They  are  found  over  pressure  points — 
the  trochanter,  the  malleoli,  and  the  side  of  the  head ;  in  several  instances 
the  ear  has  been  the  part  affected. 

Nervous  System. — Headache  is  a  frequent  initial  symptom  and  is 
usually  severe ;  it  is  more  often  frontal  than  elsewhere,  and  may  be  asso- 
ciated with  vertigo.  There  are  acute  pains  in  the  back  of  the  neck,  along 
the  spine,  and  marked  general  hyperesthesia,  which  is  often  so  intense 
that  any  movement  of  the  body  causes  agonizing  cries.  This  is  one  of 
the  most  striking  symptoms  of  the  disease,  and  may  continue  throughout 
the  acute  stage.  The  mental  state  varies  much  in  different  cases.  De- 
lirium is  frequent  in  the  early  stage  of  the  severe  form;  it  is  usually 
active,  sometimes  maniacal.  After  delirium  dulness  or  apathy  ensues, 
giving  place  to  great  irritability  when  the  patient  is  disturbed.  Con- 
vulsions are  not  uncommon  early,  but  are  seldom  repeated  in  the  course 
of  the  disease  or  toward  its  close.  There  is  rarely  continuous  stupor  or 
deep  coma  except  toward  the  end  of  fatal  cases.  In  many  cases  with  high 
temperature  and  quite  severe  symptoms,  after  the  subsidence  of  a  short 
early  stage  of  excitement  or  delirium,  the  mind  remains  perfectly  clear 
throughout  the  attack.  In  these  circumstances  an  erroneous  diag- 
nosis is  often  made,  particularly  if  the  physician  has  not  observed  the 
case  from  the  beginning. 

Tonic  spasm  of  the  various  muscular  groups  is  one  of  the  most  char- 
acteristic features  of  this  disease  and  is  seldom  absent.  Like  the  hyper- 
esthesia it  is  persistent.  The  rigidity  and  contraction  of  the  muscles 
of  the  neck  and  back  produce  cervical  or  general  opisthotonus;  cervical 
opisthotonus  is  most  marked  with  lesions  chiefly  at  the  base,  and  may 
be  wanting  in  the  rare  cases  when  the  lesion  is  almost  entirely  at  the 
convexity.  Tonic  spasm  of  the  extremities  usually  causes  general  flexion 
of  the  thighs,  legs,  and  arms.  Late  in  the  disease  this  may  be  replaced 
by  complete  extension  of  the  lower  extremities  with  dropping  of  the 
feet.  The  tonic  muscular  spasm  gives  rise  to  Kernig's  sign,  viz.,  inabil- 
ity to  extend  the  leg  when  the  thigh  is  flexed  upon  the  body.  In  young 
children  one  should  not  place  too  much  dependence  upon  this  sign. 
25 


734  DISEASES  OF  THE  NERVOUS  SYSTEM 

While  rarely  wanting  in  cerebrospinal  meningitis,  it  may  be  present 
in  other  conditions.  Br^siginski's  sign  is  frequently  present,  but  not 
diagnostic.  Muscular  rigidity  is  one  of  the  most  constant  symptoms  of 
cerebrospinal  meningitis  and  one  of  the  last  to  disappear.  It  may  be 
absent  in  the  early  stage  of  the  hyper-acute  cases,  and  very  late  in  fatal 
cases,  when  there  may  be  general  relaxation.  Other  nervous  symptoms 
frequently  present  are  ankle  clonus, .  muscular  tremor,  especially  of  the 
hands,  and  paralysis,  which  may  be  facial,  monoplegic,  or  hemiplegic. 
Early  in  the  disease  the  knee-jerks  are  usually  increased;  in  the  later 
stages  they  may  be  lost. 

Eye  and  Ear. — The  pupils  in  the  early  stage  are  generally  contracted ; 
toward  the  close  they  are  usually  widely  dilated.  Ocular  paralyses  are 
not  so  frequent  or  so  marked  as  in  tuberculous  meningitis.  The  same 
is  true  of  the  changes  in  the  optic  disc,  although  these  vary  much  in 
different  epidemics.  There  may  be  congestion  of  the  fundus,  retinitis, 
or  optic  neuritis.  In  some  epidemics  such  changes  have  been  observed 
in  fully  half  the  cases.  In  that  of  1904-5,  in  our  hospital  cases,  they 
were  rarely  seen,  and  then  were  bat  slightly  marked.  Conjunctivitis 
is  frequently  present  and  may  be  severe.  There  may  be  choroiditis 
and  sometimes  complete  destruction  of  the  eye,  but  usually  this  is  uni- 
lateral. In  most  epidemics  the  ears  are  more  frequently  affected  than 
the  eyes.  Early  deafness  may  be  due  to  a  lesion  of  the  auditory  nerve, 
is  generally  bilateral,  and  often  permanent.  Acute  otitis  media  occurs 
as  a  complication,  and  the  meningococcus  is  occasionally  found  in  the 
discharge.  Permanent  deafness  is  sometimes  due  to  changes  in  the  audi- 
tory nerve  or  in  the  brain  itself. 

Fever. — This  disease  is  usually  attended  by  high  fever,  but  the  curve 
is  apt  to  be  an  irregular  one  and  show  wide  variations.  The  temperature 
is  nearly  always  high  at  the  onset ;  in  the  hyper-acute  cases  it  may 
reach  106°  F.  or  higher.  The  usual  range  during  the  disease  is  from 
100°  to  105°  P.  (Fig.  95).  Sometimes  it  is  steadily  high;  not  in- 
frequently a  few  days  after  a  sharp  acute  onset  it  falls  nearly  or  quite 
to  normal  and  remains  there  for  several  days.  Cases  seen  in  this  afebrile 
period  are  most  difficult  of  diagnosis.  This  stage  may  be  followed  by 
another  sharp  rise,  and  afterward  continuous  fever.  Periods  of  remis- 
sion and  exacerbation  in  the  temperature  are  seen  in  a  large  proportion 
of  the  prolonged  cases.  Often  it  becomes  subnormal.  The  temperature 
may  bear  no  relation  to  the  severity  of  the  other  symptoms.  Its  course 
is  greatly  modified  by  the  serum  treatment. 

Respiration  is  disturbed  very  early  in  the  disease,  when  it  is  often 
irregular  and  may  be  slow  or  rapid.  Throughout  the  greater  part  of 
the  attack  it  may  be  nearly  normal.  Occasionally  it  is  of  the  typical 
Cheyne-Stokes  variety. 


CEREBROSPIKAL  MENINGITIS 


735 


Pulse. — Throughout  the  greater  part  of  the  disease  the  pulse  is  rapid. 
Tn  the  early  stage  it  is  often  weak,  and  sometimes  irregular.  The  average 
frequency  in  young  children  is  from  130  to  150.  A  slow,  irregular  pulse 
is  occasionally  seen  late  in  the  disease  in  patients  who  are  in  deep  coma. 

Blood. — A  leucocytosis  is  present  in  nearly  all  cases.  The  average 
is  from  25,000  to  40,000.  The  increase  is  chiefly  in  the  polymorpho- 
nuclear cells  which  usually  form  from  80  to  85  per  cent,  of  the  leu- 
cocytes. Blood  cultures  made  early  in  the  disease  have  in  some  cases 
shown  the  presence  of  the  characteristic  organism. 

Digestive  System. — Vomiting  is  one  of  the  most  frequent  symptoms 
of  onset  hut  rarely  persists  throughout  the  attack.     Late  in  the  disease 


Fig.  95. — Cerebrospinal  Meningitis.  Recovery  without  serum  treatment.  Fairly- 
typical  chart  of  prolonged  case,  showing  remissions  and  exacerbations.  Patient  3>2 
years  old;    unconscious,  blind,  and  deaf  for  ^yi  months;    complete  recovery. 


it  may  be  most  troublesome.  As  a  rule  c;onstipation  is  present.  The 
tongue  is  coated,  dry,  glazed,  sometimes  covered  with  sordes.  In  a  small 
proportion  of  cases  jaundice  has  been  observed.  On  account  of  the  loss 
of  appetite,  great  irritability,  delirium,  and  stupor,  the  greatest  difficulty 
is  often  experienced  in  feeding  these  patients.  In  young  children  gavage 
is  much  more  satisfactory  than  rectal  feeding.  Early  in  the  disease  the 
abdomen  is  natural.    In  the  late  stage  it  is  often  very  much  retracted. 

General  Nutrition . — This  is  impaired  in  nearly  all  cases.  There  is  a 
progressive  w.asting,  greater  than  would  be  explained  by  the  disturbance 
of  digestion.  In  the  protracted  cases  it  may  be  extreme.  Infants  and 
young  children  often  die  of  inanition  or  marasmus  long  after  the  active 
symptoms  of  the  disease  have  subsided. 

Other  symptoms  of  importance  are  the  tense,  bulging  fontanel,  in 


736  DISEASES  OF  THE  XERVOUS  SYSTEM 

infants  rarely  absent  early  in  the  attack,  but  often  wanting  in  the  late 
wasting  stage;  incontinence  of  urine  and  feces,  and  retention  of  urine, 
are  very  frequent  and  often  overlooked;  occasionally  swelling  of  some 
one  of  the  large  joints  is  seen. 

Course,  Duration,  and  Termination. — Excluding  the  hyper-acute 
cases  in  which  death  occurs  very  early,  the  usual  duration  of  active  symp- 
toms in  cases  not  treated  with  serum  is  from  three  to  six  weeks.  Of  350 
cases  recovering  without  serum,  the  disease  lasted  less  than  one  week  in 
three  per  cent;  in  fifty  per  cent  it  was  five  weeks  or  longer.  Some  very 
protracted  cases  terminate  favorably.  AYe  have  seen  one  child  recover 
completely  after  84  days  of  fever,  and  another  after  102  days.  Most  of 
the  prolonged  cases  are  marked  by  periods  of  exacerbation  and  remission. 
Xot  until  the  temperature  has  been  normal  for  several  days,  the  mind 
has  become  clear,  and  the  hyperesthesia  and  rigidity  have  entirely  disap- 
peared, can  we  consider  convalescence  as  established.  Recovery  is  slow, 
and  it  may  be  many  months  before  the  child  is  quite  well.  In  220  cases 
receiving  serum  treatment  the  average  duration  of  active  symptoms  after 
the  first  injection  was  11  days. 

In  fatal  cases,  death  may  come  early  from  coma,  convulsions,  or 
heart  failure.  It  may  occur  in  the  middle  period  from  complications, 
most  frequentlv  pneumonia,  or  the  terminal  stage  of  the  disease  may  be 
seen  with  extreme  wasting,  and  finally  death  from  exhaustion. 

Complications  and  S.equelae. — The  chief  complications  are  pneu- 
monia, otitis,  conjunctivitis  or  choroiditis,  and  bed-sores  ;  rarely,  nephritis 
and  arthritis.  Sequelae  are,  unfortunately,  very  common.  There  may 
be  perfect  recovery  so  far  as  physical  functions  are  concerned,  but  the 
child  be  left  mentally  deficient.  In  some  cases  the  defect  is  so  slight 
as  not  to  be  evident  for  several  months  or  even  years;  in  others  the 
mental  faculties  are  entirely  lost.  There  may  also  be  various  types  of 
paralysis — strabismus,  facial  paralysis,  monoplegia,  hemiplegia  or  diple- 
gia, and  often  contractures,  which  are  sometimes  temporary,  but  apt  to 
be  permanent.  The  acute  attack  may  be  followed  by  chronic  meningitis 
with  hydrocephalus.  Deafness  is  quite  common,  usually  of  both  ears, 
and  deaf-mutism  is  not  an  infrequent  result  in  young  children.  Blind- 
ness is  not  so  common  and  is  usually  unilateral.  As  a  late  result  epilepsy 
may  develop. 

Pro^osis. — The  mortality  is  usually  higher  in  epidemics  than  when 
the  disease  occurs  sporadically.  It  is  usually  greater  at  the  height  of 
an  epidemic  and  lower  at  its  close.  The  average  mortality  before  the 
serum  treatment  was  about  70  per  cent.  We  knoAv  of  no  recorded  epi- 
demic in  which  the  mortality  was  less  than  50  per  cent.  In  the  last  year 
(1905)  of  the  Xew  York  epidemic,  of  1,7S0  cases  tabulated  by  the  De- 
jiartmeiit  of  ILniltli  tlic  mortnlily  a\';is  7(!  ])er  cent.     Of  59  cases  treated 


CEREBROSPINAL  MENINGITIS  7:)7 

in  our  hospital  "w^ards  in  the  same  epidemic  the  mortality  was  80  per 
cent,  nearly  all  these  patients  being  nnder  three  years  of  age.  Of  24 
cases  luider  one  year  only  one  recovered.  Of  the  cases  seen  in  private 
practice,  largely  older  children,  the  mortality  was  50  per  cent.  Isone  of 
these  had  serum  treatment.  Not  all  of  those  who  do  not  die  are  to  he 
classed  as  recoveries,  for  in  fully  25  per  cent  serious  sequelae  remain. 
The  results  with  serum  are  referred  to  under  Treatment. 

Diagnosis. — Lumbar  puncture  is  the  only  accurate  means  of  diag- 
nosis we  possess.  By  it  we  can  not  only  differentiate  meningitis  from 
other  diseases  with  nervous  symptoms,  but  can  distinguish  this  from 
other  varieties  of  meningitis.  Furthermore,  this  is  possible  very  early  in 
the  disease.  With  proper  precautions  it  is  practically  free  from  danger, 
and  it  should  be  employed  whenever  meningitis  is  suspected.  The 
procedure  is  not  difficult,  but  the  technic  is  important.^  The  quantity 
of  fluid  which  may  be  removed  at  one  time  varies  from  a  few  drops  to 
three  or  four  ounces.  During  the  first  day  or  two  it  is  usually  slightly 
cloudy;  sometimes  it  is  very  turbid  and  it  may  be  thick_ and  purulent. 
As  the  disease  progresses  the  pus  cells  gradually  diminish,  and  in  favor- 
able cases  disappear,  but  may  reappear  with  an  exacerbation  of  the  symp- 
toms.   These  changes  are  much  moxlified  by  serum  injections. 

The  presence  of  many  leucocytes  in  the  cerebrosi3inal  fluid  indicates 
meningitis,  which  may  be  due  to  the  meningococcus,  but  also  to  the 
pneumococcus,  the  influenza  bacillus,  the  staphylococcus,  or  the  strepto- 
coccus.    The  variety  can  be  determined  only  by  microscopical  examiua- 

*  Puncture  should  not  be  attempted  with  an  ordinary  surgical  exploring 
needle,  but  with  the  special  lumbar  needle  devised  by  Quincke.  This  is  merely 
a  fine  trocar  and  cannula  and  is  made  stronger  than  an  exploring  needle,  which 
may  break.  The  child  is  placed  upon  the  right  side  with  the  thighs  tightly 
flexed  against  the  abdomen  to  separate  the  spines  and  laminae  of  the  vertebrae 
as  much  as  possible.  The  point  chosen  for  puncture  is  in  the  median  line  be- 
tween the  third  and  fourth  lumbar  vertebrae.  This  is  on  a  level  with  the  high- 
est part  of  the  iliac  crest.  The  strictest  asepsis  is  required.  The  skin  should  be 
cleansed  and  painted  with  iodin  and  the  needle  boiled.  The  pain  is  no  greater 
than  from  exploratoiy  punctures  elsewhere.  No  ane.sthetic  is  necessary  for  in- 
fants, but  sometimes  is  required  for  older  and  especially  sensitive  or  nervous 
children  unless  they  are  comatose.  Local  anesthesia  may  be  employed  or  a  few 
whiffs  of  chloroform  given,  but  always  with  caution,  for  the  combined  shock  of 
the  puncture  and  the  chloroform  is  sometimes  considerable.  The  child  should 
be  closely  watched  for  at  least  fifteen  minutes  after  the  puncture  is  made.  The 
canal  is  reached  at  the  depth  of  about  one  inch.  The  trocar  is  now  withdrawn 
and  the  fluid  usually  flows  freelj?-  through  the  cannula,  sometimes  spurting  forth 
some  distance,  owing  to  high  pressure.  A  dry  puncture  is  generally  due  to  the 
fact  that  the  canal  has  not  been  entered;  sometimes,  because  the  exudate  is  too 
thick  to  flow  through  the  small  needle,  or  the  needle  may  be  plugged.  Raising 
the  patient  to  a  sitting  posture  usually  causes  a  freer  flow,  as  does  also  flexing 
the  head  upon  the  chest  if  opisthotonus  is  extreme. 


738  DISEASES  OF  THE  NERVOUS  SYSTEM 

tion  of  stained  smears  from  the  sediment  of  the  fluid  obtained  after 
standing  or  after  centrifuging,  and  by  cultures,  which  should  be  made 
immediately  after  the  fluid  is  withdrawn.  In  cerebrospinal  meningitis 
diplococci  are  found  within  the  pus  cells  and  some  are  also  free  in  the 
fluid.     The  organisms  are  usually  numerous. 

The  diagnostic  value  of  lumbar  puncture,  when  properly  performed, 
is  very  great ;  not  only  are  positive  findings  conclusive,  but  early  negative 
findings  almost  certainly  exclude  meningitis.  Exceptional  cases  are  oc- 
casionally met  with  in  which  early  punctures  give  a  clear  fluid  and  no  or- 
ganisms are  found;  a  few  days  later  the  fluid  becomes  turbid  and  organ- 
isms are  abundant.  The  meningococcus  may  persist  for  a  long  time.  In 
one  of  our  cases  not  treated  by  serum  it  was  present  on  the  ninetieth  day. 

The  diagnosis  of  cerebrospinal  meningitis  by  symptoms  alone  presents 
peculiar  difficulties  at  the  beginning  of  the  attack.  The  most  valuable 
early  symptoms  for  diagnosis  are,  a  sudden  onset  with  intense  headache, 
vomiting,  high  temperature,  prostration,  the  petechial  eruption,  marked 
rigidity  of  the  neck  and  extremities,  with  hyperesthesia,  great  irritability 
or  early  stupor.  Later,  three  symptoms  are  rarely  wanting — per- 
sistent hyperesthesia,  muscular  rigidity  of  the  neck  and  extremities, 
and  fever.  Kernig's  sign  is  seen  in  other  conditions  and  is  not  diagnostic. 
The  spinal  symptoms  are  more  to  be  relied  upon  for  diagnosis  than  are 
the  cerebral  symptoms.  The  mind  in  some  cases  remains  perfectly  clear ; 
in  others  there  is  delirium,  but  seldom  continuous,  deep  coma. 

At  its  beginning,  cerebrospinal  meningitis  may  be  confounded  with 
pneumonia  or  other  diseases  with  cerebral  symptoms.  It  is  differentiated 
with  certainty  only  by  lumbar  puncture.  It  is  sometimes  difficult  to 
distinguish  cerebrospinal  from  tuberculous  meningitis  and  from  acute 
poliomyelitis  with  meningeal  symptoms.  Cerebrospinal  meningitis  is 
relatively  infrequent  except  in  epidemics.  The  fluid  is  usually  turbid 
and  contains  many  cells  of  the  polymorphonuclear  variety ;  in  tuberculous 
meningitis  the  fluid  is  clear  and  the  few  cells  found  are  nearly  all  lym- 
phocytes. Tuberculous  meningitis  may  occur  anywhere  or  at  any  time. 
Its  characteristics  are  a  gradual  onset  with  indefinite  symptoms,  low 
temperature,  persistent  drowsiness,  irregularity  of  pulse  and  respiration, 
absence  of  active  delirium,  late  coma,  less  marked  hyperesthesia  and 
rigidity,  duration  seldom  over  three  weeks  from  the  beginning  of  definite 
cerebral  symptoms,  termination  invariably  fatal.  Cerebrospinal  menin- 
gitis, however,  frequently  ends  in  recovery,  and  it  is  the  only  form  of 
acute  meningitis  which  does  so.  In  poliomyelitis  the  spinal  fluid  resem- 
bles that  of  tuberculous  meningitis. 

Treatment. — Flexner's  serum  for  the  treatment  of  cerebrospinal 
meningitis  is  more  effective  in  controlling  the  disease  than  any  other 
measure  thus  far  proposed.     It  is  obtained  by  immunizing  horses  with 


CEREBROSPINAL  MENINGITIS 


739 


toxins  and  cultures  obtained  from  many  strains  of  the  meningococcus. 
It  acts  chiefly  on  the  bacteria  themselves ;  i.  e.,  it  is  a  bacteriolytic  serum. 
It  is  used  as  follows:  After  withdrawing  by  lumbar  puncture  all  the 
fluid  that  will  flow  readily,  under  the  strictest  aseptic  precautions,  the 
serum,  warmed  to  the  body  temperature,  is  injected  without  removing 
the  needle.    In  some  exceedingly  sensitive  patients  the  administration  of 


Day 
104° 

103° 

102  ° 

101  ° 

100° 

99  ° 

98  ° 

2 

3 

4 

s 

6 

7 

8 

9 

10 

1 

, 

/ 

\ 

/ 

y 

1 

\ 

/ 

/ 

^ 

1 

/ 

\ 

/ 

f 

1 

S, 

\ 

/ 

/ 

y 

/ 

\ 

i 

f 

f 

\ 

1 

"X 

1 

j 

' 

1 

I 

/ 

f 

^ 

/    \ 

1 

\ 

y 

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' 

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\       ^ 

\ 

/ 

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i 

1 

j 

■ 

N 

J 

I 

1 

s 

/ 

V 

1 

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\   1 

V 

_ 

"l" 

""" 

■■ 

■■ 

"" 

^ 

1 

Day 

2 

3 

4 

5 

6 

1 

8 

9 

10 

Leucocytes 

20,400 

25,600 

15,000 

16,400 

16,000 

12,500 

21,000 

20,000 

Serum 
Injected 

40c. c. 

30 

35 

30 

Fluid 
Removed 

80C.O. 

40 

40 

40 

5d 

20 

Nature 
of  Fluid 

Purulent 

Slightly 
Turbid 

Slightly 
Turbid 

Almost 
Clear 

Clear 

Clear 

Organisms 

Many 

Few 

None 

None 

lO-: 

None 

None 

Fig.  96. — Cerebrospinal  Meningitis  Treated  by  Serum.  Infant,  7  months  old, 
Babies'  Hospital:  24  hours  ill;  intense  prostration;  respiration,  80;  signs  of  pul- 
monary edema;  general  relaxation;  stupor;  profuse  hemorrhagic  eruption.  First 
fluid,  purulent;  amount  removed,  amount  of  serum  injected,  and  the  changes  in 
the  fluid  shown  in  the  chart.  Immediate  improvement  in  symptoms  after  first  in- 
jection. Subsequent  symptoms  typical.  A  rise  in  temperature  on  the  8th  day 
and  the  increase  in  leucocytes  on  the  9th  and  10th  days  suggested  relapse;  but 
as  the  fluid  was  clear  and  no  organisms  could  be  found  in  smears  or  by  culture  no  more 
serum  was  given;    complete  recovery. 

a  few  whiffs  of  chloroform  may  be  necessary.  The  injection  is  made  by 
gravity,  using  a  rubber  tube  and  small  funnel.  It  should  be  made  very 
slowly,  occupying  several  minutes.  Eaising  the  hips  facilitates  the  inflow 
of  the  serum.  To  be  effective,  it  must  be  brought  into  contact  with  the 
organisms  in  the  spinal  canal  in  a  considerable  degree  of  concentration. 
The  initial  dose  of  the  serum  now  used  is  10  to  15  e.  e.  for  infants, 
and  15  to  25  c.  c.  for  children  from  two  to  twelve  years  old.  The  dose 
is  usually  repeated  in  twenty-four  hours  (in  very  severe  cases  in  twelve 


740 


DISEASES  OF  THE  NEKVOUS  SYSTEM 


hours)  and  a  daily  dose  thereafter  until  four  or  five  have  been  given.  The 
indications  for  further  injections  are :  continuance  of  marked  nervous 
symptoms^  persistence  of  temperature,  persistence  of  leucocytosis  and  of 
great  numbers  of  polymorphonuclear  cells  in  the  cerebrospinal  fluid, 
even  though  no  organisms  are  found  in  smears  and  there  is  no  growth 
from  cultures.  To  introduce  more  serum  than  the  amount  of  fluid  with- 
drawn is  somewhat  hazardous.  In  the  milder  cases  it  sometimes  hap- 
pens that  a  single  dose  may  suffice  for  a  cure;  but  even  in  such  cir- 
cumstances it  is  safer  to  give  at  least  three  doses  on  successive  days. 
The  serum  arrests  the  inflammatory  process  by  destroying  the  organisms 
which  produce  it.  To  accomplish  this  a  sufficient  dose  must  be  given, 
and  given  early,  before  important  inflammatory  changes  have  taken  place. 


Day     18       19      20      21       22       23      24      25 

26      27      28      29      30      31      32      33      34 

35      36      37      38 

TjTTj""""     1  Tr^"T|"  n 

i-^-^  i|l  -LL--jp-±-  1   1   ii|   |i: 

1  11     1  1  1     1  1           1 

..rhMi  !p4n  1    H 

•»'SaS^iS|EEEE|;l 

Wm 

m 

J\\       H^''"T 

_^^s^^¥i±=^==i=s 

^|±EEgEg||g|igg 

[rlHjIliM^lil 

Fig.  97. — Cerebrospinal  Meningitis.  Late  injection  of  the  serum,  prompt  effect; 
complete  recovery.  Boy,  11  years,  St.  Vincent's  Hospital,  New  York.  Early  symp- 
toms obscure,  and  on  account  of  swelling  and  pain  in  joints  diagnosis  of  rheuma- 
tism made;  cerebral  symptoms  not  marked.  First  lumbar  ptincture  made  on  31st 
day  and  meningococcus  found.  Serum  injected  on  the  34th  and  35th  days.  Rapid 
fall  in  the  temperature  followed  by  cessation  of  all  symptoms  and  complete  recovery. 

An  immediate  effect  of  the  injection  is  seen  in  the  cerebrospinal 
fluid.  There  is  a  marked  reduction  in  the  percentage  of  polymorphonu- 
clear cells.  The  number  of  meningococci  is  greatly  reduced  and  their 
vitality  lessened.  After  the  first  injection  they  stain  with  difficulty,  and 
after  a  second  injection  it  is  generally  impossible  to  grow  them,  although 
they  are  usually  present  in  small  numbers  (Fig.  96).  The  effect  on  the 
symptoms  is  often  striking.  There  is  a  marked  reduction  in  the  temper- 
ature, which  may  amount  to  three  or  four  degrees  in  twenty-four  hours, 
and  it  may  not  rise  again  (Fig.  97).  The  stupor  and  delirium  often 
diminish  rajjidly,  and  soon  disappear.  Improvement  is  also  seen  iii  the 
patient's  general  condition,  pulse,  and  resjDiratiou.  The  last  symptoms 
to  be  affected  are  usually  the  rigidity  of  the  neck  and  extremities. 

Intraspinal  injections  are  not  wholly  devoid  of  danger.  A  moderate 
degree  of  shock  following  the  procedure  is  quite  common.  The  eliild's 
head  should  be  lowered  and  he  should  be  closely  watched  for  half  an  hour 


CEREBROSPIXAL  MEXIXGITIS  741 

or  more.  In  rare  instances  more  serious  symptoms  are  seen,  usually  in 
the  nature  of  an  acute  failure  of  respiration.  Alarming  symptoms  gen- 
erally come  on  quite  abruptly  T\-ith  little  ^-arning,  and  unless  promptly 
recognized  and  energetically  treated  death  may  follow.  A  number  of 
theories  have  been  advanced  in  explanation  of  these  phenomena,  Imt  it 
seems  clear  tliat  they  arc  due  to  tlie  clianges  produced  in  the  intra- 
cranial i^ressure.  If  the  symptoms  develop  while  serum  is  heing 
injected,  the  funnel  should  be  lowered  and  some  of  the  fluid  siphoned 
out  of  the  canal.  Atropin  should  be  given  hypodermically  and  artificial 
respiration  employed  energetically.  We  have  seen  but  a  single  fatal 
result,  but  in  several  instances  it  was  necessary  to  use  artificial  res- 
piration for  fifteen  or  twenty  minutes  before  normal  respiration  was 
established.  It  is  evident  that  the  greatest  care  should  be  used  in  in- 
jecting serum  and  that  the  possibility  of  the  development  of  serious 
symptoms  should  always  be  kept  in  mind.  A  close  observation  of  the 
blood  pressure  during  the  injection  has  been  advocated  by  Sophian;  its 
fall  furnishes  a  warning  of  the  develojDment  of  serious  symptoms.  Our 
own  experience  leads  us  to  the  belief  that  it  is  of  some  value,  but  that 
very  careful  watching  of  the  child's  pulse  and  respiration  answers  quite 
as  well. 

The  results  of  this  treatment  show  a  much  larger  percentage  of  re- 
coveries than  has  been  obtained  by  any  other  method.^  Of  1,500  cases 
of  all  t}Tpes,  in  patients  of  all  ages  treated  by  this  serum,  the  general 
mortality  was  about  25  per  cent.  The  figures  represent  results  ob- 
tained in  many  epidemics  in  all  parts  of  the  world.  The  statistics  from 
this  country  are  not  so  favorable  as  those  from  abroad  with  the  same 
serum,  for  the  reason  that  in  the  results  here  are  included  reports  from 
many  physicians  who,  without  experience  in  the  use  of  the  serum,  treated 
but  one  or  two  cases.  The  foreign  statistics,  however,  are  in  larger 
groups,  and  the  cases  for  the  most  part  were  under  the  care  of  men  who 
had  had  experience  with  the  serum.  In  the  epidemic  in  France  the 
mortality  of  the  cases  not  treated  by  serum  was  about  70  per  cent, 
while  in  those  receiving  serum  it  was  but  15  per  cent.  This  indicates 
what  may  be  expected  with  serum  treatment  under  favorable  conditions. 
One  of  the  most  striking  evidences  of  the  value  of  this  treatment  is  the 
results  obtained  in  infants  under  one  year.  Without  serum  these  cases 
have  almost  invariably  terminated  fatally;  with  serum  over  50  per  cent 
of  them  have  recovered. 

The  results  are  much  modified  by  the  time  of  injection  as  shown  by 
the  following  table : 

^For  details,  see  articles  by  Flexner  and  his  associates  in  the  Journal  of  Ex- 
perimental Medicine,  from  September,  1908,  to  1915.  Reliable  serum  can  be  ob- 
tained from  the  New  York  Health  Department. 


742 


DISEASES  OF  THE  NEEVOUS  SYSTEM 


Time  of  Injection 

Flexner. 
(AE  sources, 
chiefly  U.  S.) 

Natter.      (France.) 

Dopter.     (France.) 

1st  to  3d  day 

14.9% 
22.0% 
36.4% 

7.14% 
11.1  % 
23.5  % 

8.2% 

4th  to  7th  day 

14.4% 

After  the  7th  day 

24.1% 

In  Xetter's  series  Flexner's  serum  was  used;  Dopter  nsed  the  serum 
jDrepared  at  the  Pasteur  Institute. 

The  effect  on  the  course  and  duration  of  the  disease  is  no  less  marked 
than  that  upon  the  mortality.  The  duration  of  acute  symptoms  is  very 
much  shortened,  and  in  about  one-fourth  of  the  cases  the  disease  termi- 
nated by  crisis  (Fig.  97).  This  is  more  often  seen  in  cases  injected 
early,  although  it  is  observed  in  some  injected  as  late  as  the  fourth 
week.  The  infrequency  of  complications  and  sequelae  is  also  noteworthy. 
jSTot  only  do  patients  recover,  but  they  recover  quickly,  and  in  most  in- 
stances completely.  The  absence  of  complications  and  sequelae  is,  no 
doubt,  to  be  explained  partly  by  the  effect  of  the  serum  in  shortening  the 
disease. 

Eelapses  occur  in  a  small  proportion  of  the  cases.  They  are  due  to 
the  fact  that  the  organisms  have  not  been  entirely  destroyed  by  the 
serum.  They  are  usually  indicated  by  a  rise  in  temperature,  an  increase 
in  the  leucocj'tosis,  and  an  aggravation  of  the  nervous  symptoms.  They 
are  to  be  treated  like  a  primary  attack,  daily  injections  being  repeated 
so  long  as  organisms  and  symptoms  persist. 

Very  little  improvement  is  to  be  expected  in  patients  who  have 
passed  the  febrile  stage  and  who  are  suffering  chiefly  from  the  effects 
of  distention  of  the  ventricles  due  to  a  chronic  basilar  lesion.  The  most 
unpromising  early  cases  are  those  of  the  fulminating  type  which  have 
usually  advanced  so  far  before  the  serum  is  given  that  recovery  is  im- 
possible. Unpromising  also  are  cases  in  which  a  very  thick  purulent 
fluid  is  present  which  can  hardly  be  withdrawn  through  the  needle.  The 
amount  which  can  be  removed  is  usually  very  small.  The  diffusion  of 
the  serum  in  the  canal  is  difficult.  In  such  cases  Eobb  (Belfast),  before 
injecting  the  serum,  has  used  with  success  irrigation  of  the  spinal  canal 
with  a  warm  sterile  salt  solution.  In  some  cases,  particularly  in  infants, 
when  the  withdrawal  of  fluid  by  lumbar  puncture  has  been  impossible 
owing  to  adhesions  or  other  causes,  fluid  may  be  removed  by  puncturing 
the  ventricles  of  the  brain  through  the  fontanel.  The  serum  is  then  in- 
jected into  the  same  cavity.  The  procedure  is  not  difficult,  and,  if 
carefully  done,  attended  by  little  risk.  We  have  used  it  in  several  cases. 
The  effect  of  the  serum  seemed  quite  as  marked  as  when  it  was  introduced 
in  the  usual  manner. 


ACUTE  MENINGITIS  DUE  TO  OTHEK  CAUSES  743 

In  any  case  suspected  to  be  cerebrospinal  meningitis  lumbar  punc- 
ture should  Le  made  as  early  as  possible.  If  the  fluid  obtained  is  puru- 
lent or  only  slightly  turbid,  the  serum  should  be  injected  at  once.  If 
the  fluid  is  clear,  the  disease  is  probably  not  cerebrospinal  meningitis, 
and  one  may  wait  for  a  bacteriological  report.  Meningitis  due  to  the 
pneumococcus,  the  bacillus  of  influenza,  or  to  pyogenic  organisms,  may 
also  give  a  purulent  fluid,  but  no  harm  would  result  from  using  the  serum 
in  such  a  case,  although  no  benefit  should  be  expected. 

The  injection  of  various  chemical  agents  (protargol,  lysol,  etc.)  has 
from  time  to  time  been  advocated ;  but  the  experimental  work  of  Flexner 
and  Amoss  has  shown  that  such  substances  are  absolutely  without  value 
and  may  even  diminish  the  chances  of  natural  recovery. 

Lumbar  puncture  per  se  has  some  slight  therapeutic  value.  It  re- 
lieves pressure  and  by  reducing  the  number  of  microorganisms  may  have 
a  slight  effect  upon  the  inflammatory  process,  especially  when  used  early ; 
but  in  most  cases  this  is  only  temporary.  An  ice-cap  should  be  applied 
to  the  head,  and  at  times  an  ice-bag  along  the  spine.  The  bowels  shoiild 
be  kept  freely  open.  Treatment  otherwise  is  directed  toward  the  symp- 
toms of  the  disease.  Severe  pain  requires  morphin  or  codein  sometimes 
in  quite  large  doses.  For  other  nervous  symptoms — delirium,  sleepless- 
ness, etc. — the  bromids  and  chloral,  sulfonal,  or  trional  may  be  given, 
or  warm  sponge  or  tub  baths.  Stimulants  are  indicated  by  a  weak,  rapid, 
and  irregular  pulse.  Caffein  and  digitalis  or  strophanthus  should  be 
used,  but  not  strychnin. 

The  nutrition  of  the  patient  is  important.  Feeding  is  often  difficult, 
and  gavage  may  be  advantageously  employed.  Bed-sores  should  be  pre- 
vented by  cleanliness,  frequently  changing  the  patient's  position,  etc. 
Retention  of  urine  may  require  the  use  of  the  catheter. 

For  the  residual  paralysis,  massage,  warm  baths,  and  friction  should 
be  employed,  but  electricity  only  when  all  symptoms  of  central  irritation 
have  subsided.  The  prolonged  use  of  iodid  of  potassium,  especially  in 
combination  with  mercury,  seems  to  have  some  value. 


ACUTE  MENINGITIS  DUE  TO  OTHER  CAUSES 

Besides  the  main  varieties  of  acute  meningitis,  viz.,  that  due  to  the 
meningococcus  and  that  due  to  the  tubercle  bacillus,  there  are  other 
forms  differing  in  etiology,  but  closely  related  clinically,  and  therefore 
they  may  be  advantageously  considered  together.  It  is  only  since  the 
general  adoption  of  lumbar  puncture  as  a  means  of  diagnosis  that  these 
forms  of  meningitis  have  been  clinically  differentiated.  Formerly  they 
were  grouped  under  the  somewhat  indefinite  heading  of  "simple  menin- 


744  DISEASES  OF  THE  NERVOUS  SYSTEM 

gitis/'  Three  of  these  varieties,  those  due  to  the  pneumococcus,  the  in- 
fluenza bacillus,  and  pyogenic  organisms,  are  sufhciently  important  to 
require  separate  description.  Cases  of  meningitis  due  to  the  typhoid 
bacillus,  the  gonococcus,  and  the  colon  bacillus,  have  all  been  reported 
in  children,  but  are  so  rare  as  only  to  deserve  mention. 

Pneumococcus  Meningitis. — This  is  the  most  important  variety  in- 
cluded in  this  group  and  the  one  most  frequently  met  with  in  young 
children.  In  our  hospital  patients  about  ten  per  cent  of  the  cases  of  acute 
meningitis  were  of  this  form.  Nearly  all  had  pulmonary  symptoms  of 
greater  or  less  severity,  usually  a  definite  pneumonia  with  consolidation ; 
several  had  also  empyema.  Less  frequently,  pneumococcus  pericarditis 
and  peritonitis  have  been  present.  Occasionally  pneumococcus  meningitis 
is  seen  when  there  are  no  definite  pulmonary  symptoms  or  signs  and 
when  it  is  apparently  a  primary  inflammation.  However,  in  most  cases 
pneumococcus  meningitis  is  one  of  the  results  of  a  generalized  pneumo- 
coccus infection.  In  every  one  of  our  cases  of  pneumococcus  meningitis 
in  which  cultures  of  the  heart's  blood  were  made  at  autopsy,  this  or- 
ganism was  present.  It  was  usually  found  in  blood  cultures  made  during 
life.  This  form  of  meningitis  occurs  in  infants  more  frequently  than 
in  older  children,  and,  in  our  experience,  usually  in  very  young  infants ; 
over  half  of  the  cases  seen  were  in  patients  under  six  months  old.  While 
the  disease  usually  develops  at  the  height  of  an  attack  of  pneumonia,  it 
may  precede  the  pulmonary  symptoms  and  it  may  develop  during  con- 
valescence.   We  once  saw  it  as  late  as  the  fourth  week. 

Lesions. — In  a  general  way  the  anatomical  changes  resemble  those 
described  in  cerebrospinal  meningitis,  with  the  exception  that  the  marked 
changes  in  the  brain  substance  which  are  usually  dependent  upon 
the  long  course  of  that  disease  are  wanting.  As  a  rule,  also,  the  lesions 
are  limited  to  the  brain.  If  the  cord  is  involved,  it  is  only  to  a  slight 
degree. 

x\cute  meningitis  due  to  the  pneumococcus  is  characterized  by  a  more 
abundant  exudation  of  fibrin  and  pus  than  is  seen  in  any  other  variety 
of  meningitis.  The  lesion  may  affect  the  entire  brain,  but  it  is  espe- 
cially marked  at  the  convexity  and  over  the  anterior  lobes.  Sometimes 
it  is  limited  to  these  regions,  the  meninges  of  the  base  escaping.  The 
exudate  may  be  so  abundant  as  almost  to  conceal  the  convolutions.  (See 
Plate  XL)  There  is  usually  less  distention  of  the  ventricles  than  in 
cerebrospinal  meningitis. 

In  cases  apparently  primary,  or  when  meningitis  occurs  very  early  in 
the  course  of  a  general  pneumococcus  infection,  the  symptoms  are  usually 
indistinguishable  from  those  of  ordinary  cases  of  cerebrospinal  menin- 
gitis. It  is  generally  not  until  lumbar  puncture  is  made  that  the  variety 
of  meningitis  is  .suspected,     When  moniugitis  occurs  as  a  secondary  in- 


PLATE  XI 


Acute  Pnetjmococctjs  Meningitis,  Complicating  PLEtrROPNEUMONiA 
Child  twenty  months  old;  on  twenty-third  day  of  a  protracted  attack  of  pneumonia, 
vomited  six  times,  and  the  temperature,  which  had  been  nearly  normal  for  four  days, 
rose  to  103°  F.  On  the  following  day  general  convulsions,  which  were  repeated  frequently 
during  the  next  few  days;  temperature,  101°  to  104°  F.;  death  in  convulsions  on  twenty- 
eighth  day. 

Autopsy. — Pleuropneumonia  of  left  side;  lung  resolving.     Anterior  portion  of  brain 
enveloped  in  lymph  and  pus,  more  marked  at  the  convexity,  but  present  also  over  the  base. 


ACUTE  MENINGITIS  DUE  TO  OTHEE  CAUSES  745 

flammation  it  is  often  latent,  and  not  infrequently  is  found  at  autopsy 
when  not  suspected  during  life.  Usually,  however,  the  meningeal  compli- 
cation is  indicated  by  the  abrupt  development,  in  the  course  of  an  attack 
of  pneumonia,  of  vomiting  or  convulsions,  followed  by  active  delirium  or 
stupor.  Because  the  lesion  is  principally,  sometimes  only,  at  the  con- 
vexity, many  of  the  symptoms  belonging  to  meningitis  with  basal  lesions 
are  absent.  There  is  rarely  cervical  opisthotonus;  the  fontanel  may  not 
be  bulging;  pulse  and  respiration  may  not  be  disturbed,  in  fact,  there 
are  no  cranial-nerve  symptoms  and  the  symptoms  due  to  spinal  in- 
volvement— hyperesthesia,  rigidity,  Kernig's  sign,  etc. — are  usually  want- 
ing. 

The  course  of  pneumococcus  meningitis  is  generally  short  and  acute, 
death  taking  place  within  three  or  four  days  from  the  first  symptoms. 
We  have  several  times  seen  a  prolonged  type  of  the  disease  lasting  many 
weeks ;  one  case  ended  fatally  near  the  end  of  the  third  month ;  another 
patient  recovered  from  the  acute  symptoms,  but  remained  partially  par- 
alyzed and  mentally  defective. 

The  diagnosis  of  pneumococcus  meningitis  can  positively  be  made 
only  by  lumbar  puncture.  The  cerebrospinal  fluid  in  gross  appearance 
does  not  differ  from  that  seen  in  cases  due  to  the  meningococcus.  The 
cells  present  are  chiefly  polymorphonuclear.  Pneumococci  are  very 
abundant  and  are  easily  found  in  smears  and  grown  readily  in  cultures. 
The  existence  of  pneumococcus  meningitis  is  not  always  shown  by  lumbar 
puncture.  We  have  met  Math  one  case  in  which  repeated  punctures  gave 
negative  results,  and  yet  the  autopsy  showed  meningitis  to  be  present, 
bnt  only  the  convexity  was  affected.  The  organisms  were  readily  found 
in  tlie  meningeal  exudate. 

Influenza  Meningitis. — This  form  of  meningitis  in  many  respects 
resembles  the  form  just  described.  According  to  Wollstein,^  there 
had  been  recorded,  up  to  1911,  49  cases  of  pure,  and  9  cases  of 
mixed,  influenza  meningitis.  Of  these,  28  were  in  infants  under  one  year 
old.  Since  then  many  additional  cases  have  been  reported.  The  disease 
is  certainly  not  very  rare.  Of  the  cases  which  have  come  under  our 
own  observation,  all  but  one  have  been  in  infants  and  all  have  ended 
fatally.  In  our  experience,  influenza  meningitis  has  been  secondary  to 
other  influenza  infection.s,  usually  those  of  the  rhinopharynx  or  bronchi. 
The  organisms  were  found  by  culture  from  the  secretions  of  these  parts 
during  life.  One  patient,  an  infant  of  eight  months,  was  admitted  to  the 
hospital  with  an  acute  abscess  of  the  elbow  joint.  Two  days  later  symp- 
toms of  meningitis  developed,  and  death  occurred  in  three  days.  The 
autopsy  showed  an  extensive  purulent  meningitis.     Pure  cultures  of  the 

*  American   Journal    of   Diseases    of   Children,   January,    1911. 


746  DISEASES  OF  THE  NERVOUS  SYSTEM 

influenza  bacillus  were  obtained  from  the  pus  of  the  elbow,  the  fluid 
drawn  by  lumbar  puncture,  the  meningeal  exudate,  and  the  heart's  blood. 
The  lungs  showed  influenza  bacilli  and  streptococci. 

The  lesions  of  influenza  meningitis,  in  the  few  cases  in  which  autop- 
sies have  been  made,  have  differed  in  no  essential  particular  from  those 
described  in  the  pneumococcus  variety.  In  the  cases  coming  under  our 
observation  in  which  examinations  were  made,  the  influenza  bacillus 
was  obtained  from  the  heart's  blood  as  well  as  from  the  cerebrospinal 
fluid. 

Clinically,  influenza  meningitis  usually  runs  a  short,  very  acute 
course.  There  are  no  features  by  which  it  can  be  distinguished  from  the 
pneumococcus  or  meningococcus  form,  except  the  findings  of  lumbar 
puncture.  In  gross  appearance  the  fluid  does  not  differ  from  that  seen  in 
the  other  forms.  There  is  usually  marked  turbidity ;  the  cells  are  abun- 
dant and  of  the  polymorphonuclear  variety.  The  organisms  are  gen- 
erally not  numerous  in  the  smears,  in  marked  contrast  to  the  other 
forms  of  meningitis.  They  are  readily  grown  upon  blood  agar,  but  not 
upon  ordinary  media.  If,  therefore,  from  a  turbid  cerebrospinal  fluid 
no  growth  occurs,  influenza  meningitis  should  be  suspected. 

Meningitis  Due  to  Pyogenic  Organisms — Septic  Meningitis. — Menin- 
geal inflammations  set  up  by  the  streptococcus  or  staphylococcus  are 
not  very  common  in  young  children.  They  are  almost  always  secondary. 
In  the  newly  born  this  form  of  meningitis  is  seen  in  general  pyemia, 
usually  from  umbilical  infection;  it  also  follows  infection  of  a  spina 
biflda.  In  older  children  it  follows  injuries  to  the  head,  erysipelas  of 
the  scalp,  operations  upon  the  brain,  and  otitis  media  with  mastoiditis 
or  sinus  thrombosis.  Such  a  complication  of  otitis  in  infancy  is,  how- 
ever, extremely  rare.  The  lesions  consist  in  a  widespread  general  in- 
flammation of  the  pi  a  with  an  abundant  exudate  of  pus,  but  with  less 
fibrin  than  in  the  two  varieties  previously  described. 

The  s3anptoms  of  septic  meningitis  are  not  distinctive.  The  course 
is  usually  a  rapidly  progressive  one,  and  the  termination  almost  invari- 
ably in  death.  The  fluid  drawn  by  lumbar  puncture  in  most  cases  is 
markedly  turbid,  and  shows  great  numbers  of  pus  cells.  The  organisms 
are  present  in  large  numbers  and  are  readily  recognized  both  in  smears 
and  by  cultures  upon  ordinary  media. 

Diagnosis. — The  differential  diagnosis  of  the  different  forms  of 
meningitis  from  each  other,  and  from  other  diseases  with  cerebral  symp- 
toms, is  made  with  certainty  only  by  means  of  lumbar  puncture,  which 
should  be  done  in  all  cases  of  doubt.  The  appearance  of  the  cerebrospinal 
fluid  is  essentially  the  same  whether  the  inflammation  is  due  to  the  men- 
ingococcus, the  pneumococcus,  the  influenza  bacillus,  or  to  the  staphylo- 
coccus or  streptococcus.     The  symptoms  of  meningitis  in  general,  de- 


TUBERCULOUS  MENINGITIS  747 

scribed  in  the  chapter  on  Cerebrospinal  Meningitis,  are  present  in  most 
of  the  cases. 

Prognosis  and  Treatment. — The  prognosis  in  all  varieties  of  acute 
meningitis,  except  that  due  to  the  meningococcus,  is  very  bad;  almost 
every  case  of  meningitis  due  to  other  causes  is  fatal.  From  what  has 
been  said,  it  would  appear  that  treatment  is  as  yet  most  unsatisfactory, 
and  is  only  symptomatic.  Wollstein's  researches  at  the  Eockefeller  In- 
stitute, however,  indicate  that  influenza  meningitis  may  occasionally  be 
controlled  by  serum  treatment.  A  goat  serum  has  been  produced  which 
regularly  controls  the  experimental  disease  in  monkeys.  Its  use  in  chil- 
dren has  thus  far  been  very  seldom  successful,  since  there  is  usually  a 
general  influenza  septicemia  and  since  the  disease  is  so  rapid  in  its  course 
that  an  early  diagnosis  is  rarely  made. 


TUBERCULOUS   MENINGITIS 

(Acute  Hydrocephalus ;  Basilar  Meningitis) 

Tuberculous  meningitis  is  a  tuberculous  inflammation  of  the  pia 
mater  of  the  brain,  sometimes  involving  also  that  of  the  cord.  It  is  by 
far  the  most  frequent  form  of  acute  meningitis  seen  in  young  children. 
In  our  hospital  experience,  apart  from  epidemics  of  cerebrospinal  menin- 
gitis, seventy  per  cent  of  the  cases  of  acute  meningitis  have  been  tuber- 
culous. It  is  more  uniformly  fatal  than  any  other  disease  of  early  life. 
It  is  doubtful  if  it  ever  occurs  as  the  only  tuberculous  lesion  of  the  body. 
In  infancy  it  is  usually  associated  with  general  or  pulmonary  tubercu- 
losis; in  older  children  with  tuberculosis  of  the  bones,  joints,  or  lymph 
nodes.  Of  our  own  cases,  forty  per  cent  of  all  deaths  from  tuberculosis 
in  children  have  been  due  to  meningitis. 

Lesions. — The  lesion  consists  in  the  production  of  miliary  tubercles, 
with  which  are  frequently  found  tuberculous  nodules  of  variable  size,  and 
in  almost  every  case  there  are  also  the  products  of  ordinary  inflammation 
of  the  pia  mater — fibrin  and  pus — together  with  an  accumulation  of 
fluid  in  the  lateral  ventricles  of  the  brain.  Frequently  there  are  tubercles 
in  the  pia  mater  of  the  upper  portion  of  the  cord.  ^When  few  in  number 
the  tubercles  are  usually  only  at  the  base.  When  numerous  they  are  seen 
scattered  over  the  convexity.  Tubercles  are  frequently  found  in  the 
choroid  coat  of  the  eye.  The  amount  of  fibrin  and  pus  in  the  exudate 
is  usually  small,  and  is  much  less  than  is  seen  in  other  forms  of  acute 
meningitis.  The  inflammatory  products  are  most  abundant  at  the  base. 
In  addition  to  the  patches  of  greenish-yellow  fibrin,  there  are  adhesions 
between  the  lobes  of  the  brain  and  thickening  of  the  pia.    In  cases  which 


748  DISEASES  OF  THE  NERVOUS  SYSTEM 

have  lasted  for  several  weeks,  this  thickening  may  be  marked,  owing 
to  cell  infiltration  and  the  production  of  new  connective  tissue.  The 
pia  is  studded  with  miliary  tubercles,  sometimes  with  small  yellow 
tuberculous  nodules;  frequently  there  is  arteritis,  which  is  sometimes 
obliterating. 

In  the  most  acute  cases  the  brain  substance  immediately  beneath  the 
pia  is  intensely  congested,  slightly  softened,  and  shows  under  the  micro- 
scope a  superficial  encephalitis.  The  lateral  ventricles  are  usually  dis- 
tended with  clear  serum,  sometimes  with  serum  containing  flocculi  of 
fibrin  or  pus ;  the  amount  present  varies  from  one  to  four  ounces  in  each 
ventricle,  being  always  greater  in  the  subacute  cases.  The  walls  of  the 
ventricles  may  be  softened.  The  distention  of  the  ventricles  leads  to 
flattening  of  the  convolutions  from  pressure  against  the  skull,  to  bulging 
of  the  fontanel,  and  sometimes  to  separation  of  the  sutures. 

Tuberculous  nodules  varying  in  size  from  a  small  pea  to  a  walnut  are 
frequently  seen  associated  with  meningitis  in  older  children,  but  not 
often  in  infants.  These  nodules  may  be  connected  with  the  meninges, 
or  they  may  be  situated  within  the  brain  substance,  usually  in  the  cere- 
bellum. The  larger  ones  are  classed  as  brain  tumors.  Inflammatory 
products  are  rarely  found  in  the  spinal  canal. 

Although  it  is  not  infrequent  to  see  meningitis  without  symptoms  of 
tuberculosis  elsewhere,  we  have  never  failed  at  autopsy  to  find  other 
tuberculous  lesions  in  the  body.  In  our  experience  the  following  are 
those  most  often  met  with,  given  in  the  order  of  frequency:  (1)  In  in- 
fants, associated  with  general  or  pulmonary  tuberculosis;  (2)  in  chil- 
dren from  three  to  twelve  years  of  age,  with  tuberculosis  of  the  vertebrae, 
hip,  knee,  or  ankle;  (3)  at  any  age,  with  tuberculosis  involving  only 
the  tracheal,  bronchial,  or  mesenteric  lymph  nodes;  (4)  much  less  fre- 
quently with  the   pulmonary  tuberculosis  of  older   children. 

Etiology. — Tuberculous  meningitis  is  produced  only  by  the  transpor- 
tation of  the  tubercle  bacilli  to  the  brain.  They  may  find  their  way 
by  the  blood-vessels  or  by  the  .lymphatics. 

The  following  table  shows  the  age  at  which  the  disease  was  observed 
in  410  cases  of  which  we  have  notes : 

Under  one  year 162 

One  to  two  years 149 

Two  to  five  years 76 

Five  to  nine  years 17 

Nine  to  sixteen  yeiars 6 

Total 410 

In  this  series  three  cases  were  in  children  three  months  old  or 
younger.  Tuberculous  meningitis  in  our  experience  occurs  much  more 
often  in  the  winter  and  spring  months  than  at  other  seasons  (Fig.  98). 


TUBERCULOUS  MENINGITIS 


749 


The  most  plausible  explanation  of  this  seems  to  be  that  these  patients, 
infected  some  time  previously,  carry  a  latent  focus  of  tuberculosis  some- 
where in  the  respiratory  tract,  usually  in  the  bronchial  glands.  Under 
the  influence  of  acute  respiratory  infections  of  the  cold  season,  the  latent 
tuberculous  disease  becomes  active,  and  a  rapidly  spreading  tuberculous 
process  results.  In  infants  and  young  children  it  rarely  happens  that 
pulmonary  lesions  are  absent;  but  these  patients  are  especially  predis- 
posed to  earl}^  meningeal  infection,  and  this  often  occurs  before  symp- 
toms of  tuberculosis  elsewhere  have  manifested  themselves.  At  the  time 
of  invasion,  therefore,  most  of  these  children  are  apparently  in  the  best  of 
health.    In  older  children  there  may  have  been  previous  evidence  of  tuber- 


JAN. 

FEB. 

MAR. 

APR. 

MAY 

JUNE 

JULY 

AUG. 

SEPT. 

OCT. 

NOV. 

DEC. 

55 

50 

A 

S^ 

45 

/ 

V 

V 

40 

V 

/ 

\ 

1400 
1200 
1000 

35 

N 

V 

K 

30 

— \ 

\ 

A 

25 

•-^, 

-,      / 

\ 
\ 

\ 

s. 

/ 

/ 

20 

'V^ 

\ 

\, 

^-~ 

~-~^ 

800 
600 
400 
200 

'>' 

* 

15 

\. 

^N 

--^ 

/^ 

^j^' 

10 

^-^. 

.--*'' 

^ 

5 

— »»^ 

0 

1400 
1200 
1000 
800 
600 
400 
200 


Fig.  98. — Seasonal  Occurrence  of  400  Cases  of  Tuberculous  Meningitis. 
Lower  Curve,  Deaths  from  Pneumonia  New  York  City,  one  year. 

culosis  in  lungs,  bones,  or  lymph  nodes.  The  modes  of  acquiring  tubercu- 
losis are  discussed  in  the  general  chapter  on  that  disease.  It  is  sufficient 
to  say  here  that  it  is  usually  from  some,  member  of  the  family  or  house- 
hold. This  may  be  not  only  a  person  who  is  in  the  active  stage  of  pul- 
monary tuberculosis;  but  one  who  is  supposed  to  have  been  cured  or  one 
in  whom  the  disease  has  not  yet  been  suspected.  Exposure  may  antedate 
symptoms  by  several  weeks  or  mouths.  Striking  evidence  in  favor  of  the 
human  origin  of  tuberculous  meningitis  is  obtained  from  a  study  of  the 
type  of  tubercle  bacillus  present  in  cases  of  meningitis.  In  thirty-two 
cases  in  our  series,  this  was  worked  out  by  Park  and  Krumwiede  in  the 
Eesearch  Laboratory  of  the  New  York  Health  Department.  In  thirty 
the  bacillus  was  of  the  human  type;  in  one  it  was  of  the  bovine  type, 
and  in  one  both  types  were  present. 

Symptoms. — In  about  two-thirds  of  the  cases  the  onset  is  gradual; 


750  DISEASES  OF  THE  NERVOUS  SYSTEM 

but  in  a  considerable  number  of  those  classed  as  abrupt,  careful  inquiry 
will  elicit  a  history  of  previous  indisposition.  The  most  frequent  early 
nervous  symptoms  are,  disinclination  to  play,  drowsiness,  or  sometimes 
constant  fretfulness  or  irritability.  Often  there  is  a  complete  change  in 
disposition.  In  a  case  under  our  observation  this  was  most  striking; 
a  little  girl  previously  devoted  to  her  mother,  could  not  endure  her 
presence  in  the  room.  Sleep  is  restless  and  disturbed;  there  may  be 
grinding  of  the  teeth.  Older  children  often  complain  of  headache.  At 
all  ages,  but  particularly  in  infancy,  early  digestive  symptoms  are  prom- 
inent. There  are  seen  frequent  attacks  of  vomiting  without  apparent 
cause;  the  bowels  are  generally  constipated  and  the  appetite  is  almost 
entirely  lost.  Usually  there  is  also  a  slight  but  continuous  elevation  of 
temperature.  Indefinite  symptoms  may  last  for  four  or  five  days,  or 
they  may  be  spread  over  two  or  three  weeks  without  perhaps  being  suf- 
ficiently severe  to  attract  much  notice.  Finally,  unmistakable  evidence 
of  brain  disease  develops.  The  early  disturbances  are  often  ascribed  to 
dentition,  or  to  indigestion. 

In  most  cases  the  first  pronounced  cerebral  symptom  is  persistent  and 
increasing  drowsiness;  exceptionally  it  is  an  attack  of  general  convul- 
sions, followed  in  a  few  hours  by  stupor.  Often  a  period  of  irritative 
symptoms  is  present,  lasting  several  days.  There  is  headache,  usually 
located  in  the  frontal  region,  and  occasionally  photophobia;  sometimes 
pain  is  indicated  by  the  child's  suddenly  screaming  out  at  night,  which 
may  be  repeated  many  times  without  waking;  sometimes  during  the 
greater  part  of  the  tim.e  for  two  or  three  days  these  frequent  screaming 
attacks  may  be  repeated.  The  skin  is  somewhat  hyperesthetic ;  the  re- 
fiexes  are  apt  to  be  exaggerated;  the  muscles  of  the  neck  may  be  rigid 
and  the  head  is  drawn  back,  or  there  may  be  rigidity  of  the  extremities. 
The  pupils  are  normal  or  contracted;  there  may  be  nystagmus.  The 
child  is  fretful,  wishes  to  be  left  alone,  and  cries  if  disturbed.  In  some 
cases  these  symptoms  are  so  marked  as  strongly  to  suggest  cerebrospinal 
meningitis.  They  may  alternate  with  periods  of  marked  apathy  and 
dulness.  During  this  stage  there  is  occasional  vomiting,  and  the  bowels 
are  obstinately  constipated.  The  pulse  is  usually  somewhat  accelerated, 
but  may  be  slow  and  occasionally  it  is  irregular.  The  respiration  is  of 
normal  frequency,  but  a  careful  observation  during  sleep  or  perfect  quiet 
will  often  show  a  distinct  irregularity  which  is  very  significant.  The 
temperature  is  usually  elevated,  ranging  from  99°  to  100.5°  F.  When 
a  high  temperature  is  seen,  it  is  usually  due  to  tuberculosis  elsewhere 
than  in  the  brain. 

As  the  disease  advances,  the  irritative  symptoms  subside,  and  the  stu- 
por becomes  deeper  and  more  continuous.  If  undisturbed,  the  child  may 
sleep  a  great  part  of  the  time,  but  can  be  roused,  and  then  appears 


•      TUBERCULOUS  MENINGITIS  751 

quite  rational.  Finally  the  stupor  becomes  so  profound  that  the  child  can 
not  be  roused  at  all.  Active  delirium  is  rare.  The  pupils  respond  slowly 
to  light  or  not  at  all;  they  may  be  unequal;  occasionally  there  is  seen 
strabismus,  ptosis,  or  paralysis  of  the  face.  More  often  there  is  hemi- 
plegia, or  paralysis  of  one  arm  or  leg.  Such  paralyses  are  often  transient, 
disappearing  after  a  day  or  two.  Automatic  movements  of  the  extre?iii- 
ties,  particularly  of  the  arms,  are  frequent.  Muscular  twitchings  may 
be  noticed.  Opisthotonus  is  marked  and  well-nigh  constant.  In  infants 
the  fontanel  is  tense  and  bulging.  In  older  children  especially,  the  ab- 
domen is  retracted,  giving  the  typical  "boat-belly."  After  drawing  the 
finger-nail  along  the  skin  of  the  abdomen,  there  appears  a  distinct  red 
streak,  which  remains  for  several  minutes.  This  is  the  tache  cerehrale, 
and  it  is  almost  always  present.  Other  vasomotor  disturbances  may  be 
seen.  The  reflexes  are  variable ;  in  the  early  part  of  the  disease  they  are 
usually  increased,  later  they  are  diminished  or  abolished.  The  pulse  now 
becomes  slow  and  irregular, 
often  intermittent.  The  res-  ^^,y^j\Aj\l\ 
piration   is  almost  always   ir-  « 

rpp-nlar-  a  vprv  characfpristic  ^ig.  99.— Tracing  of  Respiration  in  Tttbeb- 
reguiar,  a  very  cnaracterisiic  gtjlous  Meningitis. 

type  consists  in  the  movements 

becoming  deeper  and  deeper  until  there  is  a  sigh ;  followed  by  a  complete 
arrest  of  respiration  for  several  seconds.  The  phenomenon  is  then  re- 
peated. The  accompanying  tracing  illustrates  the  type  (Fig.  99).  An 
examination  with  the  ophthalmoscope  usually  shows  the  presence  of 
choked  discs,  and  in  a  very  considerable  number  of  the  cases,  if  they  are 
closely  studied,  tubercles  may  be  seen  in  the  choroid.  Their  presence  is 
of  much  diagnostic  importance.  The  blood  picture  in  this  disease  is 
fairly  characteristic.  From  230-observations  made  in  the  Babies'  Hospi- 
tal, it  was  shown  that  early  in  the  attack  the  total  leucocytes  are  only 
slightly  increased,  they  may  be  even  below  the  normal.  As  the  disease 
progresses  they  increase  in  number,  the  average  during  the  last  week  of 
the  disease  being  29,600.  The  proportion  of  polymorphonuclears  also 
shows  a  marked  increase.  The  early  range  was  60  to  65  per  cent;  during 
the  last  week  it  was  from  70  to  85  per  cent. 

The  progress  of  the  disease  is  subject  to  great  variations,  especially 
in  children  over  two  years  old.  The  advance  of  symptoms  is  slower  and 
is  interrupted  by  periods  of  remission  which  may  continue  two  or  three 
days.  After  being  in  quite  deep  stupor,  a  child  may  recover  conscious- 
ness, and  even  sit  up  and  play  with  toys,  leading  to  the  view  that  an 
error  in  diagnosis  has  been  made.  But  this  respite  is  only  temporary; 
soon  the  child  passes  again  into  coma. 

From  this  time  the  duration  of  the  disease  is  from  three  to  ten  days. 
The  child  can  not  be  roused  at  all.     The  pupils  are  widely  dilated,  and 


752 


DISEASES  OF  THE  NERVOUS  SYSTEM 


do  not  respond  to  light.  There  is  general  muscular  relaxation.  There 
may  be  retention  of  the  urine.  Deglutition  is  difficult,  often  impossible. 
The  respiration  is  more  rapid,  but  still  irregular.  The  pulse  becomes 
very  rapid  and  feeble,  often  160  to  180  a  minute.  Toward  the  end  the 
temperature  often  rises  rapidly  to  104°  F.,  sometimes  to  106°  or  107°  F. 
(Fig.  100).  Death  usually  takes  place  from  exhaustion  in  deep  coma, 
or  convulsions  develop  and  continue  from  twelve  to  twenty-four  hours 
until  death.  Sometimes  a  patient  will  live  for  days  in  a  condition  of 
prostration  so  extreme  that  death  is  hourly  expected.  A  rapidly  rising 
temperature  or  the  occurrence  of  late  convulsions  usually  indicates  ap- 
proaching death.     Of  fifty-seven  cases,  fifty  died  in  coma,  seven  in  con- 


DAY 

1 

2 

3 

4 

5 

c 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

DATE 

OCT. 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

I 
z 

I 
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s 

H 

10C° 
105° 
104° 

103° 
102° 
101° 

100° 
9a' 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

^t 

J 

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-4 

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r 

Fig.  100. 


-Fairly    Typical    Temperature    Curve    in    Tuberculous    Meningitis. 
Boy,  twenty  months  old;  death  on  seventeenth  day. 


vulsions.  The  entire  duration  of  the  disease  from  the  beginning  of 
definite  nervous  symptoms  is  rarely  over  three  weeks,  and  in  infants  it 
is  usually  shorter  than  this. 

Diagnosis. — Tuberculous  meningitis  is  often  overlooked  because  the 
patients  do  not  give  outward  evidences  of  tuberculosis.  Its  fre- 
quency should  always  lead  one  to  suspect  it  when  protracted  nervous 
symptoms  are  present  in  infants.  There  are  no  diagnostic  symptoms  in 
the  early  stage.  The  indefinite  symptoms  that  belong  to  this  stage  of 
the  disease  are  frequent  in  young  children  suffering  from  chronic  indi- 
gestion associated  with  constipation.  Cases  of  cyclic  vomiting  may 
present  many  of  the  symptoms  of  meningitis. 

The  most  diagnostic  symptoms  of  tuberculous  meningitis  enumerated 
in  the  order  of  their  frequency  are  as  follows:  persistent  drowsiness, 
obstinate  constipation,  vomiting  without  apparent  cause,  irregular  respi- 
ration, irregular  pulse,  convulsions,  opisthotonus,  and  fever  which  is 
usually  slight.  A  positive  diagnosis  is  made  only  by  lumbar  puncture ; 
by  this  means  this  form  is  distinguished  from  other  forms  of  acute 


TUBERCULOUS  MENINGITIS  753 

meningitis.  The  fluid  drawn  by  lumbar  puncture  is  usually  perfectly 
clear,  but  sometimes  after  standing  there  is  a  slight  deposit  present. 
In  rare  cases  the  fluid  may  be  turbid.  As  compared  with  the  otlier  forms 
of  acute  meningitis  the  cells  are  few  in  nunil)er.  The  usual  cell  count 
is  from  100  to  250  per  c.  mm.  Nearly  all  the  cells,  over  95  per  cent  in 
most  cases,  are  mononuclear.  Very  exceptionally  the  polymorphonuclear 
cells  are  greatly  in  excess.  The  presence  or  absence  of  sugar  has  been 
in  our  experience  of  no  diagnostic  importance. 

Tubercle  bacilli  are  almost  invariably  present  in  the  fluid,  although 
in  the  early  stage  they  are  few  in  number  and  often  difficult  to  find. 
But  at  the  height  of  the  disease  by  careful  examination  they  can  be 
found  microscopically  in  nearly  every  case.  They  were  found  in  135 
of  137  consecutive  cases  of  tuberculous  meningitis  at  the  Babies'  Hospi- 
tal.   They  are  more  numerous  late  in  the  disease. 

The  technic  is  important.  Fluid  should  be  drawn  into  several 
tubes  and  the  last  one  containing  15  to  20  c.cm.  set  aside  for  examination, 
as  the  bacilli  are  much  more  likely  to  be  found  in  this.  The  tube 
should  not  be  shaken,  but  should  be  allowed  to  stand  for  twelve  hours, 
preferably  in  an  incubator.  A  central  fibrin  eoagulum  generally  forms  in 
the  fluid,  and  in  this  the  bacilli  are  \isually  entangled.  This  should  be 
spread  out  entire  and  carefully  examined.  In  other  cases  the  bacilli 
may  be  found  after  centrifuging.  In  most  of  the  cases  the  number  of 
bacilli  present  is  not  large  and  a  search  of  half  an  hour  to  an  hour  is 
necessary;  but  not  infrequently  they  are  so  numerous  that  they  are 
discovered  in  a  few  minutes. 

The  Eoss-Jones  ^  and  Noguchi  globulin  tests  are  useful  in  distin- 
guishing inflammatory  from  normal  cerebrospinal  fluids.  They  are, 
however,  of  no  value  in  distinguishing  between  the  different  forms  of 
meningitis.  A  positive  reaction  is  obtained  with  great  uniformity  in 
every  variety  of  acute  meningitis. 

Bacilli  have  been  found  in  the  sputum,  in  our  experience,  in  nearly 
one-half  the  cases  in  infants  and  young  children  with  tuberculous  menin- 
gitis, although  in  most  of  them  there  was  little  or  no  evidence  of  pul- 
monary disease. 

The  V.  Pirquet  cutaneous  test  gives  reliable  information  except  in 
moribund  cases,  in  those  excessively  prostrated  or  with  very  poor  circula- 

*  Lancet,  May  8,  1909,  p.  113. 

A  few  cubic  centimeters  of  a  completely  saturated  solution  of  pure  am- 
monium sulphate  are  placed  in  a  test  tube  and  1  c.c.  of  cerebrospinal  fluid  is 
gently  run  on  to  the  surface.  A  positive  reaction  is  indicated  by  the  formation 
of  a  ring  at  the  point  of  contact  of  the  two  fluids.  The  ring  is  grayish  white  and 
sharp.  It  should  form  within  three  minutes.  Indirect  illumination  should  be 
used  for  its  detection. 


754  DISEASES  OF  THE  NERVOUS  SYSTEM 

tiou.    A  positive  reaction  was  obtained  in  161  of  194  cases  tested.    This 
tesL  is  of  much  assistance  in  early  diagnosis. 

If,  then,  a  child  Avith  symptoms  distinctly  meningeal  gives  a  positive 
reaction  to  the  tuberculin  test  the  probabilities  of  tuberculous  meningitis 
are  greatly  strengthened,  even  though  at  the  time  bacilli  may  not  have 
been  found  in  the  cerebrospinal  fluid. 

The  cerebral  symptoms  of  intestinal  and  many  other  acute  diseases 
sometimes  closely  resemble  those  of  tuberculous  meningitis.  From  all 
such  the  diagnosis  is  made  by  lumbar  puncture.  In  any  case  of  men- 
ingitis in  a  young  child  the  chances  are  greatly  in  favor  of  the  tuber- 
culous form,  since  it  is  much  more  frequent.  The  diagnosis  from  cere- 
brospinal meningitis  and  acute  jjoliomyelitis  is  considered  under  those 
diseases.  Differentiation  from  the  meningeal  form  of  poliomyelitis  may 
be  very  difficult,  owing  to  the  similarity  of  the  spinal  fluid  in  the  two 
diseases. 

Prognosis. — Although  there  have  been  recorded  a  few  instances  of 
recovery  after  tubercle  bacilli  have  been  found  in  the  fluid  obtained 
by  lumbar  puncture,  such  an  outcome  is  not  to  be  expected.  We  have 
never  seen  such  a  case  recover.  The  rej^orted  recoveries  in  which 
the  diagnosis  has  rested  upon  clinical  symptoms  only,  can  not  be 
accepted. 

Treatment. — From  what  has  been  said  regarding  prognosis,  it  follows 
that  if  the  diagnosis  is  correct  the  case  is  practically  hopeless,  no  matter 
what  treatment  is  employed ;  but  as  a  positive  diagnosis  is  not  always 
possible,  all  cases  should  be  treated  like  other  forms  of  acute  meningitis. 


CHRONIC  BASILAR  MENINGITIS  IN  INFANTS 

It  was  first  pointed  out  in  1898  by  Still  that  this  disease  is  usually 
due  to  the  diplococcus  intracellularis ;  in  other  words,  that  it  is  a  chronic 
form  of  cerebrospinal  meningitis.  Chronic  basilar  meningitis  is  most 
frequently  seen  after  epidemics  of  cerebrospinal  meningitis,  but  it  is 
occasionally  met  with  at  other  times  as  a  sequel  of  a  sporadic  case.  It 
occurs  after  an  acute  attack,  when  the  basilar  lesion  persists,  and  be- 
comes chronic.  As  acute  cerebrospinal  meningitis  in  infants  is  usually 
fatal  if  the  attack  is  severe,  it  follows  that  the  chronic  form  is  seen 
only  after  the  mild  attacks.  It  is  chiefly  for  this  reason  that  the  early 
symptoms  often  are  not  recognized  as  those  of  cerebrospinal  meningitis. 
The  patient  frequently  does  not  come  under  observation  until  all  acute 
symptoms  have  passed  away,  the  persistent  opisthotonus  being  the  chief 
feature  of  the  ease. 

There  is  also  seen  in  children,  though  very  rarely,  a  chronic  basilar 


CHRONIC  BASILAR  MENINGITIS  IN  INFANTS  755 

meningitis  of  syphilitic  origin.     Several  such  cases  have  come  under 
our  observation.  .  .(,:. 

Lesions. — This  process  is  usually  limited  to  the  base  of  the  brain. 
The  pia  mater  is  thickened  about  the  interpeduncular  space,  also  over 
the  medulla,  pons,  and  cerebellum.  It  may  be  adherent  to  the  inner 
surface  of  the  dura.  The  foramina  of  Magendie  and  of  Luschka  are 
usually  obliterated,  and  there  results  a  distention  of  the  lateral  ventricles 
with  clear  serum,  sometimes  in  sufficient  amount  for  the  case  to  be  re- 
garded as  hydrocephalus.  Earely,  pus  may  be  found  in  the  ventricles. 
There  may  be  a  cystic  formation  at  the  base  of  the  brain  due  to  the  accu- 
mulation of  fluid  in  one  of  the  cisterns  of  the  pia.    In  such. circumstances 


Fig.  101. — Chronic  Basilar  Meningitis — Extreme  Deformity.  Ill  for  five  months; 
followed  cerebrospinal  meningitis;  posture  shown  in  the  picture  was  maintained  for 
the  last  six  weeks;  death  at  ten  months.     Autopsy  showed  typical  lesions. 

the  cerebellum  is  often  much  compressed  by  the  fluid.    The  cranial  nerves 
may  also  be  compressed. 

Symptoms. — The  onset  is  usually  gradual,  although  in  most  cases 
there  can  be  obtained  a  fairly  distinct  history  of  an  early  active  period. 
The  most  prominent  symptoms  are  cervical  opisthotonus,  moderate  hy- 
drocephalus, and  usually  general  muscular  rigidity.  The  opisthotonus  is 
often  extreme  (Fig.  101)  and  is  greater  than  is  seen  in  any  other  disease. 
If  placed  upon  his  back  the  body  of  the  child  often  touches  the  table  only 
at  the  occiput  and  the  sacrum  (Fig.  102).  The  head  is  usually  some- 
what enlarged,  but  never  to  the  degree  seen  in  primary  hydrocephalus; 
the  fontanel  bulges,  and  the  sutures  are  separated.  These  symptoms 
are  due  to  an  accumulation  of  fluid  in  the  lateral  ventricles.  The  rigidity 
of  the  extremities  is  very  great  and  in  most  cases  constant ;  the  legs  and 


756 


DISEASES  OF  THE  XERVOUS  SYSTEM 


feet  are  usually  extended,  while  the  forearms  are  flexed  and  the  hands 
clenched.  All  the  reflexes  are  g-reatly  exaggerated.  There  is  rarely 
coma,  but  mental  dulness  alternating  with  periods  of  great  irritability 
in  which  general  convulsions  may  occur.  Vision  may  be  impaired  or 
wanting  entirely.  The  fact  that  in  most  of  the  cases  optic  neuritis  is 
absent  is  of  some  value  in  differentiating  this  disease  from  tumor.  Xys- 
tagmus  is  often  present  and  attacks  of  vomiting  occur  Avithout  evident 
cause.  There  is  no  fever  except  for  a  few  days  at  a  time  during  acute 
exacerbations.  Fluid  obtained  b}'  lumbar  puncture  is  often  clear  but 
usually  contains  a  slight  excess  of  cells  and  the  globulin  reaction  is  pos- 
itive.   Occasionally  turbid  fluid  may  be  obtained  and  there  may  be  found 


Fig.  102. — Chhonic  Basilar  Meningitis.     A  patient  in  the  Babies'  Hospital  (diagnosis 

confirmed  by  autopsy). 


a  small  number  of  meningococci,  both  intra-  and  extra-cellular.  The 
usual  duration  of  the  disease  is  from  two  to  five  months;  death  may 
occur  from  convulsions,  or  from  some  intercurrent  disease,  such  as  pneu- 
monia, but  most  frequently  from  marasmus.  The  prognosis  is  very  bad 
except  when  the  cause  is  syphilis,  when  recovery  may  take  place. 

Diagnosis, — The  disease  is  to  be  distinguished  from  tuberculous 
meningitis,  and  from  the  opisthotonus  of  reflex  origin  which  is  occa- 
sionally seen  in  infants  suffering  from  marasmus.  It  differs  from  tuber- 
culous meningitis  in  its  more  protracted  course,  in  the  absence  of  fever 
and  paralysis,  and  also  in  the  greater  prominence  of  the  opisthotonus  and 
hydrocephalus. 

Treatment. — If  meningococci  are  found,  anti-meningococcus  serum 
should  be  used.     It  will  usually  destroy  the  organisms,  although  it  can- 


THROMBOSIS  OF  THE  SINUSES  OF  THE  DURA  MATER  757 

not  affect  the  pathological  changes  that  have  taken  place  as  the  result  of 
their  long  activit}-.  If  there  is  any  reason  to  suspect  syphilis,  salvarsan 
and  the  iodid  of  potassium  and  mercury  should  be  administered.  Opera- 
tions for  the  relief  of  the  hydrocephalus  have,  up  to  the  present  time, 
met  with  little  measure  of  success. 


THROMBOSIS  OF  THE  SINUSES  OF  THE  DURA  MATER 

This  is  not  of  very  frequent  occurrence.  It  may  depend  upon  certain 
general  conditions,  when  it  is  usually  classed  as  cachectic  or  marantic 
thrombosis;  it  may  be  associated  with  local  pathological  processes,  when 
it  is  known  as  infammatory  or  septic  thrombosis. 

Cachectic  Thrombosis. — This  is  seen  in  infants  and  young  children, 
but  is  very  rare  after  the  age  of  five  years.  It  occurs  in  the  course  of 
various  diseases,  the  most  frequent  being  pneumonia,  pertussis,  diph- 
theria, nephritis,  tuberculosis,  and  the  acute  intestinal  diseases.  In 
connection  with  the  last-mentioned  group,  altogether  too  much  has  been 
made  of  it,  as  it  is  really  rare,  and  in  only  a  very  few  cases  does  it  explain 
the  cerebral  symptoms  present.  The"  actual  cause  of  the  thrombosis  is 
the.  altered  condition  of  the  blood  and  the  feeble  circulation,  as  the  walls 
of  the  sinuses  are  normal. 

The  most  frequent  seat  of  cachectic  thrombosis  is  the  superior  longi- 
tudinal sinus.  x\t  autopsy  one  must  be  careful  not  to  confound  the  soft, 
partly  decolorized,  non-adherent  thrombi  of  post-mortem  origin,  with 
those  of  ante-mortem  formation.  The  latter  are  firm,  and  when  of  long 
standing  may  be  very  hard  and  even  show  a  laminated  structure.  They 
usually  fill  the  sinus  completely,  and  are  adherent.  The  thrombus  ex- 
tends from  the  sinuses  to  the  veins  emptying  into  it,  which  stand  out 
like  dark  worms  upon  the  surface  of  the  brain.  The  brain  itself  may  be 
deeply  congested,  or  it  may  be  covered  with  a  diffuse  hemorrhage,  but 
more  frequently  the  brain  and  the  membranes  are  simply  edematous. 

The  symptoms  of  cachectic  thromljosis  are  few  and  uncertain,  and  in 
a  large  number  of  cases  the  disease  is  latent.  Very  rarely  is  a  positive 
diagnosis  possilde  during  life.  When  the  thrombosis  occurs  just  before 
death,  its  symptoms  arc  so  mingled  with  those  of  tlie  original  disease 
that  they  can  not  l)e  separated.  In  some  cases  there  may  be  localized 
or  general  convulsions,  or  paralysis,  loss  of  consciousness,  and  stra- 
bismus. 

The  prognosis  is  bad,  cases  generally  proving  fatal  in  the  course  of  a 
few  days.  The  diagnosis  is  so  uncertain  and  obscure  that  the  treatment 
must  be  symptomatic,  and  directed  toward  the  general  rather  than  the 
local  condition. 


758  DISEASES -OF  THE  NERVOUS  SYSTEM 

Inflammatory    Thrombosis — Septic     Thrombosis — Sinus-Phlebitis. — 

This  condition  is  most  frequently  seen  in  children  in  connection  with 
acute  meningitis.  It  may  exist  either  with  the  simple  or  the  tuberculous 
variety.  It  also  follows  otitis — especially  old  and  neglected  cases — usu- 
ally with  necrosis  of  the  petrous  bone,  but  sometimes  without  it.  It  is 
much  less  frequently  associated  with  disease  of  the  ear  in  children  than 
in  adults.  It  may  arise  from  traumatism,  necrosis  of  the  cranial  bones, 
or  from  septic  processes  involving  any  of  the  cavities  or  any  of  the 
structures  adjacent  to  the  brain,  such  as  the  scalp,  orbit,  nasal  fossa, 
mouth,  or  pharynx.  Infection  from  the  mouth  or  pharynx  is  most  fre- 
quent in  children  in  connection  with  scarlet  fever  or  diphtheria;  while 
usually  secondary  to  otitis  it  may  occur  without  it,  the  infection  being 
carried  by  the  blood-vessels.  Infection  from  the  nose  may  have  its 
origin  in  ulceration  from  syphilis  or  tuberculosis.  In  the  orbit,  the 
source  may  be  malignant  disease. 

The  seat  of  the  thrombosis  will  depend  upon  the  original  disease.  If 
this  affects  the  cranial  bones  or  the  scalp,  it  will  be  the  longitudinal 
sinus;  if  the  ear,  the  lateral  sinus;  if  the  base  of  the  skull,  the  orbit, 
the  mouth,  the  jaw,  or  the  nose  is  affected,  it  will  be  the  cavernous  sinus. 
When  thrombosis  occurs  with  meningitis  the  lesions  are  much  the  same 
as  in  the  cachectic  form,  with  the  exception  that  there  are  sometimes 
slight  changes  in  the  walls  of  the  sinuses.  If  the  patient  has  suffered 
from  a  local  septic  process,  there  may  be  puriform  softening  of  the 
clot,  and  general  pyemia,  with  the  development  of  secondary  abscesses 
in  the  brain,  in  the  lungs,  and  in  other  organs.  With  such  cases  there 
may  be  associated  a  general  or  localized  meningitis. 

Symptoms. — The  symptoms  of  septic  thrombosis  are  more  definite 
than  those  of  the  cachectic  form.  When  occurring  in  the  course  of  men- 
ingitis, it  usually  adds  no  new  symptoms  to  those  of  the  original  dis- 
ease. In  the  pyemic  form  the  symptoms  are  more  characteristic,  par- 
ticularly when  associated  with  otitis.  There  are  recurring  chills  with 
very  high  and  widely  fluctuating  temperature.  There  is  headache,  and 
often  localized  tenderness  of  the  scalp;  the  other  symptoms  which  are 
present  are  usually  the  same  as  those  of  ineningitis.  If  metastasis  oc- 
curs, there  may  be  evidences  of  abscesses  in  the  brain  or  in  other  organs, 
and  sometimes  there  are  signs  of  suppuration  in  the  jugular  vein.  A 
polymorphonuclear  leucocytosis  is  usually  present,  and  blood  cultures 
in  most  cases  show  the  presence  of  pyogenic  organisms. 

The  local  symptoms  of  the  thrombosis  differ  somewliat  according  to 
the  sinus  affected :  if  its  seat  is  the  superior  longitudinal  sinus,  there 
may  be  cyanosis  of  the  face,  dilatation  of  the  temporal  and  frontal  veins, 
and  sometimes  epistaxis ;  if  the  lateral  sinus  is  involved,  the  process  may 
extend  to  the  jugular  vein,  which  may  be  felt  in  the  neck  as  a  hard 


CEREBRAL  AB8CESR  759 

cord,  and  there  may  be  dilatation  of  the  veins  of  the  mastoid  region,  and 
even  localized  edema ;  when  the  cavernous  sinus  is  affected,  there  may  be 
protrusion  of  the  eyeball  of  the  affected  side,  edema  of  the  lid,  and  with 
the  ophthalmoscope  the  retinal  veins  appear  enlarged  and  tortuous,  some- 
times being  the  seat  of  thrombosis.  The  process  may  affect  either  one 
or  both  sides.  The  course  of  septic  thrombosis  is  rather  irregular,  vary- 
ing from  a  few  days  to  three  weeks.  In  fatal  cases  death  takes  place 
from  meningitis,  cerebral  abscess,  or  pyemia.  The  prognosis  is  very 
grave  unless  the  disease  is  so  situated  that  it  is  accessible  to  surgical 
operation. 

Treatment. — The  only  successful  treatment  is  surgical.  Operation 
is  easiest  in  thrombosis  of  the  lateral  sinus,  being  much  more  difficult 
if  involving  the  superior  longitudinal  sinus.  So  many  cases  are  now  on 
record  of  successful  operation  upon  septic  thrombosis  of  the  lateral  sinus 
that  it  should  always  be  urged  when  the  diagnosis  is  clear. 


CEREBRAL  ABSCESS 

Cerebral  abscess  is  quite  rare  in  children,  decidedly  more  so  than  is 
cerebral  tumor.  In  Gowers'  collection  of  333  cases,  only  twenty-four 
were  under  ten  years  of  age.  In  infants,  abscess  is  one  of  the  least  fre- 
quent diseases  of  the  brain,  and  up  to  five  years  it  is  exceedingly 
rare. 

Etiology. — By  far  the  most  frequent  cause  in  children  is  otitis.  This 
is  the  origin  of  the  great  majority  of  the  cases.  Abscess  rarely  compli- 
cates acute  otitis,  but  is  seen  with  the  chronic  form.  Exactly  how  otitis 
causes  cerebral  abscess  it  is  not  always  easy  to  determine.  Usually 
there  is  caries  of  the  petrous  bone,  but  there  may  be  none.  The  infection 
may  extend  through  the  small  veins  traversing  this  bone,  or  along  the 
lateral  sinuses  to  the  cerebellum.  Abscess  is  often  attributed  to  the  re- 
tention of  pus  in  the  ear,  but  it  may  occur  when  the  discharge  is  free. 

We  have  seen  in  a  young  infant  abscess  follow  nasal  infection,  the 
process  apparently  extending  through  the  cribriform  plate  of  the  eth- 
moid. 

Traumatism  is  the  second  important  etiological  factor.  Abscess  may 
be  associated  with  fracture  of  the  skull,  or  follow  simple  concussion.  The 
abscess  is  generally  in  the  neighborhood  of  the  injury,  but  occasionally 
is  produced  by  contre  coup.  Abscess  may  be  the  result  of  infectious 
emboli,  associated  with  general  pyemia,  though  this  is  rare  in  early  life ; 
and  finally  it  may  occur  without  any  assignable  cause.  The  organisms 
nsnally  present  are  streptococci,  staphylococci,  or  pneumococci. 

Lesions. — Tlie  most  frequent  seat  of  the  abscess  is,  first,  tlie  tern- 


760  DISEASES  OF  THE  NERVOUS  SYSTEM 

porosphenoidal  lobe ;  secondly,  the  cerebellum ;  thirdly,  the  frontal  lobes. 
Other  locations  are  very  rare.  Abscesses  are  usually  single.  In  size  they 
vary  from  that  of  a  small  cherry  to  an  orange.  We  have  seen  a  case  in 
an  infant  in  which  one  whole  hemisphere  was  replaced  by  several  large 
abscesses  with  thick  walls,  only  a  thin  layer  of  cortex  covering  them. 
No  cause  for  them  could  be  found  and  the  pus  was  sterile.  The  con- 
tents are  usually  thick  greenish-yellow  pus,  which  may  be  very  fetid. 
When  abscesses  have  lasted  for  some  time  they  are  usually  surrounded 
by  a  dense  pyogenic  membrane,  and  may  become  encysted.  The  patholog- 
ical process  may  be  slow,  and  often  is  apparently  stationary  for  a  long 
period.  Abscesses  may  rupture  into  the  ventricles,  less  frequently  upon 
the  surface  of  the  brain,  causing  meningitis,  or  the  pus  may  even  escape 
externally  through  the  auditory  meatus. 

Symptoms. — These  are  general  and  local.  The  general  symptoms  are 
much  the  more  important  for  diagnosis,  and  often  are  the  only  ones 
present.  The  local  symptoms  are  those  of  a  tumor.  The  clinical  history 
of  a  case  of  abscess  of  the  brain  may  be  divided  into  three  stages :  First, 
the  period  of  onset,  or  early  acute  inflammatory  symptoms,  fever,  etc., 
which  attend  the  formation  of  pus.  Secondly,  the  latent  period,  or  period 
of  remission,  in  which  very  few  symptoms  are  present;  in  many  acute 
cases  this  stage  is  wanting  altogether;  in  the  chronic  cases  it  may  last 
for  months,  or  even  years.  Thirdly,  the  final  period,  with  recurrence 
of  active  cerebral  symptoms,  followed  by  death  in  a  few  days. 

The  onset  may  be  accompanied  by  symptoms  so  slight  as  almost  to 
escape  notice.  In  most  cases,  however,  headaclie  and  fever  are  present. 
The  headache  is  usually  severe,  and  often  localized  upon  the  affected 
side ;  in  cerebellar  abscess  it  may  be  occipital.  The  fever  is  moderate  in 
intensity,  and  continuous.  In  addition  there  may  be  vertigo,  vomiting, 
general  convulsions,  and  cessation  of  the  aural  discharge,  if  one  has 
been  present.  The  duration  of  this  stage  is  variable;  it  may  be  only  a 
few  days,  or  several  weeks.  It  is  shorter  in  traumatic  cases,  and  in 
those  which  are  due  to  pyemia. 

The  latent  stage,  or  period  of  remission  of  symptoms  may  be  quite 
short — only  a  few  days'  duration— and  it  is  often  absent.  During  this 
period  the  temperature  may  fall  quite  to  the  normal,  and  the  headache 
disappear,  or  be  only  occasional  and  slight.  However,  if  any  focal  symp- 
toms have  been  present  they  remain  unchanged. 

The  symptoms  of  the  terminal  stage  are  due  to  a  rapid  extension  of 
the  inflammatory  process,  with  edema  and  softening  about  the  abscess, 
sometimes  to  rupture  into  the  ventricle,  and  sometimes  to  meningitis. 
The  fever  now  returns,  and  may  be  high.  There  is  headache,  often 
very  intense  and  continuous ;  there  may  be  delirium  and  convulsions,  and 
tlie  gradual  development  of  coma.     In  addition  there  may  be  vomiting, 


CEEEBPvAL  ABSCESS  761 

paralysis,  opisthotonus,  retracted  abdomen,  and  the  other  symptoms  of 
meningitis.  Occasionally  all  the  earlier  symptoms  may  he  latent,  and 
the  terminal  symptoms  may  he  the  only  ones  present.  In  infants,  the 
fontanel  is  usually  large  and  hnlging;  convulsions  are  rather  more  fre- 
quent than  in  older  children. 

The  local  symptoms  of  abscess  are  rather  indefinite,  owing  to  its 
usual  situation.  Abscesses  of  considerable  size  may  exist  in  the  temporo- 
sphenoidal  lobe,  in  the  central  part  of  the  frontal  lobe,  or  in  the  cere- 
bellum, Avithout  any  definite  local  symptoms.  If  the  abscess  is  near 
the  motor  area,  there  are  the  usual  symptoms  of  disease  in  this  location : 
spasm,  or  paralysis  of  the  face,  arm,  or  leg.  A  cortical  or  subcortical 
abscess  is  likely  to  cause  convulsions.  Cerebellar  abscess  may  give  rise 
to  occipital  headache,  frequent  vomiting,  and  when  the  abscess  is  large 
enough  to  press  upon  the  middle  lobe,  there  may  be  incoordination  of 
the  muscles  of  the  extremities.  Optic  neuritis  may  be  present,  but  other 
symptoms  relating  to  the  cranial  nerves  are  rare.  Localized  tenderness 
over  ,the  scalp,  when  persistent,  is  a  symptom  of  importance,  and  may 
serve  to  locate  the  abscess,  if  it  is  superficial. 

Diagnosis. — Of  the  general  symptoms,  the  most  important  for  diag- 
nosis are  fever,  headache,  delirum,  and  terminal  coma.  These  become 
particularly  significant  when  following  otitis  or  traumatism.  The  dif- 
ferential diagnosis  of  abscess  is  to  be  made  principally  from  tumor  and 
meningitis,  and  from  these  conditions  more  by  the  history  and  general 
course  of  the  disease  than  by  any  special  symptoms.  The  diagnosis  of 
abscess  from  tumor  is  considered  in  connection  with  the  latter  dis- 
ease. It  is  more  difficult  to  distinguish  betv/een  meningitis  and  abscess, 
since  the  two  processes  are  often  associated.  With  meningitis  convul- 
sions are  more  common,  but  they  are  rarely  localized;  rigidity  and  the 
inflammatory  symptoms  are  more  intense;  the  course  is  usually  more 
rapid  and  more  regular,  being  rarely  interrupted,  as  is  the  course  of 
abscess.  Leucocytosis  is  more  constant  and  usually  more  marked  in 
meningitis.  Lumbar  pimcture  gives  negative  results  in  uncomplicated 
abscess  while  it  gives  positive  definite  information  in  meningitis. 

Prognosis. — The  prognosis  in  cerebral  abscess  is  always  grave,  unless 
accessible  to  surgical  operation.  The  progress  may  be  slow,  or  rapid,  but 
it  is  inevitably  from  bad  to  worse,  and  sooner  or  later  the  disease,  if  not 
interfered  with,  proves  fatal. 

Treatment. — The  medical  treatment  of  abscess  in  its  active  stage  is 
that  of  any  acute  intracranial  inflammation — ice  to  the  head,  absolute 
quiet,  free  catharsis,  and  full  doses  of  the  bromids  or  morphin,  if  pain 
is  intense.  The  absolutely  hopeless  condition  of  these  cases  when  left 
to  themselves,  and  tlie  recent  brilliant  results  from  surgical  operations, 
sliould  lead  tlie  physician  to  urge  operation  in,  every  ease. 


762  DISEASES  OF  THE  NERVOUS  SYSTEM 

CEREBRAL  TUMOR 

Tumor  of  the  brain  is  not  very  infrequent,  and  may  be  seen  even  in 
infancy. "  From  this  time  up  to  puberty  there  is  no  period  of  special 
susceptibility.  In  269  of  the  cases  in  Starr's  collection,  in  which  the 
nature  of  the  tumor  was  stated,  the  following  were  the  varieties : 

Tubercle    152  cases 

Glioma    >.....  37  " 

Sarcoma 34  " 

Ghosarcoma 5  " 

Cyst    30  " 

Carcinoma    , 10  " 

Gumma    1  " 

269  cases 

Tuberculous  tumors  are  more  often  multiple  than  are  other  varieties. 
Their  most  frequent  seat  is  the  cerebellum;  next  to  this  the  pons  and 
crura  cerebri.  They  are  occasionally  cortical  or  central.  Glioma  is  most 
often  found  in  the  cerebellum  or  in  the  pons,  and  next  in  the  cortex ;  it  is 
rarely  central.  Sarcoma  is  most  frequently  in  the  cerebellum;  next  to 
this,  in  the  order  of  frequency,  in  the  pons,  the  basal  ganglia,  and  the 
cortex.  Cystic  tumors  are  either  central  or  cerebellar.  Taking  the 
cases  as  a  whole,  the  most  frequent  seat  of  tumors  in  children  is :  first, 
the  cerebellum ;  second,  the  pons ;  third,  the  centrum  ovale.  They  rarely 
spring  from  the  cortex. 

Tuberculous  tumors  are  occasionally  seen  in  infancy,  but  they  occur 
most  frequently  between  the  ages  of  four  and  twelve  years.  They  are 
always  secondary  to  tuberculosis  elsewhere,  usually  of  the  lungs  and 
of  the  bronchial  lymph  nodes.  They  most  frequently  start  from  the 
membranes,  rarely  being  centrally  situated,  and  extend  inward,  infil- 
trating the  superficial  portion  of  the  cerebellum  or  cerebrum.  In  more 
than  half  of  the  cases  they  are  multiple.  There  is  almost  invariably 
localized  meningitis  at  the  site  of  the  tumor ;  there  may  be  adhesions 
between  the  dura  and  pia  mater,  and  the  disease  may  extend  to  the 
cranial  bones.  In  size  these  tumors  vary  from  a  small  pea  to  a  child's 
fist.  They  may  be  softened  and  broken  down  at  the  center,  or  cheesy 
throughout.  They  are  the  result  of  a  localized  tuberculous  inflammation, 
which  does  not  differ  essentially  from  that  seen  in  other  parts  of  the 
body.    They  rarely  undergo  calcification. 

Glioma  is  not  infrequent  in  infancy.  It  repeats  the  structure  of 
the  neuroglia,  being  composed  of  connective  tissue  and  branching  cells. 
It  is  an  infiltrating  tumor  whose  limits  are  difficult  to  determine  even 
under  the  microscope. 

Sarcomata  may  be  of  almost  any  variety.     They  grow  much  more 


CEREBRAL  TUMOR  763 

rapidly  than  gliomata.  The  two  varieties  are  very  occasionally  combined 
in  the  same  tumor — gliosarcoma. 

Cystic  tumors  may  be  the  result  of  porencephalic  softening  or  of 
encapsulated  hemorrhages  in  early  life.  Gliomata  and  sometimes  sar- 
comata undergo  cystic  softening.  Cysts  may  be  parasitic  in  origin.  The 
cause  of  many  simple  cysts  is  entirely  obscure.  They  may  be  found  in 
any  part  of  the  brain. 

Carcinomata  are  always  metastatic  and  are  secondary  to  a  primary 
growth  elsewhere  than  in  the  brain.  Gummata  and  vascular  tumors  are 
exceedingly  rare  until  after  puberty. 

As  the  tumor  grows,  secondary  lesions  are  produced  in  most  of  the 
cases.  These  are  the  result  of  pressure  on  contiguous  parts  of  the  brain 
interfering  with  their  function,  or  of  obstruction  to  the  aqueduct  of 
Sylvius  or  the  fourth  ventricle  preventing  the  exit  of  fluid  from  the  in- 
terior of  the  brain  and  thus  causing  hydrocephalus.  Tumors  in  the  pos- 
terior fossa  are  very  frequently  accompanied  by  hydrocephalus.  Local- 
ized meningitis  over  tumors  superficially  situated  is  the  rule,  and  this 
may  be  the  cause  of  some  of  the  symptoms.  Earely,  cerebral  hemorrhage 
may  be  associated. 

Etiology. — The  causes  of  cerebral  tumors  are  for  the  most  part 
unknown.  In  a  few  instances  there  is  a  history  of  definite  traumatism. 
Sarcomata  may  be  secondary,  carcinomata  and  tuberculous  tumors  are 
probably  always  so. 

Symptoms. — These  may  be  divided  into  two  groups:  first,  the  general 
symptoms,  which  are  common  to  tumors  of  all  varieties,  are  chiefly  due 
to  pressure  and  are  more  or  less  independent  of  location;  secondly,  the 
local  symptoms  depending  upon  the  situation  of  the  growth. 

Of  the  general  symptoms  one  of  the  most  frequent  is  headache. 
Though  it  varies  much  in  its  severity,  character,  and  position,  it  is 
rarely  absent.  It  is  apt  to  be  severe,  and  may  continue  for  a  long 
period,  or  it  may  be  intermittent.  The  location  of  the  pain  has  no 
definite  relation  to  the  situation  of  the  tumor,  nor  is  the  intensity  of  the 
pain  dependent  upon  the  size  of  the  tumor.  It  may  be  accompanied 
by  sensations  of  tightness,  compression,  or  tension  in  the  head.  It  may 
be  associated  with  localized  tenderness  of  the  scalp ;  when  this  is  constant 
it  is  a  valuable  symptom  for  diagnosis,  as  it  often  occurs  with  tumors 
superficially  located. 

General  convulsions  are  frequent  in  the  early  stage,  but  separated 
by  quite  long  intervals;  they  become  more  frequent  and  more  severe 
as  the  disease  progresses.  All  degrees  of  severity  are  seen,  from  slight 
twitchings  and  temporary  loss  of  consciousness  to  typical  epileptiform 
seizures.  They  are  most  common  when  the  growth  is  rapid  and  when 
complicating  meningitis  is  present.    Attacks  of  vomiting  or  of  localized 


764  DISEASES  OF  THE  NERVOUS  SYSTEM 

spasm  may  for  a  considerable  time  precede  general  convulsions ;  and  in  a 
single  attack  there  may  be  first  localized  and  then  general  convulsions. 

Mental  symptoms  are  generally  present  in  great  variety  and  com- 
plexity. There  may  be  only  fretfulness  and  irritability,  or  a  marked 
change  in  disposition.  These  symptoms  are  so  frequent  from  other 
causes  in  children  that  they  excite  no  apprehension,  unless  to  them  are 
added  dulness,  apathy,  and  somnolence.  Later  in  the  disease  there  may 
be  attacks  of  melancholia  or  there  may  be  periods  of  wild,  almost 
maniacal,  excitement ;  and,  finally,  the  mental  impairment  may  approach 
a  condition  of  imbecility. 

Disturbances  of  sleep  are  frequent.  There  is  usually  insomnia,  but 
sleep  may  be  broken  by  hallucinations,  accompanied  by  attacks  of 
screaming;  rarely  is  there  persistent  drowsiness  until  toward  the  end  of 
the  disease. 

Optic  neuritis  or  papillo-edema  (choked  disc)  is  very  frequent,  occur- 
ring in  80  to  90  per  cent  of  the  cases.  This  is  only  recognized  by  the 
ophthalmoscope,  as  there  may  be  no  disturbauce  of  vision.  The  choked 
disc  is  generally  double.  It  is  nearly  constant  with  tumors  of  the 
posterior  fossa,  especially  of  the  cerebellum.  It  is  also  very  frequent 
with  tumors  of  the  corpora  quadrigemina  and  of  the  parieto-occipital 
region.  Papillo-edema  is  usually  associated  with  tumors  of  the  basal 
ganglia,  but  is  late  in  appearance  or  frequently  absent  with  tumors 
of  the  pons,  corpus  callosum  or  convexity. 

Vomiting  is  a  very  frequent  symptom,  but  diagnostic  only  when  it 
occurs  suddenly  without  assignable  cause,  and  without  nausea  or  other 
symptoms  of  indigestion.  Usually  attacks  come  several  days  apart,  often 
occurring  early  in  the  morning.  Vomiting  is  especially  significant  when 
frequently  repeated,  and  of  more  importance  in  older  children  than  in 
infants. 

Vertigo  is  often  associated  with  vomiting.  At  first  it  is  occasional 
and  seen  upon  changing  position,  but  later  it  may  be  quite  constant, 
especially  with  tumors  in  the  posterior  fossa. 

A  slow  pulse  is  occasionally  observed  with  brain  tumors.  It  may  be 
as  low  as  40  or  50  to  the  minute.  This  is  the  result  of  increased  intra- 
cranial pressure,  and  is  only  found  when  the  pressure  is  great.  It 
is  therefore  usually  a  late  symptom.  Enlargement  of  the  head,  secondary 
to  the  hydrocephalus,  at  times  occurs.  It  is  more  apt  to  be  found  before 
the  fontanel  has  closed  and  the  sutures  are  firmly  ossified,  but  separation 
of  the  sutures  and  marked  enlargement  of  the  head  may  take  place  as 
late  as  the  eighth  or  tenth  year.  Pressure  of  the  tumor  may  cause 
erosion  of  the  contiguous  bone.  The  most  frequent  seat  of  this  erosion 
is  the  sella  turcica  with  tumors  of  the  pituitary.  This  can  often  be 
made  out  by  the  X-ray,  which  also  shows  frequently  separation  of  the 


CEREBRAL  TUMOR  765 

sutures  and  digital  markings  on  the  skull,  the  result  of  hydrocephalus. 
Very  infrequently  the  shadow  of  a  tumor  is  revealed.  Diabetes  insipidus 
is  a  symptom  occasionally  associated  with  tumors  at  the  base,  especially 
when  the  pituitary  is  involved. 

Local  Symptoms. — These  depend  upon  the  situation  of  the  tumor, 
but  not  at  all  upon  its  character.  They  are  the  result  of  pressure  or  of 
destruction  of  brain  tissue.  They  may  therefore  be  irritative  or  paral5^ic 
symptoms.  Local  symptoms  may  be  wanting  entirely,  and  they  may 
vary  much  in  different  cases  even  with  tumors  in  the  same  situation. 
They  are  modified  by  the  size  and  by  the  rapidity  of  growth,  and  by  the 
existence  of  localized  meningitis. 

Tumors  situated  in  the  frontal  lobe,  as  a  rule,  present  few  symptoms 
and  may  be  entirely  latent.  Irritation  of  the  frontal  lobe  may  extend 
to  the  motor  area  and  cause  convulsions  either  local  or  general;  but 
not  often  is  there  paralysis.  Tumors  of  the  left  side  (of  the  right  side 
in  left-handed  persons)  may  cause  apraxia,  and  when  in  the  third  frontal 
convolution,  motor  aphasia. 

Tumors  in  the  motor  convolutions  along  the  fissure  of  Eolando 
produce  the  most  definite  and  uniform  local  symptoms.  When  situated 
at  the  upper  portion  the  leg  is  affected,  at  the  middle  portion,  the  arm, 
and  at  the  lower,  the  face.  Irritative  symptoms,  such  as  rigidity  or 
clonic  spasm,  commonly  precede  for  some  time  the  paralysis  which  re- 
sults from  pressure  or  destruction.  These  attacks  of  localized  convulsions 
begin  in  the  face,  arm,  or  leg;  but  they  usually  extend  more  or  less 
rapidly  until  all  three  are  involved.  They  are  often  followed  by  slight 
transient  paralysis.  Consciousness  is  often  retained  and  when  lost  is  lost 
late  in  the  attack.  Such  attacks  are  known  as  "Jacksonian  epilepsy,"  and 
form  one  of  the  most  diagnostic  symptoms  of  cerebral  tumor.  Localized 
spasm  may  be  associated  with  anesthesia  or  other  disturbances  of  sensa- 
tion. The  paralysis  g'enerally  first  affects  one  extremity — the  arm  or  leg, 
according  to  the  location  of  the  tumor — and  afterward  it  may  involve 
the  entire  side,  including  the  face. 

If  the  tumor  is  centrally  located,  or  at  the  base,  hemiplegia  may  be 
an  early  symptom  from  pressure  on  the  motor  tract.  With  cortical 
paralysis  there  may  be  associated  ataxia  and  paresthesia  or  anesthesia. 

Tumors  of  the  parietal  lobe  may  give  no  local  symptoms.  If  the 
tumor  is  deeply  situated  there  may  be  hemianopsia  from  pressure  on 
part  of  the  optic  tract.  If  the  inferior  parietal  lobule  of  the  left  side 
is  affected,  there  may  be  word-blindness,  or  inability  to  understand  writ- 
ten language. 

Tumors  of  the  occipital  lobe  produce,  as  the  only  constant  local 
symptom,  hemianopsia.  This  is  usually  bilateral,  affecting  the  same  side 
of  both  eyes,  being  on  the  side  opposite  to  that  of  the  lesion,  i.  e.,  a 
26 


766  DISEASES  OF  THE  NERVOUS  SYSTEM 

tumor  on  the  right  side  causes  blindness  in  the  left  half  of  both  eyes, 
so  that  the  patient  sees  nothing  to  the  left  of  a  line  directly  in  front 
of  him.  Instead  of  hemianopsia,  there  may  be  only  irritation  and  various 
disturbances  of  sight.  ■' 

Tumors  of  the  temporosphenoidal  lol)e  may  be  latent,  or,  if  on  the 
left  side,  may  cause  word-deafness,  i.  e.,  inability  to  understand  the 
significance  of  spoken  language. 

Tumors  in  the  island  of  Eeil  when  situated  upon  the  left  side 
(right  side  in  left-handed  persons)  may  cause  motor  aphasia  or  disturb- 
ances of  speech.  If  they  are  large  they  may  produce  symptoms  by 
pressure  upon  the  motor  tract — hemiplegia  or  monoplegia. 

Tumors  of  the  basal  ganglia  cause  marked  general  symptoms,  but 
none  of  a  definitely  local  character.  The  important  symptoms  relate  to 
the  various  tracts  or  bundles  of  fibers  which  pass  from  the  cortex  through 
the  internal  capsule.  These  include  the  motor  and  the  various  sensory 
tracts,  the  olfactory,  auditory,  visual,  and  speech  tracts.  Any  of  these 
•may  be  pressed  upon,  and  the  nature  of  the  symptoms  will  depend  upon 
the  size  of  the  tumor  and  the  extent  of  the  pressure.  If  only  the 
anterior  part  of  the  capsule  is  affected  there  may  be  no  symptoms ;  if  the 
middle  fibers,  hemiplegia  and  disturbances  of  articulation ;  if  the  posterior 
fibers,  hemianesthesia.  All  these  may  be  associated,  and  any  of  them 
may  be  complete  or  partial.  Tumors  in  this  situation  are  apt  to  im- 
plicate the  cranial  nerves.  Optic  neuritis  is  quite  constant,  but  may 
not  appear  early.    Localized  or  general  convulsions  are  rare. 

The  peculiar  symptoms  pointing  to  tumors  of  the  crura  cerebri  are 
nystagmus,  strabismus,  and  loss  of  pupillary  reflex,  sometimes  with  gen- 
eral muscular  incoordination,  and  a  staggering  gait.  There  is  usually 
third-nerve  paralysis  on  the  side  of  the  tumor,  and  on  the  side  opposite 
to  the  hemiplegia  with  which  it  is  often  associated.  This  variety  of 
crossed  paralysis  is  quite  diagnostic.  The  symptoms  of  third-nerve 
paralysis  are  external  strabismus,  dilatation  of  the  pupil,  and  ptosis. 
While  hemiplegia  is  commonly  present  with  large  tumors,  it  may  be 
absent  with  small  ones,  or  may  appear  later  than  paralysis  of  the  third 
nerve. 

Tumors  of  the  pons  are  quite  common.  The  diagnostic  symptoms 
consist  in  crossed  paralysis,  the  cranial-nerve  symptoms  being  on  the 
side  of  the  tumor,  and  the  general  motor  and  sensory  symptoms  on 
the  opposite  side.  When  the  seat  is  the  upper  half  of  the  pons,  the  third 
and  fifth  nerves  are  apt  to  be  implicated,  giving  rise  to  ptosis,  dilatation 
of  the  pupils,  external  strabismus,  trophic  disturbances  such  as  ulcera- 
tion of  the  cornea,  and  neuralgic  pain  in  the  face.  Tumors  in  the  lower 
half  of  the  pons  involve  the  sixth,  seventh,  and  eighth  nerves,  causing 
internal  strabismus,  contracted  pupils,  facial  paralysis,  sometimes  deaf- 


CEREBRAL  TUMOR  767 

ness,  and  auditory  vertigo.  Other  symptoms  associated  with  tumors  of 
the  pons  are  headache,  vomiting  and  optic  neuritis;  convulsions  being 
rare. 

Tumors  of  the  medulla  are  recognized  by  the  involvement  of  the 
glossopharyngeal,  pneumogastric,  spinal  accessory,  and  hypoglossal 
nerves.  There  is  difficulty  of  deglutition,  irregular  respiration,  irregu- 
lar pulse,  and  vasomotor  disturbances,  such  as  flushing  of  the  face  and 
perspiration.  There  may  be  projectile  vomiting,  polyuria  or  glycosuria, 
opisthotonus,  difficulty  in  articulation  or  in  sucking,  and  in  protrusion 
of  the  tongue.  Hydrocephalus  is  often  marked.  These  tumors  may 
produce  symptoms  of  pressure  upon  the  motor  or  sensory  tracts — paraly- 
sis, or  partial  anesthesia,  with  rigidity  and  exaggerated  reflexes. 

Tumors  of  the  pituitary  gland  or  in  the  immediate  neighborhood 
may  give  characteristic  symptoms.  These  are  referred  to  hypopituitar- 
ism, a  decrease  in  the  function  of  the  anterior  lobe  of  the  pituitary. 
There  may  be  a  marked  deposition  of  subcutaneous  fat  with  a  tendency 
to  mental  dulness  and  with  a  retardation  of  sexual  development  at  the 
time  of  puberty.  This  is  frequently  spoken  of  as  "Frohlich's  syndrome.'* 
In  some  children  with  these  symptoms  there  is  an  increased  sugar 
tolerance  so  that  as  much  as  150  g^ams  of  glucose  may  be  taken  at  one 
time  without  glycosuria.  These  symptoms  are  usually  found  with  benign 
growths.  j\Ialignant  growths  such  as  sarcomata  are  destructive  and 
usually  produce  no  such  syndrome.  Symptoms  frequently  associated 
with  pituitary  growths  are  bitemporal  hemianopsia  from  pressure  on 
the  optic  chiasm  and  later  amblyopia.  There  may  be  paralysis  of  the 
extraocular  muscles.  Headache  is  not  a  striking  symptom  and  hydro- 
cephalus is  inconstant.     Acromegaly  is  rarely  seen  in  children. 

Tumors  of  the  cerebellum  are  especially  important,  this  being  the 
most  frequent  location  in  childhood.  When  only  one  hemisphere  is 
affected  there  may  be  no  local  symptoms.  Tumors  involving  the  middle 
lobe,  or  those  large  enough  to  produce  pressure  upon  the  middle  lobe, 
give  rise  to  vertigo  and  cerebellar  ataxia.  Vertigo  is  especially  frequent ; 
it  may  be  associated  with  headache.  Cerebellar  ataxia  is  different  from 
the  ataxia  due  to  a  spinal-cord  lesion,  and  strikingly  resembles  that  of 
intoxication.  •  It  may  increase  until  the  patient  is  unable  to  walk, 
although  there  is  no  loss  of  muscular  power.  Vomiting  is  a  frequent 
symptom,  as  are  also  optic  neuritis  and  headache,  whicli  is  usually 
occipital.  When  there  is  secondary  hydrocephalus,  as  is  usual,  mental 
symptoms  are  present,  and  there  may  be  enlargement  of  the  head.  Opis- 
thotonus is  occasionally  seen,  but  general  convulsions  are  rare. 

Course. — This  is  usually  progressive  toward  a  fatal  termination. 
The  rajjidJly  de] tends  much  upon  the  character  of  the  growili.  Malig- 
naijt  tumors,  especially  sarcomata,   may  cause   death   in   a   few  weeks. 


768  DISEASES  OF  THE  NERVOUS  SYSTEM 

Tuberculomata  may  give  s}Tiiptoms  for  many  mouths  but  are  usually 
fatal  before  that  time  from  general  miliary  tuberculosis  or  tuberculous 
meningitis.  Occasionally  symptoms  of  brain  tumor  may  be  present  for 
several  years  without  any  distinct  advancement  and  then  with  a  sudden 
increase  of  symptoms  death  may  take  j^lace  in  a  few  days. 

Diagnosis. — Cerebral  tumor  may  be  confounded  with  abscess,  chronic 
basilar  meningitis,  and  chronic  hydrocephalus.  The  symptoms  distin- 
guishing tumor  from  abscess  are  the  following:  Tumor  may  occur  at 
any  age;  without  definite  etiology,  excepting  when  tuberculous;  the 
progress  is  steady,  but  generally  slow,  new  symptoms  being  continually 
added;  headache  is  more  constant  and  more  severe;  optic  neuritis  more 
frequent;  cranial  nerves  more  often  involved;  meiital  disturbances  more 
marked;  focal  symptoms  are  often  definite;  fever  and  leucocytosis  are 
absent;  duration,  six  months  to  two  years.  As  compared  with  the  above, 
abscess  is  not  so  frequent,  being  especially  rare  in  infancy;  there  is  a 
definite  history  of  traumatism  or  ear  disease;  progress  more  irregular; 
symptoms  often  intermittent;  headache  less  severe;  mental  symptoms 
less  marked ;  optic  neuritis  and  involvement  of  the  cranial  nerves  less 
frequent;  focal  s3'mptoms  usually  indefinite;  fever  and  leucocytosis 
jDresent  except  in  the  latent  period;  the  most  frequent  complication 
is  acute  meningitis. 

Chronic  basilar  meningitis  may  produce  symj^toms  almost  identical 
with  those  of  tumor  in  the  posterior  fossa.  It  is,  however,  confined  to 
infancy;  hydrocephalus  and  opisthotonus  are  much  more  marked  than 
are  usually  seen  with  tumor.  An  examination  of  the  fluid  obtained  by 
lumbar  puncture  will  assist  much  in  the  diagnosis. 

Chronic  hydrocephalus  may  resemble  tumor;  this  occurs  so  fre- 
quently as  a  lesion  secondary  to  tumor  that  the  question  often  arises 
whether  there  is  only  hydrocephalus,  or  there  is  in  addition  a  tumor. 
Hydrocephalus  is  often  congenital,  is  usually  encountered  in  the  first 
year  of  life  and  commonly  attains  to  a  greater  degree  than  is  seen  in 
secondary  hydrocephalus.  There  is  an  entire  absence  of  focal  symp- 
toms.   Papillo-edema  is  rare  but  optic  atrophy  very  common. 

A  diagnosis  of  brain  tumor  should  not  be  made  from  the  presence 
of  Frohlich's  syndrome  alone.  The  association  of  the  general  symptoms 
of  tumor  with  hemianopsia  or  amblyopia  or  deformity  of  the  sella  tur- 
cica, is  necessary.  ]\Iany  children  shoAV  adiposity,  sluggishness  and  a 
moderate  delay  in  the  development  of  the  secondary  sexual  characteris- 
tics and  eventually  manifest  nothing  abnormal.  A  diagnosis  as  to  the 
nature  of  a  tumor  is  very  difficult,  but  some  information  upon  this  point 
may  be  gained  from  the  consideration  of  its  etiolog}',  the  rapidity  of 
its  growth  and  the  age  of  the  patient. 

Prognosis. — The  prognosis  of  cerebral  tumor  is  very  bad.     In  the 


HYDROCEPHALUS  769 

overwhelming  majority  of  cases  the  progress  is  steadily  downward  until 
death.  Cases  are  occasionally  seen  which  exhibit  all  the  characteristic 
symptoms  of  tumor,  even  including  optic  neuritis,  which  recover  per- 
fectly. "We  have  seen  several  such  cases.  They  are  probably  not  tumors 
but  circumscribed  areas  of  encephalitis  that  undergo  complete  resolu- 
tion. An  arrest  of  the  growth  very  occasionally  occurs  in  tumors  of  a 
tuberculous  nature  and  recovery  takes  place  with  some  function  of  the 
brain  impaired.  Such  an  outcome  is  distinctly  unusual.  The  calcified 
tubercles  that  are  sometimes  found  at  autopsy  have  usually  given  no 
symptoms  during  life.  Very  little  is  to  be  expected  from  treatment 
unless  the  tumor  is  susceptible  of  operative  interference. 

Treatment. — If  there  is  any  reason  to  suspect  syphilis,  the  iodid  of 
potassium  should  be  given  in  large  doses  and  continued  for  a  long 
period.  Except  for  operative  measures  the  treatment  is  entirely  symp- 
tomatic. The  possibility  of  total  removal  of  a  growth  in  childhood  is 
very  slight.  The  chief  tumors  are  either  infiltrating  (gliomata,  sarco- 
mata) or  part  of  a  more  or  less  generalized  tuberculosis.  The  most 
favorable  tumors  for  operative  removal  (endotheliomata)  are  very  infre- 
quent in  childhood.  The  best  outlook  is  probably  with  cysts.  Without 
operation,  however,  the  result  is  so  nearly  always  in  death  that  if  there 
is  any  possibility  of  removal  of  the  growth  it  should  be  attempted.  If 
enucleation  of  the  growth  is  not  possible,  cerebral  decompression  may 
preserve  the  sight  for  a  long  time  and  do  much  to  diminish  the  pain 
and  general  discomfort. 

HYDROCEPHALUS 

Hydrocephalus,  or  "water  on  the  brain,"  consists  in  an  accumulation 
of  serum  in  the  cranial  cavity.  This  may  be  between  the  dura  mater 
and  the  pia  (external  hydrocephalus)  or  in  the  ventricles  of  the  brain 
(internal  hydrocephalus).  The  former  is  secondary  and  is  quite  rare, 
while  the  latter  is  not  uncommon.  Hydrocephalus  may  be  acute  or 
chronic. 

Acute  hydrocephalus  is  secondary  to  basilar  meningitis,  which  is 
usually  of  tuberculous  origin.  The  terms  tuberculous  ineningitis  and 
acute  hydrocephalus  are  sometimes  used  synonymously.  A  moderate  dis- 
tention of  the  ventricles  is  frequent  in  all  varieties  of  acute  meningitis. 
The  amount  of  fluid  in  acute  hydrocephalus  is  not  great,  there  being 
rarely  more  than  three  or  four  ounces  present. 

Chronic  external  hydrocephalus  except  in  its  mild  form  is  extremely 
rare,  and  is  nearly  always  a  secondary  lesion.  It  may  follow  meaingeal 
hemorrhage,  pachymeningitis,  or  any  lesion  causing  cerebral  atrophy.  It 
is  seen  in  its  most  marked  form  associated  with  congenital  malforma- 


770 


DISEASES  OF  THE  NERVOUS  SYSTEM 


tions  of  the  brain,  particularly  imperfect  development  of  the  hemi- 
spheres. (See  Fig.  103.)  On  incising  the  dura  mater  a  few  ounces,  or 
sometimes  even  a  pint,  ef  fluid  may  escape.  The  convolutions  are 
somewhat  flattened,  and  may  be  greatly  atrophied.     Other  lesions  are 


Fig.  103. — Brain  in  External  Hydrocephalus,  Showing  Imperfect  Development 
OF  THE  Hemispheres.  Patient  three  and  a  half  months  old;  head  measured  20 >^ 
inches;  increase  in  size,  2  inches  in  the  six  weeks  before  death;  symptoms  were  typical 
of  ordinary  internal  hydrocephalus.  In  the  picture  the  small  size  of  the  cerebrum  A  is 
best  judged  by  comparison  with  the  cerebellum  B,  which  is  normal.  The  hemispheres 
were  rudimentary;  the  basal  ganglia  were  normal;  the  cranial  cavity  contained 
about  one  pint  of  fluid. 

found  either  in  the  brain  or  in  the  dura  mater.  External  hydrocephalus 
may  cause  enlargement  of  the  head  and  separation  of  the  sutures,  and 
in  fact  most  of  the  symptoms  of  the  internal  variety;  but  usually  it  is 
not  severe  enough  to  give  rise  to  any  decided  symptoms. 


CHRONIC  INTERNAL  HYDROCEPHALUS 


This  is  the  important  variety,  and  when  no  qualifying  term  is 
mentioned  this  is  the  form  of  hydrocephalus  Avhich  is  always  under- 
stood. 

Internal  hydrocephalus  may  result  from  many  different  diseases  of 
the  brain  and  meninges.     In  some  the  amount  of  fluid  is  moderate  and 


CHRONIC  INTERNAL  HYDROCEPHALUS  771 

its  presence  adds  little  or  nothing  to  the  symptomatology  of  the  condi- 
tion. Tuberculous  meningitis  is  an  example.  In  others,  such  as  tumors 
of  the  base  of  the  brain,  the  collection  of  fluid  may  be  considerable  and 
cause  definite  symptoms  but  the  primary  condition  and  not  the  hydro- 
cephalus is  the  important  one. 

Etiolo^. — The  etiology  of  hydrocephalus  in  many  instances  has 
been  obscure.  This  has  been  largely  due  to  the  difficulty  of  studying 
brains   at   autopsy   on   account   of   the    injury  that   results   from  their 


Fig.  104. — Sagittal  Section  of  6  Mos.  Old  Child,  Dying  of  Hydrocephalus,  showing 
Dilated  Lateral  and  Third  Ventricles  and  Obliterated  Aqueduct  of  Sylvius. 
(From  Dandy  and  Blackfan.) 

removal  unless  special  precautions  are  taken.  It  has  been  customary 
to  divide  cases  of  hydrocephalus  into  the  primary,  when  the  cause  was 
obscure,  and  secondary,  when  the  cause  such  as  tumor  or  abscess  was 
readily  apparent.  There  is  no  longer  any  justification  for  such  a  divi- 
sion. It  seems  now  established  that  internal  hydrocephalus  is  always  a 
secondary  condition  depending  upon  mechanical  causes.  The  receni, 
studies  of  Dandy  and  Blackfan  have  shown  that  the  cerebrospinal  fluid 
is  formed  by  the  choroid  plexus  in  the  lateral,  third  and  fourth  ventricles 
— l)ut  that  it  is  not  absorbed  there.  It  passes  out  of  the  brain  through 
the  aqueduct  of  Sylvius  into  the  fourth  ventricle  and  from  there  to  the 
sul)arachnoid  space  by  means  of  the  foramina  of  Magendie  and  of 
Luschka.     There  is  an  automatic  regulation  of  .production  and  absorp- 


772  DISEASES  OF  THE  NEKVOUS  SYSTEM 

tion  by  means  of  which  the  amount  of  fluid  is  maintained  at  the 
proper  level.  Hydrocephalus  results  when  the  aqueduct  or  the  foramina 
are  obstructed;  or  when  in  consequence  of  injury  to  the  meninges  as  a 
result  of  inflammation,  the  cerebrospinal  fluid  can  not  be  absorbed  with 
sufficient  rapidity  from  the  subarachnoid  space.  In  the  latter  instance 
the  fluid  is  dammed  back  toward  its  source  and  the  greatest  pressure  is 
thus  exerted  on  the  interior  of  the  ventricles. 

Obstruction  to  the  flow  from  the  ventricles  is  frequently  brought 
about  by  a  narrowing  or  complete  absence  of  the  aqueduct.      (Figs. 


Fig.  105. — Sagittal  Section  op  Normal  Brain  of  an  8  Months  Old  Child,  showing 
Patent  Aqueduct  of  Sylvius.     (From  Dandy  and  Blackfan.) 

104,  105.)  This  condition  must  be  considered  a  congenital  abnormality. 
Obliteration  of  the  foramina,  however,  is  almost  always  the  result  of 
inflammation.  This  may  occur  in  intra-uterine  life  or  at  any  time  after 
birth.  Except  for  those  cases  plainly  following  upon  meningococcus 
meningitis,  the  organism  causing  the  inflammation  is  unknown.  Inter- 
ference with  the  absorption  of  cerebrospinal  fluid  is  dependent  upon  some 
previous  meningeal  inflammation.  It  is  probable  that  this  in  turn  may 
be  of  intra-uterine  or  extra-uterine  origin.  No  sufficient  pathological 
examination  of  cases  due  to  this  cause  has  been  made.  It  is  the  opinion 
of  Dandy  and  Blackfan  that  the  diminished  absorjjtion  is  due  to  adhe- 
sions limiting  the  size  of  the  subarachnoid  space. 


CHRONIC  INTERNAL  HYDROCEPHALUS  773 

In  a  large  proportion  of  cases  the  disease  is  congenital,  hydroceplialns 
beginning  in  the  latter  months  of  intra-uterine  life.  Syphilis  is  re- 
sponsible for  a  certain  proportion  of  cases.  By  some  authors  the  propor- 
tion is  considered  a  large  one.  Sufficient  data  have  not  been  accumulated 
since  the  introduction  of  the  Wassermann  reaction  to  justify  a  conclusive 
statement  upon  this  point.  In  our  own  experience  the  association  is  not 
frequent, — certainly  fully  four-fifths  of  the  cases  are  not  syphilitic. 
Heredity  is  a  factor  of  some  importance,  as  numerous  instances  are  on 
record  where  two  children  in  the  same  family  have  been  affected.  The 
most  obvious  explanation  seems  to  be  that  the  same  meningeal  inflam- 
mation or  the  same  congenital  abnormality  has  existed. 

Hydrocephalus  not  infrequently  develops  after  successful  operations 
upon  spina  bifida  or  encephalocele.  In  such  an  event  it  is  likely  that 
an  inadequate  meningeal  absorption  was  compensated  for  by  the  in- 
creased area  afforded  by  the  sac  of  the  spina  bifida.  When  the  sac  is 
removed  the  absorption  of  fluid  is  no  longer  adequate.  There  is  no 
reason  to  believe  that  neuroses,  alcoholism,  tuberculosis  or  consanguinity 
in  the  parents  is  responsible  for  hydrocephalus.  The  rachitic  head  has 
been  so  often  mistaken  for  hydrocephalus  that  an  erroneous  notion  has 
arisen  as  to  the  association  of  the  two  diseases.  There  is  no  etiological 
connection  between  them. 

Pathology. — Depending  upon  the  cause  and  the  duration  of  the  con- 
dition the  amount  of  fluid  may  be  small  or  large.  It  may  be  only  a 
few  ounces  or  several  pints.  We  have  seen  three  pints  in  an  infant  two 
weeks  old  and  five  pints  in  one  who  died  at  four  months.  Much  larger 
quantities  than  this  have  been  reported,  but  in  children  living  several 
years.  In  composition  the  fluid  resembles  normal  cerebrospinal  fluid. 
Minor  changes  have  been  reported  but  are  not  uniform.  The  fluid  may 
be  slightly  yellow  and  there  may  be  an  excess  of  cells  in  cases  following 
a  recent  meningitis.  The  effusion  may  become  purulent  from  accidental 
infection  resulting  from  operation,  from  rupture,  or  from  infection 
through  the  sac  of  a  complicating  spina  bifida. 

A  satisfactory  examination  of  the  brain  can  only  be  made  if  it  is 
injected  with  formalin  through  the  carotid  arteries  and  two  or  three 
hours  allowed  to  elapse  before  it  is  removed.  The  meninges  may  be 
normal.  Frequently,  however,  they  are  thickened  and  there  may  be 
adhesions  between  them  and  tlie  brain,  especially  at  the  base.  The  cis- 
terna  magna  may,  in  this  way,  be  greatly  diminished  in  size  or  actually 
obliterated  and  adhesions  may  close  the  foramina  of  Magendie  and  of 
Luschka.  The  aqueduct  of  Sylvius  may  not  be  demonstrable.  Ordi- 
narily this  is  as  large  as  a  small  quill.  Microscopically,  remains  of  it 
may  be  found  in  small  islands  of  ependymal  cells  with  or  without  a 
central  opening.     A  gliosis  has  obliterated  the  aqueduct. 


774 


DISEASES  OF  THE  NERVOUS  SYSTEM 


The  chief  changes  in  the  brain  result  from  the  distention  of  the  ven- 
tricles by  fluid.  This  continues  until  the  hemispheres  are  destroyed  to  a 
greater  or  less  extent.  The  convexity  of  the  brain  thus  suffers  most. 
The  basal  ganglia  and  cerebellum  are  somewhat  flattened  but  otherwise 
relatively  normal.  The  progressive  distention  results  in  a  gradual  thin- 
ning of  the  brain  substance  which  forms  the  ventricular  walls;  often 
these  are  found  only  one  fourth  of  an  inch  in  thickness  or  the  cortex  may 
be  a  mere  shell  (Fig.  106).  The  ependyma  of  the  ventricle  and  the  pia 
mater  are  at  times  actually  in  contact,  all  of  the  brain  tissue  having  been 

absorbed.  The  brain  in 
such  instances  resembles  a 
large  double  cyst.  In  less 
marked  cases  there  may  be 
only  a  flattening  of  the 
convolutions.  The  fora- 
men of  Monro  is  dilated, 
and  occasionally  the  fora- 
men of  Magendie  also. 
The  septum  lucidum  is 
greatly  thinned  or  may 
have  disappeared.  The 
brain  is  anemic  and  the 
gray  and  white  substance 
may  be  indistinguishable. 
The  ependyma  may  be 
normal.  It  is  usually 
somewhat  thickened  and 
pale,  sometimes  granular 
and  may  be  infiltrated 
with  new  cells.  The  mi- 
croscopical changes  are  inconstant  and  not  marked.  There  is  a  tendency 
to  atrophy  and  disappearance  of  the  ganglion  cells. 

The  cranium  is  markedly  affected.  The  bones  are  often  very  thin; 
the  fontanels  are  very  large  and  the  sutures,  especially  those  of  the 
vault,  widely  separated.  There  may  be  a  formation  of  Wormian  bones. 
After  the  removal  of  the  fluid  which  alone  gives  it  its  configuration,  the 
head  may  collapse.  It  should  not  be  forgotten,  however,  that  hydro- 
cephalus may  coexist  with  premature  ossification,  in  which  case  the 
head  may  be  small.  Pressure  of  the  fluid  upon  the  roof  of  the  orbit 
causes  it  to  become  less  concave  or  even  convex.  When  recovery  occurs 
the  sutures  and  fontanels  may  close  with  the  help  of  the  Wormian  bones, 
and  irregular  thickening  of  the  bones  of  the  skull  take  place.  The  most 
frequent  lesion  associated  with  congenital  hydrocephalus  is  spina  bifida; 


Fig.  106. — Vertical  Transverse  Section  of  a 
Brain  in  Congenital  Hydrocephalus.  From 
a  child  who  died  at  the  age  of  three  weeks.  A, 
distended  lateral  ventricle;  5,  its  descending 
horn. 


CHRONIC  INTERNAL  HYDROCEPHALUS  775 

more  rarely  there  is  meningocele  or  encephalocele.  Sometimes  there 
are  deformities  in  other  parts  of  the  body,  such  as  club  foot  or  hare-lip. 

Symptoms. — Many  cases  of  hydrocephalus  are  congenital  and  the 
child  may  die  in  utero.  At  other  times  the  process  may  be  so  far 
advanced  before  birth  that  Caesarian  section  or  puncture  of  the  head 
may  be  necessary  before  delivery  is  possible.  In  perhaps  the  majority 
of  cases,  no  symptoms  are  observed  at  birth,  or  the  head  is  only  slightly 
larger  than  normal.  Usually,  nothing  is  noticed  until  the  child  is  two 
or  three  months  old,  when  it  is  discovered  that  the  head  is  increasing 
in  size  at  an  abnormal  rate.  Instead  of  the  usual  half  an  inch  a  month 
it  may  be  two  or  three  times  this.  If  the  progress  is  rapid,  other  symp- 
toms are  soon  evident — the  infant  cannot  hold  up  his  head,  he  is  lethargic 
and  all  his  perceptions  are  dulled.  Only  in  rare  instances  is  there  blind- 
ness, but  there  is  usually  some  interference  with  sight,  which  is.  how- 
e\er,  very  diificult  to  make  out  with  young  infants.  Very  rarely  there 
is  deafness.  The  pupils  are  usually  contracted  and  equal,  though  they 
may  be  dilated.  Nystagmus  and  convergent  strabismus  are  often  pres- 
ent. In  severe  cases  the  eyes  protrude  slightly  and  are  rotated  down- 
ward, leaving  some  of  the  sclera  visible.  This  gives  a  very  characteristic 
expression  and  is  due  to  the  alteration  of  the  roof  of  the  orbit.  If  the 
hydrocephalus  has  developed  very  rapidly,  a  papillo-edema  is  sometimes 
seen.  This  is,  however,  exceptional  and  optic  atrophy  of  greater  or 
less  extent  is  the  rule. 

There  is  usually  rigidity  of  the  muscles  of  the  extremities,  more 
marked  in  the  legs,  sometimes  also  in  the  arms;  the  hands  being  clenched 
with  the  thumbs  adducted.    The  reflexes  are  exaggerated. 

For  a  time  the  nutrition  is  well  maintained,  but  when  the  head 
enlarges  markedly,  the  body  wastes  and  the  disproportion  between  the 
two  may  seem  greater  than  it  really  is.  Convulsions  are  seldom  seen. 
Cases  which  develop  early  and  progress  rapidly  rarely  live  to  the  end  of: 
the  first  year,  and  are  often  fatal  before  six  months.  The  causes  of 
death  are  marasmus,  convulsions,  intercurrent  disease,  and  rarely  rup- 
ture of  the  head. 

The  cases  which  develop  slowly  are  usually  those  that  follow  some 
meningeal  inflammation.  There  may  be  a  history  of  frank  cerebrospinal 
meningitis.  Sometimes  there  is  only  a  history  of  unexplained  fever 
without  symptoms  to  draw  attention  to  the  meninges.  When  the  symp- 
toms develop  slowly,  the  head  may  be  but  little  larger  than  normal. 
The  brain  seems  able  to  tolerate  an  almost  indefinite  amount  of  pressure 
if  this  develops  gradually.  The  surprising  thing  about  many  of  these 
cases  is  that  the  distinctly  cerebral  symptoms  are  so  few.  The  more 
readily  the  bones  of  tlie  skull  yield  to  pressure,  the  fewer  are  the  nervous 
syiiiploms,  hojice,  oilier  things  being  equal,  tliey  are  U^ss  jnai'ki'd  wbcu 


776  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  disease  begins  before  the  sutures  are  firmly  ossified  than  in  the  later 
cases.  A  comparatively  small  amount  of  effusion  may  cause  very  marked 
symptoms  in  a  child  two  or  three  years  old,  while  a  much  larger  amount 
in  an  infant  of  a  year  may  produce  much  less  disturbance. 

Even  though  the  progress  of  the  disease  is  slow  the  development  of  the 
children  is  greatly  retarded.  If  the  course  is  progressive,  however,  death 
eventually  takes  place,  although  it  may  be  postponed  for  many  months. 
The  special  senses  are  generally  not  noticeably  affected;  but  intelligence 
in  most  cases  is  interfered  with,  in  some  only  slightly;  in  others,  very 
markedly.  Avhile  some  are  idiotic.  Contractions  of  the  extremities  are 
occasionally  seen  but  usually  more  of  the  hands  than  of  the  legs.  Sensa- 
tion is  not  often  affected.  The  course  is  a  very  chronic  one  and  from 
time  to  time  there  may  be  exacerbation  of  the  symjotoms. 

Spontaneous  arrest  may  occur  at  almost  any  stage.  There  may 
remain  only  a  moderate  enlargement  of  the  head  and  fair  intelligence, 
or  recovery  may  be  delayed  until  the  head  has  reached  an  enormous 
size,  and  the  child,  on  account  of  this,  quite  unable  to  move.  Such  an 
outcome,  hoAvever,  is  rare. 

Dandy  and  Blackfan  have  shown  that  there  are  two  distinct  varieties 
of  hydrocephalus,  one  due  to  obstruction  and  the  other  due  to  dimin- 
ished absorption  of  the  cerebrospinal  fluid.  Wben  a  solution  of  phenol- 
sulphonephthalein  is  injected  into  the  normal  ventricle  the  dye  appears 
in  the  cerebrosjDinal  fluid  within  five  minutes  and  is  absorbed  very 
rapidly,  so  that  15  to  20  per  cent  of  it  is  excreted  by  the  kidneys  in  the 
course  of  two  hours.  After  its  injection  into  the  spinal  subarachnoid 
space,  its  appearance  in  the  urine  is  prompt  and  from  35  to  60  per  cent 
is  excreted  in  the  course  of  two  hours. 

In  the  one  variety  of  hydrocephalus,  the  'phthalein,  after  injection 
into  the  ventricle,  does  not  appear  in  the  fluid  obtained  by  lumbar 
puncture  for  a  long  time,  and  is  excreted  by  the  kidneys  very  gradually 
and  during  several  days.  If  it  is  injected  into  the  subarachnoid  space, 
the  excretion  is  as  prompt  as  under  normal  circumstances.  This  demon- 
strates that  there  is  an  obstruction  to  the  outflow  of  fluid  from  the 
ventricles  into  the  subarachnoid  space,  the  cause  of  which  may  be  mal- 
formations or  adhesions  blocking  the  foramina  of  exit. 

In  the  other  variety,  the  'phthalein  injected  into  the  ventricle 
appears  promptly  in  the  subarachnoid  fluid  but  is  excreted  by  the 
kidneys  slowly  and  when  it  is  injected  into  the  lumbar  region  of  the 
cord,  it  is  also  excreted  slowly.  This  delayed  absorption  is  the  result  of 
inflammation  which  has  injured  the  meninges  and  diminished  the  area 
for  absorption. 

Prognosis. — Cases  developing  soon  after  birth  and  progressing  rap- 
idly are  usually  fatal  Ijefore  the  end  of  the  first  year.     It  is  very  rare 


CHRONIC  INTERNAL  HYDROCEPHALUS  777 

that  a  hydrocephalic  child  reaches  the  age  of  seven  years.  The  process 
may,  however,  go  on  up  to  a  certain  age  and  then  cease  spontaneously 
and  the  child  may  go  through  life  with  a  head  much  larger  than  normal 
and  usually  with  a  somewhat  impaired  mental  condition.  In  others  the 
mentality  is  nearly  or  quite  normal  and  yet  some  muscular  weakness 
or  even  paralysis  persists.  This  arrest  of  hydrocephalus  is  probably 
brought  about  by  an  adjustment  which  has  taken  place  by  which  the 
meninges  are  able  to  absorb  sufficiently  to  keep  pace  with  the  production 
of  the  cerebrospinal  fluid. 

Diagnosis. — The  most  important  symptom  is  the  enlargement  of  the 
head,  and  this  can  only  be  arrived  at  by  careful  measurement  and 
comparison  with  the  normal  size.  The  rapidity  of  growth  is  quite  as 
important  for  diagnosis  as  the  fact  of  enlargement.  If  the  head  grows 
as  much  as  an  inch  a  month  there  can  be  little  doubt.  The  enlarge- 
ment most  frequently  confounded  with  hydrocephalus  is  that  which 
occurs  in  rickets.  In  the  latter  disease  it  is  almost  invariably  irregu- 
lar; there  are  prominences  over  the  two  frontal  eminences  and  over  the 
parietal  bones,  often  with  furrows  between  them;  the  size  of  the  head  is 
chiefly  due  to  thickening  of  the  bones  of  the  skull;  the  marked  promi- 
nence of  the  forehead  is  not  seen,- and  the  increase  in  the  biparietal 
diameter  is  not  present;  furthermore,  there  are  other  signs  of  rickets. 

Pachymeningitis  interna  may  be  confounded  with  hydrocephalus. 
The  fluid,  however,  is  usually  either  reddish  and  reddish-yellow  or  is 
quite  blood-stained  and  may  contain  red  blood-cells.  A  differential 
diagnosis  may  be  very  ditficult. 

Treatment. — If  syphilis  is  suspected,  energetic  treatment  by  mer- 
cury and  salvarsan  should  be  instituted.  In  our  experience,  benefit 
from  these  has  not  been  very  marked  and  little  is  to  be  expected  unless 
they  are  employed  very  early.  Eepeated  lumbar  punctures  have,  in  a 
small  proportion  of  cases,  apparently  been  of  value  in  bringing  about 
an  arrest  of  the  process.  Since  differentiation  between  the  different 
varieties  has  been  possible,  we  have  seen  benefit  result  in  cases  with 
a  free  communication  between  the  ventricles  and  the  subarachnoid  space. 
On  a  priori  grounds,  this  is  the  only  variety  in  which  lumbar  puncture 
offers  a  possibility  of  benefit.  Various  operative  measures  have  been 
proposed.  Communications  have  been  established  between  the  lateral 
ventricles  and  the  subarachnoid  space.  A  number  of  cases  have  been 
treated  in  this  way.  The  dangers  of  the  operation  are  considerable; 
nearly  half  of  the  patients  have  died  as  a  direct  result.  Of  those  who 
have  survived,  a  few  have  shown  striking  improvement,  but  no  complete 
cures  have  been  reported. 

Drainage  into  the  jugular  vein  and  into  the  subcutaneous  tissues  has 
also  been  employed.    These  operations  offer  but  little  possibility  of  cure. 


778 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Eetrogression  of  the  symptoms  is  not  to  be  looked  for.  The  most  that 
can  be  hoped  is  to  prevent  any  further  injury  to  the  brain.  With  the 
knowledge  that  has  been  recently  acquired  in  regard  to  the  cause  of  this 
disease,  there  is  a  much  greater  possibility  of  intelligently  attacking  the 
condition  by  surgical  means. 

Cranial  Deformities  Associated  with  Hydrocephalus. — Various  cra- 
nial deformities  may  at  times  be  associated  with  a  considerable  de- 
gree of  hydrocephalus.  The  two  most  frequent  of  these  are  oxyceph- 
aly ("steeple-head"  or  turmschadel)  and  scaphocephaly.  In  oxycephaly 
(Fig.   107)    the  head  is  very  high  and  short;  in  scaphocephaly    (Fig. 


Fig.  107. — Oxycephaly  with  Exoph- 
thalmus  and  partial  blindness, 
WITH  Optic  Nerve  Atrophy. 
Child  2  years  old. 


Fig.  108. 


-Scaphocephaly;   in  infant  17 
months  old. 


108),  it  is  narrow  and  elongated  from  before  backwards.  In  addition 
to  the  change  in  the  shape  of  the  head,  there  may  be  with  either  form 
some  degree  of  exophthalmus  and  optic  atrophy  which  causes  impairment 
of  vision.  This  varies  in  severity  from  slight  interference  with  sight  to 
complete  blindness.  The  intelligence  is  usually  quite  normal.  Smell  is 
often  completely  lost.  Taste  very  rarely  is  affected.  These  cranial  de- 
formities seem  to  have  no  effect  upon  the  duration  of  life.  They  are  not 
amenable  to  treatment  and  the  optic  atrophy  is  usually  progressive.  It 
is  possible  that  cerebral  decompression  may  retard  the  optic  changes  but 
this  has  not  yet  been  sufficiently  employed  to  warrant  a  conclusion  as  to 
its  influence. 


INFANTILE  CEREBRAL  PARALYSIS 


779 


INFANTILE  CEREBRAL  PARALYSIS 

{Spastic  Diplegia,  Paraplegia,  or  Hemiplegia) 

Under  the  term  cerebral  paralysis  are  included  several  groups  of  cases 
with  causes  quite  dissimilar,  but  having  certain  definite  clinical  features 
in  common.  While  the  symptomatology  is  quite  clear,  there  are  many 
questions  relating  to  the  pathology  that  are  not  yet  fully  settled,  al- 
though much  has  been  added  to  our  knowledge  within  the  last  few  years. 
Paralysis  depending  upon  cerebral  tumor,  abscess,  or  hydrocephalus  is 
not  included  in  this  chapter. 


Fig.  109. — Extensive  Atrophy  and  Sclerosis  of  the  Right  Hemisphere.  From  an 
infant  seven  and  a  half  months  old;  probably  the  result  of  a  meningeal  hemorrhage 
at  birth.  History. — Twelve  hours  after  birth  was  seized  with  general  convulsions, 
which  continued  for  three  days.  No  other  symptoms  noticed  till  one  month  before 
death,  when  weakness  of  the  left  arm  was  observed.  Never  held  head  erect.  Was 
plump  and  well  nourished;  died  from  erysipelas.  Autopsy. — Pia  not  adherent;  a 
large  cyst  occupied  the  region  of  the  occipital  and  posterior  part  of  the  parietal  lobes, 
showing  in  its  floor  discoloration  and  pigmentation,  evidently  from  an  old  hemorrhage. 
Right  optic  nerve,  tract,  and  cms  much  smaller  than  the  left. 


The  cases  of  cerebral  paralysis  may  be  divided  into  three  groups, 
according  as  the  paralysis  depends  upon  conditions  existing  prior  to 
birth,  upon  those  connected  with  birth,  or  upon  those  of  subsequent 
development. 

I.  Paralysis  of  Intra-Uterine  Origin. — This  is  the  least  frequent  con- 
dition. In  such  cases  there  is  some  congenital  defect  in  the  brain,  due 
sometimes  to  arrest  of  development,  at  others  to  such  intra-uterine  lesions 
as  hemorrhage  or  thrombosis.  There  may  be  porencephalus,  or  cysts 
extending  deeply  into  the  substance  of  the  brain,  sometimes  communicat- 
ing with  the  ventricles.  The  origin  of  this  condition  is  for  the  most 
part  unknown.     In  rare  cases  the  paralysis  is  due  to  cortical  agenesis,  a 


780  DISEASES  OF  THE  NERVOUS  SYSTEM 

condition  in  which  the  brain  may  seem  normal  to  the  naked  eye,  but  the 
microscope  shows  a  more  or  less  complete  arrest  in  the  development  of 
the  cells  of  the  cortex,  usually  affecting  both  hemispheres.  In  still  other 
cases  there  are  found  gross  defects  in  development  in  the  motor  centers 
of  the  cortex.  Such  a  lesion  is  shown  in  Fig.  114.  Cases  in  which 
there  is  conclusive  evidence  of  intra-uterine  hemorrhage  are  very  rare. 

In  most  of  the  paralyses  due  to  intra-uterine  lesions,  loss  of  power  is 
only  one  of  the  symptoms  and  usually  not  the  most  prominent.  It  is 
rare  that  there  is  not  some  mental  impairment,  and  usually  idiocy  is 
present.  The  type  of  paralysis  is  nearly  always  diplegic  or  paraplegic. 
When  this  is  due  to  arrested  cortical  development,  a  general  flaccidity  of 
the  muscles  may  be  seen  instead  of  the  rigidity  so  characteristic  of  the 
other  forms  of  cerebral  paralysis. 

II.  Birth-Paralysis. — Cerebral  birth-paralysis  is  due  in  nearly  all 
cases  to  meningeal  hemorrhage.  The  primary  lesions  and  the  early 
symptoms  have  already  been  described  in  connection  with  the  Diseases  of 
the  Newly  Born.  The  secondary  lesions  present  considerable  variety. 
There  may  be  found  (1)  meningo-encephalitis,  (2)  atrophy  and  sclerosis 
of  the  cortex,  (3)  cysts  upon  the  surface,  (4)  secondary  degenerations  in 
the  spinal  cord. 

1.  Meningo-enceplialitis. — This  lesion  is  often  quite  diffuse.  There 
is  thickening  of  the  pia  mater,  and  it  is  usually  adherent  to  the  brain 
substance.  The  cortex  is  involved  to  a  variable  degree,  depending  some- 
what upon  the  time  which  elapses  between  the  initial  lesion  and  the 
autopsy.  The  following  were  the  microscopical  changes  found  in  the 
brain  of  a  child  in  the  Babies'  Hospital,  who  died  at  the  age  of  one  year 
of  measles  ^  :  The  lesions  were  found  everywhere  in  the  cortex.  The 
pia  was  universally  adherent,  and  showed  general  cellular  infiltration; 
its  blood-vessels  showed  marked  cell  proliferation,  and  the  veins  in  the 
sub-pial  space  were  dilated  and  filled  with  blood.  In  the  pia  dipping  in 
between  the  convolutions  similar  changes  were  present.  In  the  cortex 
few,  if  any,  normal  pyramidal  cells  were  found,  but  in  the  outer  layers 
were  an  enormous  number  of  small  glia  cells.  Many  of  the  blood- 
vessels showed  a  cell-proliferation  of  their  walls.  There  was  also  de- 
generation in  the  pyramidal  tracts  of  the  lateral  columns  of  the  cord. 

2.  Atropliy  and  Sclerosis. — These  changes  vary  much  in  extent  and 
degree.     There  may  be  only  a  circumscribed  area  in  which  the  convolu- 

*The  child  was  a  first-born,  delivered  after  a  dry  labor  of  forty-eight  hours. 
He  was  asphyxiated,  and  from  the  first  days  of  his  life  he  had  attacks  of  convul- 
sions, usually  repeated  many  times  a  day.  (Photographed  during  one  of  these 
attacks.  Fig.  110.)  The  child  had  the  symptoms  of  typical  spastic  paraplegia — 
the  arms  being,  however,  slightly  involved — retarded  mental  development,  and 
convergent  strabismus. 


INFANTILE  CEREBRAL  PARALYSIS  781 

tions  are  small,  firmer  than  usual,  and  covered  with  an  adherent  pia,  or 
there  may  be  an  atrophy  so  extensive  as  to  involve  a  large  part  of  one 
hemisphere  (Fig.  109),  or  sometimes  of  both  hemispheres.  Usually  the 
lesion  is  somewhat  diffuse  over  the  convexity  of  both  sides,  and  much 
more  frequently  of  the  anterior  than  of  the  posterior  half  of  the  brain. 
Where  a  depression  of  the  brain  exists  the  space  is  filled  with  cerebro- 
spinal fluid,  and  in  many  cases  there  is  a  deformity  of  the  skull. 

3.  Cysts  upon  the  surface  may  occur  alone  or  in  connection  with  the 
lesions  just  mentioned.  These  are  usually  small,  about  the  size  of  a 
walnut,  but  they  may  cover  a  large  part  of  a  hemisphere.  Such  large 
cysts  are  sometimes  classed  as  cases  of  external  hydrocephalus. 


Fig.  110. — -Convulsions  in  Spastic  Paraplegia. 

4.  Secondary  degenerations  of  the  internal  capsule  and  the  lateral 
columns  of  the  cord  are  found  in  most  of  the  cases  associated  with  ex- 
tensive atrophy  and 'sclerosis,  and  in  many  of  those  in  which  only  men- 
ingo-encephalitis  is  present. 

Symptoms. — The  type  of  paralysis  will,  of  course,  depend  upon  the 
extent  and  position  of  the  original  lesion.  A  diffuse  lesion  is  followed 
by  dijDlegia ;  one  not  quite  so  extensive  by  paraplegia ;  one  affecting  one 
side  only,  by  hemiplegia,  or  even  monoplegia,  though  this  is  very  rare. 
The  relative  frequency  of  the  different  forms  will  vary  according  to  the 
age  at  Avhich  the  patients  come  under  observation.  According  to  our 
observations,  which  have  been  chiefly  upon  infants,  the  cases  of  diplegia 
and  paraplegia  have  outnumbered  those  of  hemiplegia  more  than  four 
to  one.  The  great  majority  of  the  congenital  cases,  or  those  due  to 
hemorrhage  occurring  at  birth,  are  without  doubt  diplegias  or  para- 
plegias, and  very  many  of  them  succumb  during  the  first  two  years; 
however,  the  cases  of  hemiplegia,  because  of  the  less  serious  lesion,  live 
much  longer.     Diplegia  and  paraplegia  will  therefore  be  considered  as 


782 


DISEASES  OF  THE  NERVOUS  SYSTEM 


the  characteristic  types  of  cerebral  birth-palsy,  as  the  cases  of  hemiplegia 
do  not  differ  from  those  due  to  later  causes — i.  e.,  the  acquired  form. 

In  the  most  severe  cases  that  survive  the  symptoms  of  the  early  days 
of  life  there  remains  some  rigidity  of  the  extremities,  chiefly  of  the  legs, 

which  is  constant  or  intermittent,  slight 
or  well  marked.  There  is  often  spasm 
of  the  muscles  of  the  neck  and  trunk, 
giving  rise  to  opisthotonus.  In  many 
cases  there  are  frequent  attacks  of  con- 
vulsions. The  general  physical  develop- 
ment of  the  child  is  often  interfered 
with,  so  that  he  remians  small  and  del- 
icate, or  perhaps  dies  of  some  acute  dis- 
ease in  early  infancy,  never  having  been 
able  to  sit  erect,  or  even  support  his 
head.  In  other  cases  the  general  nutri- 
tion is  not  affected,  and  life  may  be  pro- 
longed indefinitely,  but  usually  with 
some  mental  impairment.  This  is  seen 
in  all  degrees;  it  may  be  so  slight  as  not 
to  be  noticed  until  the  child  is  two  or 
three  years  old,  or  the  child  may  be 
idiotic.  Often  these  children  are  not 
able  to  stand  until  they  are  over  three 
years  old  and  do  not  walk  alone  until 
they  are  four  or  five  years  old,  and  then 
with  a  peculiar  cross-legged  gait,  owing 
to  spasm  of  the  adductors  of  the  thighs. 
This  may  be  so  great  as  entirely  to  pre- 
vent walking,  and  while  sitting  or  lying 
the  thighs  may  cross  each  other.  These 
form  the  typical  cases  of  spastic  para- 
plegia, sometimes  called  "Little's  dis- 
ease" (Fig.  111).  All  the  reflexes  are 
greatly  exaggerated.  The  arms  are 
much  less  affected  than  the  legs,  and  in  about  half  the  number  they  are 
not  involved  at  all. 

In  the  milder  cases  the  early  symptoms  may  be  overlooked,  and  noth- 
ing excite  suspicion  until  the  infant  is  six  or  eight  months  old.  There 
is  then  discovered  unmistakable  muscular  weakness;  the  child  does  not 
sit  up,  or  even  hold  up  the  head  when  the  trunk  is  supported.  Often 
there  is  observed  before  this  time  a  tendency  to  stiffen  the  body  and  to 
throw  the  head  backward,  owing  to  spasm  of  the  cervical  or  spinal  mus- 


FiG.  111.  —  Spastic  Paraplegia, 
Child  two  and  one-half  years  old. 
New  York  Foundling  Hospital, 
unable  to  walk  or  even  to  stand 
without  assistance.  The  habitual 
position  of  the  limbs,  which  is  due 
to  strong  adductor  spasm,  is 
shown  in  the  picture. 


INFANTILE  CEREBRAL  PARALYSIS  783 

cles.  The  muscular  weakness  is  often  mistaken  for  rickets,  or  regarded 
simply  as  backwardness.  A  closer  examination  usually  discloses  the  pres- 
ence of  some  rigidity  of  the  extremities,  particularly  of  the  legs,  and 
exaggeration  of  the  knee-jerks.  As  the  child'  grows  older  other  symp- 
toms of  imperfect  development  become  more  and  more  evident. 

There  are  changes  in  the  shape  of  the  skull,  this  being  usually  smaller 
than  normal  in  all  its  diameters,  or  there  may  be  asymmetry.  There  is 
an  arrest  of  development  in  the  paralyzed  limbs.  These  are  both  smaller 
and  shorter  than  normal.  In  many  cases  abnormal  movements  are  seen, 
which  may  be  of  an  irregular  choreic  type,  or  they  may  be  athetoid. 
Epilepsy  develops  in  from  thirty-three  to  fifty  per  cent  of  all  these 
patients, 

III.  Acute  Acquired  Paralysis. — This  is  usually  of  the  hemiplegic 
type,  although  diplegia  and  paraplegia  may  in  rare  instances  be  met 
with.  This  group  includes  cases  developing  at  any  time  after  birth,  but 
the  great  majority  of  those  seen  in  childhood  begin  before  the  fifth 
year. 

The  etiology  is  often  obscure.  The  paralysis  sometimes  follows 
traumatism.  It  is  occasionally  seen  in  the  course  of  scarlet  fever, 
measles,  diphtheria,  variola,  pneumonia,  or  pertussis.  The  frequency 
with  which  these  cases  are  ushered  in  with  convulsions  has  led  many 
to  assign  this  as  the  cause  of  the  paralysis.  It  is  probable  that  the  convul- 
sions are  more  often  the  result  than  the  cause  of  the  lesion.  In  the  acute 
inflammatory  cases  the  cause  is  probably  the  same  as  in  acute  polio- 
myelitis. 

Lesions. — The  lesions  of  acute  cerebral  palsy  may  be  grouped  under 
three  heads:  (1)  those  of  the  blood-vessels:  (2)  those  of  the  membranes; 
(3)  those  of  the  brain  substance. 

1.  Lesions  of  the  Blood-vessels. — There  may  be  hemorrhage,  em- 
bolism, or  thrombosis.  Hemorrhage  is  by  far  the  most  important.  It  is 
usually  meningeal,  rarely  cerebral.  It  occurs  more  frequently  at  the  con- 
vexity than  at  the  base,  and  is  often  diffuse.  Meningeal  hemorrhage 
may  result  from  pachymeningitis.  It  may  be  due  to  traumatism,  when 
it  is  also  from  the  dura  mater ;  or  from  the  acute  hyperemia  accompany- 
ing paroxysms  of  pertussis,  when  it  may  be  from  the  dura  or  the  pia; 
or  it  may  be  secondary  to  thrombosis  of  the  superior  longitudinal  sinus. 
The  association  of  hemorrhage  with  sinus-thrombosis  is  not  very  in- 
frequent. It  was  found  in  two  of  our  autopsies  upon  patients  who  died 
of  pneumonia.  Cerebral  hemorrhage  is  extremely  rare,  but  it  occurs 
even  in  young  infants. 

Embolism  is  rarely  found  unless  associated  with  acute  rheumatic 
endocarditis,  and  then  usually  in  children  who  are  over  seven  years 
old.     As  in  adults,  the  usual  seat  of  the  embolus  is  a  branch  of  the 


784 


DISEASES  OF  THE  NERVOUS  SYSTEM 


middle  cerebral  artery.     Thrombosis  has  been  met  with  in  a  small  num- 
ber of  cases,  but  is  extremely  rare. 

2.  Lesions  of  the  Membranes. — These  are  generally  the,  result  of 
an  old  cerebrospinal  meningitis;  sometimes  they  may  be  of  syphilitic 
origin.  In  both,  however,  the  process  is  rarely  confined  to  the  mem- 
branes; it  is  a  meningo-encephalitis. 

3.  Lesions  of  the  Brain  Substance. — Atrophy  and  sclerosis  are  found 
in  a  large  number  of  the  autopsies  made  upon  cases  when  the  paralysis 

has  been  of  long  standing. 
They '  represent  terminal 
conditions,  however.  They 
vary  in  severity  and  extent, 
and  are  followed  by  secon- 
dary degeneration  in  the 
cord,  as  in  cases  of  birth 
paralysis.  There  may  be 
the  same  development  of 
cysts  of  the  pia  mater,  or  an 
accumulation  of  fluid  in  the 
arachnoid  cavity,  these  tak- 
ing the  place  of  the  atro- 
phied convolutions.  The 
nature  of  the  primary  lesion 
in  these  cases  is  not  always 
clear.  In  a  certain  number 
of  them  it  is  an  acute  poli- 
encephalitis,  analogous  to 
acute  poliomyelitis,  and 
probably  due  to  the  same 
cause.  The  cerebral  lesion 
may  be  associated  with  cord 
lesions  or  it  may  occur  alone.  Their  nature  is  considered  in  the  chapter 
on  Poliomyelitis.  In  still  other  cases  a  chronic  diffuse  encephalitis  with 
atrophy  is  found  at  autopsy,  closely  resembling  tbe  conditions  which 
follow  a  meningeal  hemorrhage  occurring  at  birth,  yet  the  children 
were  normal  up  to  the  second  or  third  year,  and  there  was  no  acute 
onset. 

Acute  paralysis  sometimes  occurs  for  which  no  explanation  can  be 
found  at  autopsy.  An  infant  with  pneumonia  was  admitted  to  the 
Babies'  Hospital,  who  had  developed,  a  few  days  before,  typical  right 
hemiplegia.  It  came  on  suddenly,  Avith  convulsions,  and  involved  the 
face,  arm,  and  leg.  The  arm  and  leg  appeared  to  be  completely  para- 
lyzed, but  in  the  face  the  paralysis  was  incomplete.     The  paralysis 


Fig.  112. — Recent  Meningeal  Hemorrhage. 
Brain  of  an  infant  seven  months  old  in  the 
Babies'  Hospital.  A,  punctate  hemorrhages; 
B,  thrombosed  vessels;  C,  diffuse  extravasa- 
tion. 


INFANTILE  CEREBRAL  PARALYSIS  785 

had  begun  to  improve  somewhat  at  the  time  of  the  child's  death, 
which  occurred  a  little  over  a  week  after  the  onset.  At  the  autopsy 
no  gross  lesion  could  be  discovered.  A  careful  microscopical  exam- 
ination was  made,  and  nothing  abnormal  was  found  except  a  slight 
increase  of  small  spheroidal  cells  about  some  of  the  meningeal  and 
cortical  vessels  of  the  motor  area.  Such  cases  are  most  likely  a  cerebral 
form  of  poliomyelitis. 

Symptoms. — ^While  diplegia  and  paraplegia  are  occasionally  seen, 
the  great  majority  of  cases  of  acquired  cerebral  palsy  are  of  the  hemi- 
plegic  variety.  When  diplegia  and  paraplegia  occur,  it  is  usually  in 
early  infancy,  and  their  symptoms  and  course  differ  in  no  M'ise  from  the 
birth  palsies.  We  may  therefore  regard  hemiplegia  as  the  chief  mani- 
festation of  acquired  cerebral  palsy. 

.  The  onset  of  the  paralysis  is  almost  invariably  acute,  Avith  convul- 
sions, which  are  usually  repeated,  and  in  severe  cases  followed  by  loss  of 
consciousness.  In  the  secondary  cases  these  are  generally  the  only  symp- 
toms. In  one  of  our  cases  the  patient  went  to  bed  apparently  well,  and 
awoke  in  the  morning  with  hemiplegia.  Such  an  onset,  however,  is  very 
exceptional. 

When  the  paralysis  is  due  to  acute  poliencephalitis,  the  onset  is  usu- 
ally Avith  high  fever,  vomiting,  often  convulsions,  followed  by  delirium 
or  stupor.  These  general  symptoms  continue  for  a  variable  time,  usually 
two  or  three  days,  before  paralysis  is  seen.  The  temperature  in  most 
cases  is  from  101°  to  103°  F.,  and  the  fever  sometimes  follows,  sometimes 
precedes,  the  convulsions.  The  loss  of  consciousness  may  last  for  several 
days,  and  the  paralysis  is  frequently  not  discovered  until  consciousness 
is  regained.  If  there  is  a  very  extensive  lesion  there  may  be  diplegia, 
deep  coma,  and  death,  but  this  is  very  infrequent.  Usually  the  lesion  is 
more  limited,  and  the  symptoms  are  those  of  typical  hemiplegia.  The 
face  sometimes  escapes,  and  if  involved  it  generally  soon  recovers.  The 
paralysis  of  the  arm  and  leg  is  at  first  complete,  but  may  improve  rap- 
idly in  the  course  of  a  few  weeks.  Disturbances  of  sensation  may  be 
present,  but  are  usually  of  a  transient  character.  After  a  variable 
period,  from  one  to  several  weeks,  the  patient  begins  to  use  the  paralyzed 
extremities,  first  the  leg,  afterward  the  arm,  as  in  adult  hemiplegia. 
The  convulsions  may  be  repeated  for  the  first  day  or  two.  but  prolonged 
or  continuous  convulsions  are  rare.  They  may  be  general  or  unilateral. 
With  lesions  of  the  left  side  of  the  brain,  speech  may  be  affected,  and 
not  infrequently  in  young  children  when  the  lesion  is  upon  the  right 
side.  The  reflexes  are  increased  upon  the  affected  side,  and  a  slight 
ankle-clonus  may  be  present. 

After  a  few  weeks  the  child  may  be  able  to  walk,  dragging  the  af- 
fected leg.     The  recovery  in  the  leg  is  sometimes  complete,  but  in  most 


786 


DISEASES  OF  THE  NERVOUS  SYSTEM 


cases  a  slight  halt  in  the  gait  remains.  The  arm  usiTally  recovers  more 
slowly  than  the  leg,  and  contractures  are  likely  to  develop  after  a  variable 
time,  generally  two  or  three  years.  In  Fig.  113  is  shown  a  characteris- 
tic deformity  of  the  upper  extremity.  Contractures  of  the  leg  lead  to 
various  forms  of  talipes,  generally  equinus,  from  shortening  of  the  tendo- 

Achillis.  Sometimes  the  arm  or  the  leg 
recovers  so  perfectly  that  the  case  may 
be  regarded  as  one  of  monoplegia.  In 
old  cases  the  paralyzed  limbs  are  atro- 
phied ;  there  is  more  or  less  rigidity,  and 
the  spastic  condition  may  be  quite 
marked.  We  have  seen  this  limited  to 
a  single  group  of  muscles  in  the  leg. 
Aphasia  is  common  in  right  hemi- 
plegias, and  it  is  not  very  rare  in  those 
of  the  left  side,  because  infants  appear 
to  use  both  sides  of  the  brain  with  nearly 
equal  facility. 

The  mental  condition  of  these  chil- 
dren is  often  normal,  in  striking  con- 
trast with  the  cases  of  congenital  di- 
plegia. The  earlier  the  paralysis  occurs 
the  more  likely  are  mental  symptoms  to 
be  present,  since  we  have  here  not  only 
the  direct  effect  of  the  lesion,  but  an 
arrested  development  of  some  part  of 
the  brain.  Epilepsy  is  not  an  uncom- 
mon sequel ;  it  may  be  of  the  Jacksoniau 
type,  or  there  may  be  attacks  of  general 
convulsions.  In  other  cases  there  are 
post-hemiplegic  movements  of  a  choreic 
or  athetoid  character,  or  irregular  inco- 
ordinate movements. 

Prognosis  of  Infantile  Cerebral  Pa- 
ralysis.— In  diplegia  and  paraplegia  the 
A  very  large  number  of  these  cases  which 
are  due  either  to  intra-uterine  or  birth  lesions  never  reach  the  third  year, 
but  die  in  infancy  from  malnutrition  or  acute  intercurrent  disease. 
Those  who  survive  usually  show  serious  mental  defects,  and  many  are 
practically  helpless  on  account  of  the  extreme  spastic  condition  of  the 
muscles  of  the  extremities. 

In  hemiplegia  the  prognosis  is  much  more  favorable.     In  most  of 
these  cases  the  paralysis  is  of  the  acute  acquired  variety,  and  the  later 


Fig.  113.  —  Deformity  of  Left 
Hand  the  Result  of  Contrac- 
tures Following  an  Attack  of 
Hemiplegia  Four  Years  Be- 
fore.   Child  seven  years  old. 


outlook  is  always  unfavorable. 


INFANTILE  CEREBRAL  PARALYSIS  787 

the  period  of  onset,  the  less  likely  is  the  brain  to  be  seriously  damaged. 
In  some  of  these'  patients  complete  recovery  takes  place;  in  others  the 
residiial  paralysis  is  so  slight  as  to  be  easily  overlooked  except  on  careful 
examination,  the  occurrence  of  epilepsy  being  perhaps  the  first  thing 
which  leads  one  to  suspect  that  a  previous  paralysis  has  existed.  The 
great  majority  of  children  who  have  suffered  from  infantile  cerebral 
palsy  have  some  degree  of  permanent  paralysis  and  usually  some  deformi- 
ties from  contractures,  the  extent  of  both  varying,  of  course,  with  the 
severity  of  the  primary  lesion.  In  all  cases  seen  in  young  infants  it  is 
exceedingly  difficult  to  give  a  prognosis  in  regard  to  future  mental  de- 
velopment. As  a  rule,  the  impairment  is  directly  proportionate  to  the 
extent  of  the  paralysis  and  its  intensity. 

Diagnosis. — The  diagnosis  between  the  congenital  and  acquired 
forms  of  cerebral  palsy  is  of  no  great  practical  importance,  and  it  may 
be  impossible;  for  the  symptoms  in  congenital  cases  are  often  not  suffi- 
ciently marked  to  attract  attention  until  children  are  old  enough  to  sit 
alone  or  to  walk. 

It  may  be  quite  difficult  to  distinguish  cerebral  paralysis  from  infan- 
tile spinal  paralysis.  The  history  of  an  acute  onset,  the  atrophied  limbs, 
the  deformities,  and  the  absence  of 'sensory  disturbances,  may  be  found 
in  both  conditions.  Spinal  paralysis  is,  as  a  rule,  monoplegic,  and  often 
affects  but  a  single  group  of  muscles.  Cerebral  paralysis  is  either  di- 
plegic  or  hemiplegic  in  character,  and  even  though  only  a  leg  or  an  arm 
may  seem  to  be  affected,  a  critical  examination  will  usually  reveal  the 
fact  that  the  other  limb  of  the  same  side  has  also  suffered.  The  presence 
of  rigidity  and  exaggerated  reflexes  is  quite  as  important  evidence  of 
this  as  loss  of  power.  The  electrical  reactions,  however,  are  usually  con- 
clusive ;  the  reaction  of  degeneration  is  absent  in  cerebral  paralysis,  while 
it  is  usually  present  in  spinal  paralysis. 

Simple  as  the  differentiation  may  seem  in  most  cases,  the  mistake  is 
frequently  made  of  confounding  cerebral  diplegia,  particularly  of  the 
flaccid  type,  with  rickets.  Cases  of  acute  acquired  paralysis  at  the  onset 
may  be  mistaken  for  acute  meningitis,  but  early  loss  of  consciousness, 
the  early  development  of  the  paralysis,  its  permanent  character,  and  the 
shorter  duration  of  the  acute  symptoms,  usually  distinguish  these  cases 
from  those  of  meningitis.  The  only  definite  means  of  differential  diag- 
nosis is  by  lumbar  puncture;  this  gives  negative  results  in  cerebral  paral- 
ysis and  positive  results  in  meningitis. 

Treatment. — The  course  and  the  results  of  cerebral  paralysis  depend 
upon  the  extent  of  the  injury  to  the  brain,  its  nature,  and  the  age  at 
which  it  is  inflicted — all  these  being  conditions  which  are  beyond  the 
power  of  the  physician  to  modify  or  control.  The  treatment  of  cerebral 
palsy  is  therefore  extremely  unsatisfactory.     For  the  congenital  cases 


788  DISEASES  OF  THE  NERVOUS  SYSTEM 

practically  nothing  can  be  done,  except  for  the  deformities  and  compli- 
cations. The  acquired  cases  during  the  acute  onset  are  to  be  managed 
like  all  other  cases  of  acute  cerebral  congestion  or  inflammation — abso- 
lute rest,  ice  to  the  head,  and  bromids.  Electricit}^  is  not  to  be  used 
in  early  cases,  and  little  or  nothing  is  to  be  expected  from  it  in  the  late 
ones.  Much  can  be  accomplished  in  an  educational  way-for  the  mental 
derangements  resulting  from  cerebral  palsy.  An  important  part  of  the 
treatment  relates  to  the  deformities.  Many  of  these  may  be  prevented 
by  the  early  use  of  orthopedic  apparatus.  Serious  deformities  in  old 
cases  may  be  greatly  benefited  by  tenotomy  or  myotomy,  followed  by 
the  use  of  suitable  apparatus.  The  results  of  all  other  operative  meas- 
ures have  been  in  our  experience  most  unsatisfactory.  Epilepsy  is  to  be 
treated  as  when  it  depends  on  other  causes. 


AMAUROTIC   FAMILY  IDIOCY 

Amaurotic  family  idiocy  is  a  relatively  rare  disease.  It  is  confined, 
almost,  if  not  entirely,  to  the  Jewish  race.  It  shows  strong  familial 
tendencies — often  two  or  three  and  sometimes  even  four  or  five  children 
in  the  same  family  dying  of  the  disease.  There  are  no  other  known 
etiological  influences. 

The  first  symptoms  are  usually  noticed  between  the  sixth  and  the 
tenth  months,  up  to  which  time  the  infant  has  generally  appeared 
normal.  At  first  it  is  only  noticed  that  the  child  is  making  no  progress 
in  his  development,  or  that  his  eyesight  is  not  so  good  as  formerly.  He 
does  not  gain  in  ability  to  sit  up  or  to  use  his  muscles;  he  lies  quietly, 
does  not  respond  as  he  once  did,  and  takes  less  interest  in  his  surround- 
ings. After  a  few  weeks  it  is  clear  that  the  child,  instead  of  advancing, 
is  actually  retrograding  both  physically  and  mentally.  His  muscles 
become  so  weak  that  he  can  no  longer  sit  up  or  even  hold  up  his 
head.  Vision  becomes  less  and  less  distinct;  the  child  no  longer  recog- 
nizes the  faces  of  friends  or  objects  shown  him.  Finally,  he  becomes 
dull,  apathetic  and  quite  indifferent  to  his  surroundings;  then  it  is 
evident  that  he  can  not  see  at  all.  '  In  the  early  stages  the  muscles 
are  usually  weak  and  flaccid;  later  there  is  rigidity  with  increased  knee 
jerks  and  often  marked  spasticity.  Children  with  amaurotic  family 
idiocy  are  often  fat  and  well  nourished,  but  with  the  onset  of  weakness 
loss  of  weight  occurs  and  eventually  this  may  be  so  extreme  that  the 
emaciation  may  be  a  prominent  factor.  There  may  be  general  convul- 
sions. The  characteristic  features  of  the  disease  are  revealed  by  the 
ophthalmoscope.  Occupying  the  place  of  the  macula  lutea  there  is  a 
large,  milky  blue  or  white  area  with  a  bright  cherry-red  spot  in  its 


MENTAL  DEFICIENCY  789 

center.  "With  this  there  is  also  atrophy  of  the  optic  discs.  The  ocular 
changes  are  symmetrical. 

The  outlook  is  absolutely  bad.  The  disease  is  progressive  and 
usually  fatal  within  a  year  from  the  time  when  the  first  symptoms  are 
seen;  but  occasionally  the  blind,  helpless  child  may  live  for  several 
years  if  feeding  with  the  stomach  tube  is  resorted  to,  for  swallowing 
eventually  may  become  quite  impossible. 

There  are  characteristic  pathological  changes  to  be  found  in  the 
cells  of  the  central  nervous  system.  The  brain  itself  is  not  diminished 
in  size,  but  is  more  firm  and  elastic  than  normal.  The  same  is  true  of 
the  cord.  Microscopically,  the  ganglion  cells  show  a  marked  and  striking 
degeneration.  They  are  swollen,  their  protoplasm  is  undifferentiated 
and  the  nucleus  is  excentrically  situated  and  degenerating.  There  are 
oftentimes  large,  ovoid  swellings  upon  the  cell  processes.  Ultimately 
the  nerve  cells  disappear  and  are  replaced  by  neuroglia.  These  changes 
are  very  wide-spread  and  are  found  in  the  retina  as  well  as  in  the 
brain  and  cord.  In  many  cases  hardly  a  normal  ganglion  cell  may 
be  found. 

To  be  differentiated  from  amaurotic  family  idiocy  is  a  less  frequent 
form  of  degeneration,  known  as  "familial  maculo-cerebral  degeneration." 
It  attacks  several  children  in  a  family  and  at  about  the  age  of  six  or 
seven  years.  These  children  become  dull,  stupid,  lose  their  power  of 
attention  and  eventually  their  ability  to  read,  speak  or  even  recognize 
people.  With  these  symptoms  there  is  a  central  scotoma  which  may  be 
of  high  degree  but  does  not  produce  complete  blindness.  The  physical 
condition  of  the  child  may  remain  normal  for  a  long  time.  The  eyes 
show  a  combination  of  atrophy  of  the  retina  with  pigmentation  espe- 
cially in  the  region  of  the  macula.  The  condition  is  incurable.  It  is 
progressive,  though  the  patients  may  live  many  years.  Death  occurs 
from  intercurrent  infection  rather  than  from  the  disease  itself. 


MENTAL  DEFICIENCY 

{Idiocy — Imbecility) 

By  mental  deficiency  is  meant  any  interference  with  intclligenco 
or  a  limitation  in  the  adaptation  of  the  child  to  his  environment.  This 
interference  with  intelligence  may  occur  in  children  as  the  result  of 
various  general  diseases  or  those  confined  to  the  nervous  system. 
In  other  chapters  the  mental  deficiency  occurring  secondary  to  general 
diseases  and  also  to  organic  disease  of  the  nervous  system,  such  as  hydro- 
cephalus, chronic   meningitis,  paresis,   meningeal  hemorrhage,   etc.,   is 


790  DISEASES  OF  THE  NERVOUS  SYSTEM 

discussed.     The  present  chapter  will  treat  only  of  mental  deficiency 
as  an  apparently  primary  condition. 

Of  all  the  factors  that  operate  to  produce  mental  deficiency,  heredity 
is  the  most  important.  This  statement  does  not  require  substantiation. 
It  is  generally  recognized.  The  descendants  of  mental  defectives  may 
be  normal,  they  may  be  so  defective  that  it  is  readily- appreciable  in  the 
first  year  or  two,  or  the  disturbance  of  mentality  may  be  so  slight  that 
it  can  be  recognized  only  after  several  years  of  life.  The  influence 
of  parental  alcoholism,  especially  chronic  alcoholism,  has  been  much 
discussed  and  there  is  a  wide  difference  of  opinion  in  regard  to  it. 
Some  claim  that  it  plays  a  distinct  part  in  the  production  of  feeble- 
mindedness ;  some,  that  it  plays  little  or  none.  It  seems  to  us  that  it  is  a 
factor  of  some  importance.  While  it  cannot  be  entirely  ignored,  it 
certainly  does  not  have  the  influence  that  has  been  ascribed  to  it  by 
many.  Whether  syphilitic  infection  per  se  tends  to  produce  mental 
deficiency  is  open  to  question.  It  does  not  appear  likely  that  its  influence 
can  be  great  unless  it  produces  organic  changes  in  the  meninges  or  in 
the  brain  itself  or  in  the  hlood  vessels.  Poverty,  poor  surroundings, 
bad  atmosphere,  etc.,  have  been  claimed  to  have  an  influence  by  affecting 
the  health  of  the  mother.  Associated  with  these  are  almost  always 
other  factors  such  as  heredity  and  alcoholism  that  probably  have  much 
more  effect  upon  the  offspring. 

The  changes  to  be  found  in  the  brains  of  defectives  are  of  all  degrees 
of  severity.  (Fig.  114.)  There  may  be  an  atrophy  of  one  or  more 
portions  of  the  brain,  failure  of  development  of  one  hemisphere,  poorly 
developed  convolutions  and  shallow  sulci.  In  certain  cases  no  changes 
are  to  be  made  out  macroscopically.  The  position  can  be  well  main- 
tained, however,  that  even  in  such  cases,  mental  deficiency  is  dependent 
upon  actual  organic  changes  in  the  brain,  for  practically  all  observers 
have  found,  as  did  Hammaberg,  that  even  when  no  gross  alteration 
was  apparent  the  ganglion  cells  were  infrequent  and  poorly  developed. 

There  may  be  all  grades  of  mental  deficiency.  It  is  usual  in  this 
country  to  separate  mentally  defective  children  into  three  groups:  (1) 
the  idiots,  those  that  never  develop  beyond  the  mental  age  of  an  average 
child  of  two  years;  (2)  the  imbeciles,  those  that  never  acquire  a  higher 
degree  of  mentality  than  the  average  child  of  seven,  and  (3)  the  morons, 
who  do  not  acquire  a  liiglier  degree  of  mentality  than  children  of 
twelve. 

It  is  frequently  necessary  for  the  physician  to  determine  whether  or 
not  a  child  is  mentally  deficient.  In  doing  so  it  should  be  remembered 
that  normal  mental  development  is  very  dependent  upon  physical 
development ;  but  it  does  not  necessarily  go  on  with  equal  rapidity. 
If  an  infant  has  been  premature  or  badly  nourished  for  many  months  or 


MENTAL  DEFICIENCY  7m 

has  suffered  from  some  very  severe  illness,  he  may  at  the  end  of  a 
year  show  no  more  mental  development  than  an  average  child  of  six  or 
eight  months.  Yet,  with  improvement  in  his  physical  condition  his 
mental  condition  also  improves  so  that  eventually  the  normal  is  reached. 
There  is  a  wide  variation  in  the  rapidity  of  development  of  normal  cliil- 
dren.    Some  are  quite  slow,  especially  in  certain  families.    Proper  atten- 


FiG.  114. — Arrested  Development  of  the  Frontal  Lobes  of  the  Brain,  Particu- 
larly OF  the  Right  Side.     From  an  idiotic  child  twelve  months  old.^ 

tion  should  be  paid  to  this  fact  and  too  much  emphasis  should  not  be 
placed  upon  only  slight  deviations  from  the  normal.  The  abnormal  in- 
fant is  distinguished  not  by  slight,  but  by  gross  deviation  from  the 
normal.  A  high  degree  of  mental  deficiency  can  usually  be  recognized 
very  early;  the  lesser  degrees  require  longer  observation.  Even  those 
children  that  are  only  slightly  affected  often  give  some  definite  evidence 
of  it  during  infancy.    Their  mental  development  begins  late  and  usually 

^Microscopical  Examination:  Cortex  in  affected  region  one-third  normal 
thickness;  membranes  and  white  substance  normal;  striking  absence  of  char- 
acteristic nerve  cells;  very  few  large  or  small  pyramidal  cells  present. 


792 


DISEASES  OF  THE  NERVOUS  SYSTEM 


ends  early.  It  is  fair  to  assume  that  those  whose  mental  development,  in 
the  absence  of  sufficient  physical  cause,  is  abnormally  delayed,  will  suffer 
some  permanent  impairment  of  the  mental  faculties;  but  owing  to  the 
differences  in  the  length  of  time  that  improvement  may  occur  in  differ- 
ent children,  it  is  impossible  to  predict  closely  as  to  the  final  out- 
come. 

To  appreciate  the  abnormal,  one  must  be  familiar  with  the  mental 
and  physical  development  of  normal  children.  Mental  development 
shows  itself  in  the  early  months  of  life  chiefly  by  the  acquisition  of  the 
ability  to  do  certain  physical  things.  The  normal  child  about  the 
third  month  begins  to  grasp  objects — at  the  fourth  month  he  recognizes 
people,  between  the  third  and  fifth  months  he  holds  his  head  up  firmly, 
at  the  fifth  month  he  reaches  for  things,  holds  them  in  his  hands  and 


^  ^jiHi 

-    -             3| 

■^^^^^^^^^ 

H'"' 

,  ^  ^ 

■|| 

*  -^^ 

m\ 

^__ «[ 

^Bt 

Fig.  115. 


Fig.  IIG. 


Fig.  117. 


Fig.  115. — Boy  twelve  years  old;  microcephalic;  walked  at  about  four  years;  can  read 
and  write;   development  like  that  of  a  normal  child  of  eight  years. 

Fig.  116. — Microcephalic,  seven  years  old;  understands  most  of  what  is  said;  cannot 
talk  intelligibly. 

Fig.  117. — Girl  of  eight  years;  imbecile;  cannot  walk  without  help. 


observes  them.  From  seven  to  nine  months,  he  sits  alone,  and  laughs 
in  play.  From  nine  to  ten  months,  many  children  stand.  At  a  year 
they  often  begin  to  walk  and  to  repeat  single  words.  The  mentally 
deficient  child;,  on  the  other  hand,  may  not  even  hold  his  head  up  at  the 
end  of  a  year.  He  makes  no  attempt  to  grasp  objects,  perhaps  holds 
them  for  only  a  moment  and  then  drops  them.  He  cannot  sit  alone,  he 
does  not  attempt  to  stand,  and  does  not  recognize  people  until  perhaps 
the  end  of  the  second  year  or  very  much  later. 

Some  mentally  deficient  children  are  exceedingly  placid;  others  cry 
continually  without  apparent  cause  and  are  often  exceedingly  restless. 
The  expression  of  the  normal  child  is  intelligent,  bright  and  alert;  the 
abnormal  (Figs.  115,  116,  117)  may  betray  his  lack  of  mental  capacity 
by  his  vacant,  stupid  expression,  his  open  mouth,  protruding  tongue, 
drooling  and  his  irregular,  aimless  movements  of  the  hands.  As  time 
goes  on,  mentally  deficient  children  not  only  remain  backward  in  things 
that  they  should  do,  but  they  also  do  things  that  normal  children  do  not 


MONGOLIAN  IDIOCY  793 

do.  They  develop  screaming  attacks,  they  throw  their  heads  backward  or 
frequently  stiffen  out.  Strabismus  is  often  present  and  there  may  be  ill- 
defined  attacks  of  a  convulsive  nature  or  typical  convulsions. 

It  may  be  exceedingly  difficult  at  times  to  differentiate  between  the 
merely  backward  child  or  the  mentally  deficient.  The  backward  child 
is  usually  distinguished  chiefly  by  the  things  which  he  does  not  do. 
He  does  not  show  an  abnormal  mentality.  Children  merely  backward 
as  the  result  of  disease  may  not  be  able  to  talk  until  two  years  old  or  may 
not  walk  until  after  that  time,  yet  may  understand  what  is  said  and 
done  for  them;  their  expression  is  normal;  they  seem  bright,  and  the 
development,  although  slow,  is  steady  and  progressive.  Mentally  defi- 
cient children,  on  the  other  hand,  are  not  only  very  backward,  but  they 
usually  reach  the  end  of  their  development  fairly  early  and  it  is  not  a 
complete  development.  As  Scholz  says,  "the  mentally  deficient  child  of 
twelve  is  not  a  normal  child  of  six;  he  is  not  merely  a  dwarf,  but  a 
cripple."  This  becomes  increasingly  evident  as  the  defective  child  be- 
comes older  and  his  character  and  mental  processes  find  better  expres- 
sion. He  may  be  disobedient,  unruly,  untrustworthy,  cruel  to  animals 
and  playmates,  not  interested  in  the  play  of  children,  and  may  not 
conform  to  the  ordinary  standards  of  cleanliness  and  neatness.  Most  of 
the  children  are  clumsy  in  their  movements  and  especially  not  dextrous 
Avith  their  hands.  There  are  many  cliildren,  however,  that  are  docile, 
kind  and  affectionate,  but  whose  faculties  are  totally  inadequate  when 
compared  with  those  of  the  average  child.  One  with  experience  in  testing 
mentally  deficient  children  is  able  to  tell  with  a  considerable  measure 
of  accuracy  what  their  mental  capacity  is.  This  is  accomplished  by 
observation  and  various  tests,  including  the  Binet-Simon  test.  This 
standardizing  need  not  concern  us  here;  but  all  physicians  should  be  in 
a  position  to  recognize  the  abnormal.  The  standardization  of  the  abnor- 
mal and  particularly  the  training  should  be  in  the  hands  of  experts 
in  that  field. 

MONGOLIAN  IDIOCY 

A  form  of  mental  deficiency  that  can  be  at  once  recognized  by  the 
physical  characteristics  of  the  child  is  the  so-called  Mongolian  Idiocy, 
also  known  as  "Kalmuck  Idiocy."  The  cause  of  this  is  obscure.  It  cannot 
l)e  shown  that  it  is  due  in  any  way  to  syphilis  or  to  the  excessive  use  of 
alcohol  in  the  parents.  The  condition  appears  with  equal  frequency  in 
the  sexes.  It  is  found  in  the  Caucasian  race  and  we  have  seen  several 
instances  in  the  colored,  but  it  has  apparently  not  been  reported  among 
the  Malay  or  Mongolian  races.  The  factor  of  greatest  importance  is 
the  age  of  the  mother.     The  majority  of  Mongolian  idiots  are  born  to 


794 


DISEASES  OF  THE  NERVOUS  SYSTEM 


women  over  35  years  of  age.  The  number  of  pregnancies  also  appears 
to  have  an  influence.  These  children  are  not  infi-equently  the  last  after 
the  birth  of  a  number  of  healthy  children.  Much  less  frequently,  they 
are  the  first,  but  the  number  of  first  or  last  children  that  are  Mongols 
is  greatly  in  excess  of  those  in  the  middle  of  families.  It  is  evident  that 
the  reproductive  function  has  an  important  bearing  upon  their  develop- 
ment. They  are  probably  the  result  of  incomplete  or  inhibited  develop- 
ment, and  have  been  called  by  Shuttleworth  "exhaustion  products." 

This  is  one  of  the  common  forms  of  mental  defect,  apparently  more 
frequent  in  England  and  in  this  country  than  elsewhere,  perhaps  on 

Mongolian  Types 


Fig.  118. 


Fig.  119. 


Fig.  120. 


Fig.  118.— Six  months  old;  died  at  twenty-two  months;  could  not  hold  up  the  head,  or 

understand  anything. 
Fig.  119. — Boy,  twenty-one  months  old;   did  not  hold  up  his  head  until  eighteen  months; 

mental  development  that  of  a  child  of  eleven  or  twelve  months. 
Fig.  120. — Girl  four  years  old;    mental  development  like  that  of  a  normal  child  of  two 

and  a  half  years;  walks  very  awkwardly. 


account  of  closer  observation,  as  the  result  of  the  frequent  attention  that 
has  been  called  to  it. 

Pathologically,  the  brains  are,  as  a  rule,  small.  The  convolutions 
are  poorly  developed  and  there  is  apt  to  be  an  aplasia  of  some  parts,  such 
as  the  cerebellum,  pons  or  medulla.  The  cortex  is  frequently  thin  and 
the  ganglion  cells  few  in  number,  with  rather  scanty  cell  processes. 

The  appearance  of  these  children  is  very  striking  (Figs.  118,^  119, 
120)  and  it  can  at  once  be  seen  whence  they  have  derived  their  name. 
There  is  a  peculiar  Mongolian  type  of  countenance ;  the  eyes  are  set 
closely  together,  they  are  slanting  and  the  palpebral  fissures  narrow. 
There  is  frequently  epicanthus.  The  head  is  brachycephalic  and  small. 
At  twelve  months  it  is  often  two  inches  below  the  average  in  circumfer- 
ence. The  children  are  short  for  their  age.  Their  hands  are  short  and 
thick,  especially  the  fingers;  tlie  little  finger,  not  uncommonly,  is  so 
short  that  it  does  not  reach  to  llie  last  iiiterphalaiigeal  joint  of  the  ring 
finger.     The  nnisdcs  are  ])oorly  d('\'eloped,  and  lliore  is  a  great  relaxa- 


DEAF-MUTISM  795 

tion  of  the  ligaments,  so  that  the  strangest  and  most  uncomfortable  posi- 
tions can  be  assumed  at  will  and  often  by  preference.  The  tongue  is 
usually  prominent,  slightly  protruding  and  deeply  fissured.  There  is 
usually  drooling  from  the  mouth  and  often  a  nasal  discharge,  so  that 
the  lips  may  be  greatly  excoriated.  Mouth-breathing  is  nearly  always 
present.  The  nasopharynx  is  often  small,  sometimes  owing  to  back- 
ward projection  of  the  vomer,  sometimes  to  a  forward  projection  of 
the  bodies  of  the  cervical  vertebrae.  A  very  moderate  amount  of  adenoid 
tissue  may  produce  marked  symptoms  of  nasal  obstruction.  The  expres- 
sion is  often  that  of  a  child  suffering  from  very  large  adenoid  growths, 
and  sometimes  the  early  cases  are  passed  over  as  simply  "adenoids  with 
mental  dulness."  Other  defects  are  often  associated.  The  ears  are  fre- 
quently misshapen;  congenital  malformations  of  the  heart  are  quite 
common;  in  one  of  our  cases  there  was  absence  of  the  patella. 

Mongolian  idiots  are  very  backward  in  development.  They  fre- 
quently do  not  hold  up  their  heads  until  a  year  of  age,  or  later,  and  may 
not  walk  until  the  end  of  the  second  or  third  year.  Speech  is  greatly 
delayed  and  seldom  normal ;  although  almost  all,  if  they  live  sufficiently 
long,  do  eventually  talk  to  a  certain  extent.  These  children  have  but  lit- 
tle resistance  to  any  acute  disease.  They  are  particularly  susceptible  to 
infection,  and  the  majority  die  in  infancy  or  early  childhood.  We  see 
many  of  them  as  infants  and  few  after  the  eighth  or  tenth  year.  They 
succumb  chiefly  to  pulmonary  infections  or  to  tuberculosis.  There  is  a 
certain  degree  of  variation  in  their  mental  capacity,  but  it  is  singularly 
slight,  and,  as  the  majority  of  them  look  much  alike,  so  also  their  mental 
processes  are  alike,  and  very  few  of  them  reach  a  higher  mental  develop- 
ment than  that  represented  by  a  normal  child  of  four  or  five  years. 
They  are  restless,  inattentive,  and  can  be  taught  with  great  difficulty. 


DEAF-MUTISM 

Excluding  the  cases  in  which  idiocy  is  present,  which  are  not  con- 
sidered in  this  chapter,  deaf-mutism  may  be  due  either  to  congenital  or 
acquired  conditions ;  the  larger  proportion  of  the  cases  belong  in  the  lat- 
ter class.  When  congenital,  deaf-mutism  may  result  from  ostitis,  or 
periostitis  of  the  temporal  bone,  encroaching  upon  the  cavity  of  the 
middle  ear,  from  ankylosis  of  the  ossicles,  from  absence  of  the  internal 
ear  or  any  of  its  parts.  There  may  also  be  colloid  degeneration  of  the 
labyrinth.  It  may  result  from  atrophy  of  the  auditory  nerve,  and  it 
may  be  due  to  a  lesion  of  the  brain.  These  congenital  conditions  are 
often  hereditary.  An  unusual  form  of  congenital  deafness  is  occasionally 
present  with  goiter.     It  is  found  especially  in  those  regions  in  which 


796  DISEASES  OF  THE  NEEVOUS  SYSTEM 

goiter  is  endemic.  Its  cause  is  unknown.  Acquired  deaf-mutism  is  most 
frequently  the  result  of  scarlet  fever,  and  is  due  to  otitis.  The  second 
important  cause  is  cerebrospinal  meningitis,  where  it  ma}'  be  due  to  a 
lesion  of  the  brain,  the  auditory  nerve,  or  the  ear.  It  occasionally  follows 
mumps,  diphtheria,  measles,  and  other  infectious  diseases.  It  may  result 
from  repeated  attacks  of  acute  otitis  associated  with  adenoid  growths  or 
chronic  rhinopharyngitis. 

The  younger  the  child  at  the  time  the  deafness  occurs  the  sooner  the 
power  of  speech  is  lost.  In  most  of  the  infectious  diseases,  if  the  attack 
occurs  before  the  fifth  year,  speech  is  lost.  According  to  Love,  total  deaf- 
ness is  rare  among  deaf-mutes ;  hearing  for  speech  is  present  to  a  useful 
degree  in  about  twenty-five  per  cent  of  the  cases,  while  hearing  by  cranial 
conduction  exists  in  nearly  all  cases.  Deaf-mutism  should  be  suspected 
if  a  child  not  idiotic  shows  at  the  end  of  two  years  no  signs  of  beginning 
to  talk.  A  careful  distinction  should  be  made  between  deaf-mutism 
and  idiocy  resulting  either  from  congenital  conditions  or  acquired  dis- 
ease. 

It  is  necessary  that  this  condition  be  recognized  as  early  as  possible, 
in  order  that  the  child  may  have  the  advantages  of  proper  training 
during  his  early  years.  The  physician  should  insist  upon  the  child  being 
sent  as  early  as  the  third,  and  certainly  by  the  fourth  year  to  an  institu- 
tion where  he  may  be  taught  to  speak. 

The  treatment  is  mainly  prophylactic.  The  most  important  relates 
to  the  care  of  the  ears  in  scarlet  fever,  and  the  removal  of  adenoid  vegeta- 
tions of  the  pharynx  and  other  causes  which  produce  attacks  of  acute  or 
chronic  otitis.  For  the  condition  itself  education  is  the  only  thing  to 
be  considered. 


CHAPTER  IV 


DISEASES  OF  THE  SPINAL  CORD 

MALFORMATIONS 

Malformations  of  the  cord  are  very  frequently  associated  with  those 
of  the  brain,  and  bear  a  certain  degree  of  resemblance  to  them.  (1) 
The  cord  may  be  absent  (amyelia)  ;  this  condition  may  exist  alone  or 
with  absence  of  the  brain.  (2)  The  lack  of  development  may  be  only 
partial  (atelomyelia),  as  when  some  of  the  tracts  are  wanting.  The 
most  important  one  is  defective  development  of  the  lateral  tracts,  which 
may  be  a  cause  of  spastic  paraplegia  (Charcot).  (3)  There  may  be  a 
malposition  of  some  of  the  gray  matter  (heterotopia).     (4)  There  may 


MALFORMATIONS  797 

be  a  double  cord  (diplomyelia) ;  the  division  is  generally  incomplete, 
and  is  attributed  to  an  abnormal  development  of  the  central  canal ;  it  is 
usually  associated  with  other  deformities.  All  of  these  malformations 
are  extremely  rare  and  of  very  little  practical  interest. 

There  remains  to  be  mentioned  the  only  one  which  is  really  impor- 
tant— spina  bifida. 

Spina  Sifida. — This  is  a  malformation  of  the  vertebral  canal  with  a 
protrusion  of  some  part  of  its  contents  in  the  form  of  a  fluid  tumor. 
The  tumor  is  elastic,  compressible,  usually  increased  by  crying,  and 
sometimes  by  pressure  upon  the  anterior  fontanel.  The  contained  fluid 
is  clear,  resembling  in  all  respects  the  cerebrospinal  fluid.  It  is  one  of 
the  most  frequent  congenital  deformities. 

Spina  bifida  is  due  to  an  early  failure  in 
development — in  most  cases  before  the  cord  is 
segmentated  from  the  epiblastic  layer  from 
which  it  is  developed.  Hence  it  remains  ad- 
herent to  the  epiblastic  covering,  and  the  struc- 
tures which  should  be  formed  between  the  cord 

and  the  skin  are  undeveloped.     For  this  reason 

,1  •      •      11  n      J?  j-i,  J?      •  £  ±-u         Fig.     121. — Meningocele 

there  is  m  the  wall  of  the  sac  a  fusion  of  the         (partially diagrammatic). 

elements  of  the  cord,  nerves,  meninges,  verte-         A,  the  membranes;    B, 

1       1    •       1  1  1    •    X  X        Ti?    xi_  the   spinal   cord;     C,   the 

brai  arches,  muscles,  and  integument,     if  the         integument.        The   ac- 

error  in  development  occurs  later,  the  cord  and         cumulation  of  fluid  is  be- 

1         XX     1     1   X     XT  IX         X    •  hind  the  cord,  which  does 

nerves  may  be  attached  to  the  sac,  but  not  m-         ^^^  ^^^^j.  ^^^  gg^^ 
timately  fused  with  it;  in  still  other  cases  the 

cord  does  not  enter  the  sac  at  all.  The  malformation  may  occur  before 
the  central  canal  is  closed;  or,  if  closed,  it  may  reopen  from  the  ac- 
cumulation of  fluid.  It  is  probable  that  the  accumulation  of  fluid  first 
occurs,  and  that  this  prevents  the  union  of  the  parts  of  the  vertebral 
arches.      ^ 

Although  the  tumor  is  generally  associated  wdth  a  bifid  spine,  this 
is  not  necessarily  the  case.  The  protrusion  may  take  place  through  the 
intervertebral  notch  or  foramen,  or  there  may  be  a  fissure  of  the  bodies 
of  the  vertebrae,  and  an  anterior  tumor  projecting  into  the  cavity  of  the 
thorax,  abdomen,  or  pelvis ;  the  tumor  may  be  so  small  as  not  to  be  recog- 
nized externally — spina  bifida  occulta.  The  principal  anatomical  varie- 
ties are  meningocele,  meningomyelocele,  and  syringomyelocele. 

Meningocele. — In  this  form  there  is  a  protrusion  of  the  membranes 
only  (Fig.  121).  The  accumulation  of  fluid  is  either  in  the  arachnoid 
cavity  or  the  subarachnoid  space  posterior  to  the  cord.  The  opening  of 
communication  between  the  tumor  and  the  spinal  canal  is  small  in  this 
variety,  usually  being  about  one-twelfth  to  one-sixth  of  an  inch  in  diam- 
eter. There  may,  however,  be  no  communication.  The  skin  is  usually 
27 


798 


DISEASES  OF  THE  NERVOUS  SYSTEM 


fully  developed  (Fig.  123).  The  tumor  is  frequently  globular,  some- 
times pedunculated,  and  may  attain  a  very  large  size,  being  as  much  as 

five  or  six  inches  in  diameter.  This 
is  because  spontaneous  rupture  is 
not  likely  to  occur,  and  the  tumor 
does  not  become  infected  except  by 
operative  interference.  With  such 
tumors  patients  may  live  to  adult 
life.  This  variety  is  most  frequent- 
ly seen  in  the  cervical  region.  It  has 
the  best  chance  of  natural  recovery, 
and  in  it  operation  gives  the  best  re- 
sults. 

Meningom,yelocele. — This  is  by 
far  the  most  frequent  variety  of 
spina  bifida.  It  is  the  form  usually 
seen  in  the  sacrolumbar  region. 
The  accumulation  of  fluid  takes 
place  in  the  anterior  subarachnoid 
space,  less  frequently  in  the  anterior 
arachnoid  cavity  (Fig.  123).  In 
this  form  the  cord  is  contained  in 
the  sac,  and  usually  forms  a,  part  of 
its  wall.  The  tumor  is  smaller  than  the  meningocele,  the  usual  size  being 
that  of  a  mandarin  orange.  It  is  sessile,  never  pedunculated.  As  a  rule 
it  is  only  partly  covered  by  skin,  but  has  a  central  area,  usually  elliptical 
in  shape,  where  there  is  only  a 
thin,  translucent  membrane.  This 
surface,  which  is  known  as  the  cen- 
tral cicatrix,  is  sometimes  covered 
with  granulations,  and  frequently 
ulcerates.  The  tumor  often  has  a 
vertical  furrow  or  a  central  umbil- 
ication,  corresponding,  to  the  at- 
tachment of  the  cord  on  its  inner 
surface.  The  usual  relation  of  the 
parts  is  for  the  cord  to  run  hori- 
zontally across  the  upper  part  of 
the  tumor  to  the  central  cicatrix, 
with  which  it  becomes  blended,  and 

from  which  again  the  nerves  arise.  These  re-enter  the  canal  at  the  lower 
part  of  the  tumor,  and  are  distributed  below  as  usual.  In  other  cases  the 
cord  Joins  the  wall  of  the  sac  soon  after  its  entran<?e,  and  its  attenuated 


Fig.  122. 


-Meningocele,    in 
One  Year  Old. 


Child 


Fig.  123 


Meningomyelocele  (partially 
diagrammatic).  A,  the  membranes; 
B,  the  cord;  C,  the  integument.  The 
accumulation  of  fluid  is  in  front  of  the 
cord,  the  filaments  of  which  are  spread 
out,  forming  a  part  of  the  wall  of  the 
sac. 


SPINA  BIFIDA  799 

fibers  are  found  spread  out  all  over  the  sac,  coming  together  again  below 
and  entering  the  spinal  canal. 

The  following  case,  upon  which  an  autopsy  was  made,  is  a  good  ex- 
ample of  the  common  variety :  The  child  died  on  the  third  day  after  birth 
from  rupture  of  the  sac.  The  tumor  occupied  the  sacral  region.  The 
first  sacral  vertebra  was  normal,  and  beneath  this  the  cord  passed  out  of 
the  spinal  canal,  terminating  in  the  cauda  equina  soon  after  entering  the 
sac,  and  continued  back  to  the  central  cicatrix.  Here  nerve  filaments 
blended  with  the  other  tissues  in  an  indefinite  structure,  from  which 
again,  with  tolerable  distinctness,  the  nerve  structures  could  be  seen  to 
pass  over  the  wall  of  the  sac  and  return  to  the  canal.  The  afferent  and 
efferent  nerves  and  the  part  of  the  membranes  they  carried  with  them 
formed  several  septa,  making  a  smaller  separate  sac  within  the  larger 
one.  The  large  sac  was  clearly  a  dilatation  of  the  anterior  subarach- 
noid space,  and  communicated  freely  with  the  same  space  in  the  cord 
above. 

Syringomyelocele. — In  this  variety  the  accumulation  of  fluid  is  in 
the  central  canal  of  the  cord,  the  lining  of  the  sac  being  here  the  at- 
tenuated and  atrophied  cord  elements.  This  is  the  rarest  form  of 
tumor,  but  the  one  most  frequently  associated  with  hydrocephalus,  and 
consequently  has  the  worst  prognosis.  It  may  be  found  in  the  dorsal 
or  dorsolumbar  region  as  well  as  in  the  lumbosacral. 

With  spina  bifida  other  deformities  are  frequently  associated,  the 
most  common  being  club-foot,  hydrocephalus,  more  rarely  encephalo- 
cele  or  cerebral  meningocele,  and  hare-lip.  If  hydrocephalus  exists, 
there  is  in  most  cases  a  dilatation  of  the  central  canal  of  the  cord  and 
a  direct  communication  between  the  tumor  and  the  lateral  ventricles  of 
the  brain.  Pressure  upon  the  anterior  fontanel  causes  an  increase  in 
the  size  of  the  tumor,  and  conversely.  Club-foot  is  usually  double,  most 
frequently  talipes  equinovarus.  In  a  number  of  cases  there  is  a  history 
of  some  deformity  in  other  members  of  the  family.  We  have  seen  two 
successive  children  in  the  same  family  with  spina  bifida. 

Symptoms.— The  tumor  in  spina  bifida  is  present  at  birth,  and  is 
most  frequently  lumbosacral.  Paralysis  is  frequent  in  myelocele  and 
syringomyelocele,  but  is  not  seen  in  meningocele;  its  degree  and  its 
location  depend  upon  the  situation  of  the  tumor  and  the  extent  to 
which  the  cord  is  involved.  It  is  rare  in  cervical  tumors,  and  most 
marked  in  those  situated  in  the  lumbosacral  region.  In  the  worst 
cases  there  is  complete  paraplegia,  with  paralysis  of  the  bladder  and 
rectum.  If  the  tumor  is  sacrolumbar  or  sacral,  only  the  cauda  equina 
is  likely  to  be  involved,  and  this  but  partially,  so  that  the /paralysis 
of  the  extremities  is  incomplete,  and  the  bladder  and  rectum  may 
escape.    Spina  bifida  occulta  is  in  rare  instances  the  explanation  of  obsti- 


800 


DISEASES  OF  THE  NERVOUS  SYSTEM 


nate  incontinence  of  urine  and  sometimes  of  feces  also.     It  may  occur 
without  paraplegia. 

In  Fig.  124  is  shown  a  very  remarkable  case  of  sacral  s]3ina  bijEida 
in  a  boy  of  five  years,  who  came  under  observation  for  incontinence  of 
feces.  The  tumor  was  a  little  more  to  the  left  than  to  the  right  side, 
and  had  been  overlooked.  It  had  evidently  pressed  upon  the  lower 
branches  of  the  sacral  plexus,  so  as  to  affect  the  sphincter  and  the  gluteal 
muscles  of  the  left  side.    The  atrophy  was  very  marked,  as  shown  in  the 

illustration. 

The  natural  course  of  spina 
bifida  is  to  increase  steadily  in 
size ;  and  if  the  tumor  is  covered 
by  skin,  its  growth  may  be  almost 
unlimited.  It  has  been  known  to 
attain  a  circumference  of  twenty- 
two  inches.  If  the  integument  is 
wanting,  and  the  sac  wall  is  very 
thin,  rupture  is  pretty  certain  to 
take  place,  either  spontaneously 
or  by  some  accident,  in  the  course 
of  the  first  few  months;  usually 
death  then  results  from  convul- 
sions owing  to  the  rapid  draining 
away  of  the  cerebrospinal  fluid,  or 
from  infection.  In  a  large  num- 
ber of  cases  death  is  due  to  maras- 
mus dependent  upon  the  asso- 
ciated conditions.  Infection  of 
the  tumor  may  take  place  without 
rupture,  the  germs  passing  through  the  wall  of  the  sac.  If  the  opening 
communicating  with  the  spinal  canal  is  small,  this  infection  may  excite 
an  inflammation  limited  to  the  wall  of  the  sac,  and  result  in  a  cure  of 
the  spina  bifida,  usually  with  sloughing.  We  have  seen  such  a  case  in  a 
girl  ten  years  old  in  whom  this  occurred  in  infancy.  The  site  of  the 
former  tumor  was  marked  by  a  large  dense  cicatrix,  and  there  still  re- 
mained partial  paralysis  of  the  legs.  If  the  opening  into  the  spinal 
canal  is  large,  inflammation  of  the  sac  is  usually  followed  by  spinal 
meningitis,  which  may  extend  upward  and  involve  also  the  meninges  of 
the  brain. 

Prognosis. — This  depends  chiefly  upon  the  anatomical  variety  and 
tlie  existence  of  complications.  Simple  meningocele,  when  covered  by 
integument,  gives  the  best  prognosis,  and  complete  recovery  may  occur. 
In  meningomyelocele,  especially  if  complete  paralysis  exists,  the  prog- 


FiG.  124.— Sacral  Spina  Bifida. 


SPINA  BIFIDA  801 

nosis  is  bad ;  and  if  there  is  also  hydrocephalus,  the  case  is  hopeless.  In 
many  cases  in  which  cure  of  the  spina  bifida  has  followed  operation, 
hydrocephalus  has  subsequently  developed.  Of  fifty-seven  cases  reported 
by  Demme,  twenty-five  were  operated  upon,  with  seven  recoveries  and 
fifteen  deaths,  while  three  were  unimproved ;  of  the  thirty-two  cases  not 
operated  upon,  twenty-eight  died  within  the  first  month,  and  not  one 
lived  over  two  years — the  causes  of  death  being  marasmus,  rupture  of 
the  sac,  and  meningitis. 

Diagnosis. — It  is  usually  easy  to  recognize  spina  bifida,  but  it  is  often 
difficult  to  distinguish  between  the  diiferent  varieties.  The  absence  of 
a  palpable  fissure  in  the  spine,  perfect  translucency,  and  a  pedunculated 
tumor,  all  point  strongly  to  meningocele.  Paralysis  of  the  sphincters 
and  lower  extremities,  umbilication  of  the  center  of  the  tumor,  a  sessile 
tumor,  a  palpable  bony  fissure,  and  a  large  central  cicatrix,  point  to 
meningomyelocele.  The  coexistence  of  hydrocephalus  points  to  syringo- 
myelocele. 

Treatment. — In  all  cases  the  tumor  should  be  protected  from  pres- 
sure, and  when  it  is  not  covered  by  integument,  care  taken  that  the  sur- 
face is  kept  absolutely  clean  and  aseptic.  It  should  be  covered  with 
some  antiseptic  powder  and  surrounded  by  a  large  pad  of  absorbent  cot- 
ton, or  a  rubber  ring-cushion.  Complete  paraplegia  with  involvement  of 
the  bladder  and  rectum,  hydrocephalus,  or  extreme  marasmus — all  con- 
traindicate  operative  interference.  If  these  are  absent,  operation  should 
be  considered.  The  time  of  operation  will  depend  somewhat  upon  the 
nature  of  the  tumor.  If  it  is  covered  by  integument  and  growing 
slowly,  it  is  well  to  wait  until  the  child  is  at  least  six  months  old.  In 
other  cases  delay  is  dangerous,  because  of  the  liability  to  spontaneous  or 
accidental  rupture. 

The  treatment  by  injection  has  now  been  entirely  superseded  by  the 
operation  of  excision  of  the  sac.  For  a  description  of  this  and  the 
various  plastic  operations  that  have  been  proposed  in  connection  with 
it  the  reader  is  referred  to  works  upon  operative  surgery.  In  operating, 
it  should  not  be  forgotten  that  in  the  great  proportion  of  the  cases  (nine- 
ty-five per  cent,  according  to  the  London  Clinical  Society's  Eeport, 
which,  however,  refers  only  to  fatal  cases)  some  part  of  the  cord  is  in 
the  sac.  The  cord  is  often  present  in  tumors  situated  below  the  third 
lumbar  vertebra,  owing  to  its  attachment  to  the  sac. 

Although  recovery  may  follow  operation,  in  a  very  large  number  of 
cases  it  is  incomplete;  some  degree  of  paralysis,  with  atrophy,  contrac- 
tures and  deformities,  remaining  because  of  the  implication  of  cord  ele- 
ments in  the  sac.  In  a  considerable  proportion  of  cases,  hydrocephalus 
subsequently  develops,  as  after  similar  operations  upon  cerebral  menin- 
ffocele. 


802  DISEASES  OF  THE  NERVOUS  SYSTEM 


SPINAL  MENINGITIS 

In  acute  meningitis  usually  only. the  pia  mater  is  involved.  This 
rarely  occurs  alone,  unless  it  is  due  to  traumatism.  It  is  most  frequently 
associated  with  inflammation  of  the  pia  of  the  brain,  and  may  occur 
either  with  the  meningococcus  or  the  tuberculous  variety.  A  certain 
amount  of  acute  inflammation  of  the  pia  mater  accompanies  most  of  the 
cases  of  acute  myelitis. 

Chronic  spinal  meningitis  in  children  usually  involves  the  dura  only. 
Inflammation  of  the  external  layer  (external  pachymeningitis)  is  usually 
secondar}'-  to  caries  of  the  vertebrae.  This  is -considered  in  the  article  on 
Compression-Myelitis. 

Symptoms. — The  symptoms  of  inflammation  of  the  spinal  mem- 
branes, no  matter  with  what  pathological  condition  it  may  be  associated, 
are  due  to  irritation  of,  or  pressure  upon,  the  cord  or  nerve  roots.  Those 
which  are  most  common  are :  pain  in  the  back,  which  is  increased  by 
movement,  and  usually  by  pressure  upon  the  spinous  processes ;  radiating 
pains  following  the  course  of  the  spinal  nerves,  felt  in  the  extremities  or 
in  the  trunk ;  rigidity  of  the  spinal  column  due  to  spasm  of  the  spinal 
muscles,  or  rigidity  of  the  muscles  of  the  extremities;  and  hyperesthesia 
along  the  spine,  which  may  be  quite  acute.  When  pressure  upon  the 
cord  is  added,  there  is  paralysis  or  paresis,  sometimes  muscular  atrophy 
and  anesthesia.-  Any  of  the  above  symptoms  may  be  acute  or  chronic, 
according  to  the  nature  of  the  primary  disease. 

The  diagnosis  between  spinal  meningitis  and  myelitis  is  often  not 
easy,  for  excerpt  in  acute  cases  the  two  processes  are  usually  associated ; 
and  in  a  given  case  it  may  be  difficult  to  decide  whether  the  lesion  of  the 
cord  or  of  the  membranes  is  the  more  important  one.  In  meningitis, 
pain,  tenderness,  spasm,  and  irritative  symptoms  are  generally  more 
prominent,  while  loss  of  power  and  anesthesia  are  usually  partial.  In 
myelitis  the  pain,  tenderness,  and  other  irritative  symptoms  are  less 
marked,  while  paralysis  and  anesthesia  may  be  complete. 

Treatment. — This  relates  first  to  the  disease  with  which  it  is  asso- 
ciated ;  in  addition,  counter-irritation  by  means  of  the  Paquelin  cautery, 
rest  in  bed,  and  in  severe  cases  even  immobilization  of  the  spine  by  a 
mechanical  support.     lodid  of  potassium  is  often  useful. 


MYELITIS 

Myelitis  is  a  rare  disease  in  children,  with  the  exception  of  two  vari- 
eties which  are  discussed  under  separate  heads,  viz.,  compression-myelitis 


MYELITIS  803 

and  acute  poliomyelitis.  Otherwise  myelitis  usually  results  from  injury, 
but  it  may  occur  as  a  complication  of  any  of  the  acute  infectious  dis- 
eases, especially  typhoid,  scarlet  fever,  and  diphtheria,  and  even  as  a 
primary  disease,  when  it  is  attributed. to  exposure  or  cold,  but  when  it 
is  probably  of  infectious  origin.  We  have  seen  it  follow  varicella. 
Chronic  myelitis  may  be  due  to  hereditary  syphilis. 

Myelitis  usually  occurs  in  children  over  ten  years  of  age.  In  situa- 
tion, it  may  be  transverse,  diffuse,  or  disseminated;  the  process  may  be 
acute,  subacute,  or  chronic.  The  lesions  and  the  symptoms  are  essen- 
tially the  same  as  when  the  disease  occurs  in  the  adult. 

Symptoms. — Myelitis  usually  comes  on  rather  gradually,  with  only 
local  symptoms;  but  the  onset  may  be  quite  acute,  with  several  general 
symptoms — fever,  pain,  prostration,  and  localized  or  general  convulsions. 
The  local  symptoms  vary  with  the  seat  and  the  extent  of  the  disease. 

In  transverse  myelitis  loss  of  power  and  anesthesia  are  present  below 
the  level  of  the  lesion ;  either  of  these  may  be  partial  or  complete.  At  the 
level  of  the  lesion  there  is  a  zone  of  hyperesthesia  and  "girdle-pains." 
All  the  reflexes  below  the  seat  of  the  lesion  are  exaggerated.  Those 
at  the  level  of  the  lesion  are  lost.  There  may  be  loss  of  control 
of  the  sphincters,  bed-sores,  degenerative  changes  in  the  paralyzed 
muscles,  contractures,  and  vasomotor  disturbances.  The  paralyzed  mus- 
cles may  be  rigid  or  flaccid,  according  to  the  seat  and  extent  of  the 
lesion. 

When  transverse  myelitis  is  situated  in  the  cervical  region  there  is 
paralysis  and  anesthesia  of  the  arms,  legs,  and  trunk.  All  the  reflexes 
are  exaggerated,  and  there  is  general  rigidity  of  the  paralyzed  muscles. 
There  is  incontinence  of  feces  and  retention  of  urine,  followed  by  in- 
continence from  overflow.  The  pupils  are  frequently  contracted,  and 
there  may  be  optic  neuritis.  Atrophy,  when  present,  usually  affects  the 
muscles  of  the  arms,  and  indicates  that  the  cord  to  a  considerable  extent 
is  involved.  There  is  great  danger  to  life,  owing  to  paralysis  of  the 
muscles  of  respiration. 

When  the  seat  of  disease  is  the  dorsal  region,  the  symptoms  are  simi- 
lar to  those  above  described,  with  the  exception  that  the  arms  escape, 
and  that  the  ocular  symptoms  are  usually  wanting.  This  is  the  most 
favorable  seat  of  the  disease. 

When  the  disease  is  situated  in  the  lumbar  region,  in  addition  to 
paraplegia  and  anesthesia  of  the  legs,  there  is,  from  the  beginning,  in- 
continence of  urine  and  feces,  "^'he  knee  reflexes  are  lost;  the  muscles 
atrophy,  and  usually  give  the  reaction  of  degeneration.  Bed-sores  are 
frequent. 

In  diffuse  myelitis  the  symptoms  are  a  combination  of  the  above 
groups.    If  a  large  part  of  the  cord  is  involved,  there  are  general  paral- 


804  DISEASES  OF  THE  NERVOUS  SYSTEM 

ysis  and  anesthesia,  loss  of  reflexes,  marked  trophic  disturbances,  bed- 
sores, etc. 

The  course  of  myelitis  is  slow,  and  it  usually  progresses  steadily  from 
bad  to  worse.  Death  is  due  to  exhaustion  or  complications — cystitis,  bed- 
sores, or  hypostatic  pneumonia — or  to  some  intercurrent  disease.  In  a 
small  proportion  of  the  cases  there  may  be  partial  recovery,  but  very 
rarely  is  recovery  complete.  The  diagnosis  is  to  be  made  from  spinal 
meningitis,  tumors,  and  hemorrhage. 

Treatment. — The  treatment  of  the  early  stage  consists  in  the  use  of 
ice  to  the  spine,  or  counter-irritation  by  means  of  dry  cups  or  mustard. 
Later,  the  iodid  of  potassium  should  be  given  in  full  doses ;  improvement 
may  follow  its  use,  even  when  there  is  no  suspicion  of  syphilis.  Elec- 
tricity is  contraindicated  except  in  chronic  cases,  and  then  but  little 
improvement  is  likely  to  result  from  its  use.  In  these  patients  the  most 
important  thing  is  careful  attention  to  cleanliness  and  to  posture,  in 
order  to  prevent  bed-sores,  cystitis,  and  pneumonia. 


COMPRESSION  -  MYELITIS 
{Pressure-paralysis  of  the  Spinal  Cord;  Pott's  Paraplegia) 

Compression-myelitis  is  sometimes  traumatic,  but  usually  follows 
caries  of  the  spine.  It  most  frequently  complicates  this  disease  when  the 
cervical  or  upper  dorsal  vertebrae  are  involved,  rarely  when  the  lower  half 
of  the  spinal  column  is  affected.  This  difference  is  probably  due  to  the 
smaller  size  of  the  spinal  canal  in  its  upper  portion.  According  to  Gib- 
ney,  paraplegia  is  seen  in  fifty  per  cent  of  the  cases  of  caries  of  the  upper 
half  of  the  spine.  Essentially  the  same  condition,  so  far  as  the  cord  is 
concerned,  may  result  from  tumors  of  the  spinal  cord,  or  from  anything 
else  causing  pachymeningitis.  These,  however,  are  exceedingly  rare  in 
childhood. 

Lesions. — In  spinal  caries  there  occurs  am  a  result  of  tuberculous 
disease  a  softening  of  the  bodies  of  the  vertebrae,  Avhich  fall  together  from 
the  pressure  due  to  the  superincumbent  weight  of  the  body.  This  causes 
a  backward  projection  known  as  the  kyphosis,  or  angular  deformity.  The 
spinal  canal  is  encroached  upon  by  the  remains  of  the  vertebral  bodies 
whose  ligamentous  attachments  have  been  loosened,  and  also  by  inflam- 
matory products,  the  result  of  periostitis,  and  localized  inflammation  of 
the  dura  mater,  chiefly  of  the  external  layer,  but  which  sometimes  affects 
the  internal  layer  also.  All  these  conditions  lead  to  the  production  of  a 
mass  of  inflammatory  material,  often  containing  tuberculous  deposits, 
which  is  chiefly  in  front  of  the  cord,  but  may  surround  it.    The  compres- 


COMPRESSION-MYELITIS  805 

sion  takes  place  slowly  in  most  of  the  cases,  from  the  gradual  progress  of 
the  lesions  mentioned."  In  a  small  number  of  cases  there  may  be  a 
sudden  pressure  from  the  slipping  backward  of  one  of  the  vertebral 
bodies. 

In  recent  cases  the  cord  at  the  seat  of  compression  is  a  little  smaller 
than  normal.  It  is  usually  involved  to  the  extent  of  from  half  an  inch 
to  two  inches.  Paraplegia  may  have  existed  when  the  changes  found  in 
the  cord  are  very  slight,  and  sometimes  when  no  changes  are  visible  to 
the  naked  eye.  In  more  protracted  and  more  severe  cases,  the  cord  is 
much  smaller  at  the  point  of  disease,  and  under  the  microscope  shows 
the  changes  of  interstitial  myelitis  (Gowers)  with  meningitis.  In  old 
cases  there  is  degeneration  of  the  nerve  elements,  atrophy,  and  some- 
times disappearance  of  the  ganglion  cells,  with  more  or  less  destruction 
of  the  nerve  fibers;  sometimes  all  distinction  between  the  gray  and  white 
substance  is  lost.  In  addition  to  these  marked  changes  at  the  point  of 
pressure,  there  may  be  ascending  or  descending  degeneration,  as  from 
other  focal  lesions.  There  is  usually  inflammation  of  the  nerve  roots, 
which  have  also  suffered  compression.  It  is  in  many  cases  surprising 
to  see  to  what  degree  the  cord  may  be  compressed  and  still  preserve  its 
functions. 

Symptoms. — In  caries  of  the  cervical  region  the  symptoms  of  com- 
pression-myelitis not  infrequently  precede  the  deformity,  and,  in  fact, 
the  other  objective  symptoms  of  bone  disease.  The  earliest  symptoms  of 
caries  usually  arise  from  irritation  of  the  nerve  roots,  and  consist  of 
acute  pains  often  not  referred  to  the  spine,  but  radiating  to  the  different 
regions  to  which  these  nerves  are  distributed.  They  are  felt  in  the  neck, 
in  the  chest,  in  the  epigastrium,  and  sometimes  in  the  loins.  Accom- 
panying these  pains,  there  is  noticed  a  gradual  weakness  in  the  lower 
extremities,  and  sometimes  also  in  the  arms,  according  to  the  location 
of  the  disease.  This  may  steadily  increase  for  several  weeks  until  there 
is  complete  paralysis.  Other  symptoms  are  then  commonly  present. 
There  is  usually  some  degree  of  anesthesia,  and  there  may  be  numbness, 
tingling,  formication,  and  pain.  The  sphincters  are  not  often  involved. 
When  the  disease  is  in  the  upper  half  of  the  cord,  there  is  rigidity  of 
the  extremities  and  great  exaggeration  of  all  the  reflexes,  with  marked 
ankle-clonus.  In  the  rare  cases  in  which  the  lumbar  enlargement  is  in- 
volved, there  may  be  loss  of  reflexes,  paralysis  of  the  sphincters,  and  bed- 
sores. 

The  distribution  of  the  paralysis  will  depend  upon  the  point  of  com- 
pression. If  this  is  in  the  cervical  region,  all  four  extremities  will  be 
paralyzed ;  if  in  the  dorsal  region,  only  the  legs.  According  to  the  extent 
of  the  secondary  lesions  in  the  cord,  there  may  occur  muscular  atrophy 
and  contractures.     With  disease  in  the  upper  cervical  region,  death  may 


806  DISEASES  OF  THE  NERVOUS  SYSTEM 

result  from  sudden  pressure  upon  the  cord,  owing  to  a  dislocation  of  the 
odontoid  process;  or  there  may  be  vomiting,  pupillary  symptoms,  irri- 
tation of  the  phrenic  nerve  causing  hiccough,  or  pressure  causing  paral- 
ysis of  the  diaphragm. 

Course  and  Prognosis. — These  depend  much  upon  the  treatment  of 
the  case.  In  many  cases  of  paralysis  occurring  early  in  caries,  complete 
recovery  takes  place  in  the  course  of  a  few  weeks,  sometimes  in  a  few 
days,  after  the  application  of  a  proper  mechanical  support.  In  the  cases 
which  have  been  long  neglected,  or  those  in  which  the  paralysis  develops 
while  proper  mechanical  treatment  is  being  carried  out,  the  chances  are 
not  so  good.  Gibney  gives  the  following  statistics  of  133  cases  under  his 
personal  observation:  31  proved  fatal;  9  dying  from  myelitis,  14  from 
other  diseases  subsequent  to  recovery  from  the  paralysis,  and  6  from  tu- 
berculosis before  complete  recovery;  74  recovered  from  the  paraplegia; 
27  were  recorded  as  improved  or  still  under  treatment.  Eelapses  oc- 
curred in  about  fifteen  per  cent  of  the  cases.  The  usual  duration  of  the 
paralysis  is  from  three  months  to  two  years.  Eecovery  has  often  taken 
place  in  cases  that  have  persisted  for  four  or  five  years. 

Diagnosis. — This  is  rarely  difficult.  Spinal  caries  should  be  sus- 
pected in  every  case  when  the  symptoms  point  to  transverse  myelitis 
coming  on  without  definite  cause. 

Treatment. — The  indications  are  the  removal  of  pressure  and  the 
fixation  of  the  spine  by  a  proper  mechanical  support.  From  his  very 
extensive  experience,  Gibney  has  more  confidence  in  the  iodid  of  potas- 
sium than  in  all  else  except  mechanical  treatment.  Large  doses  are 
required,  often  from  sixty  to  ninety  grains  being  given  daily  for 
months.  The  iodid  should  always  be  largely  diluted.  Patients  should 
be  kept  scrupulously  clean,  and  the  position  changed  frequently  to  pre- 
vent the  formation  of  bed-sores.  Electricity  is  contraindicated.  When 
the  paralysis  develops  rapidly  or  occurs  suddenly,  relief  may  sometimes 
be  obtained  by  the  operation  of  laminectomy;  but  little  is  to  be  expected 
from  this  in  the  slow  cases. 


ACUTE  POLIOMYELITIS 

(Epidemic   Poliomyelitis;   Acute   Infantile   Paralysis) 

There  are  few  diseases  regarding  which  our  knowledge  has  increased 
so  rapidly  during  recent  years  as  acute  poliomyelitis.  The  first  great 
step  in  advance  was  made  by  Landsteiner  and  Popper,  who,  in  the  sum- 
mer of  1909,  succeeded  in  producing  the  disease  in  a  monkey  ])y  intra- 
peritoneal inoculation  with  the  spinal  cord  of  a  patient  dying  of  acute 


ACUTE  POLIOMYELITIS  807 

poliomyelitis.  They  were  not  successful  in  carrying  the  transmission 
further.  Shortly  after  this  Flexner  and  Lewis,  using  the  intracranial 
method  of  inoculation,  had  no  difficulty  in.  reproducing  the  disease 
and  transmitting  it  through  an  indefinite  series  of  monkeys.  No  other 
animal  seems  to  be  susceptible.  These  observations,  now  many  times 
repeated,  have  not  only  definitely  established  the  infectious  character  of 
poliomyelitis,  but  have  cleared  up  many  doubtful  points  in  its  pathology. 

Acute  poliomyelitis  is  now  regarded  as  a  communicable,  infectious 
disease  which  prevails  both  epidemically  and  sporadically.  Although 
possibly  its  most  characteristic  lesions  are  in  the  anterior  horns  of  the 
cord,  any  part  of  the  central  nervous  system  may  be  affected.  The 
changes  in  the  cord  substance  are  preceded  by  lesions  of  the  meninges. 
Although  the  name  poliomyelitis  is  still  retained,  the  scope  of  the  term 
has  been  greatly  widened. 

This  disease  is  characterized  by  an  acute  onset,  with  fever  and  usu- 
ally other  marked  constitutional  and  nervous  symptoms,  from  which 
there  may  be  rapid  recovery;  but  generally  there  follows  early  and  ex- 
tensive loss  of  power.  After  this  there  is  usually  seen  a  gradual  im- 
provement, and  sometimes  complete  recovery.  More  often,  however, 
there  is  left  some  permanent  paralysis  in  certain  groups  of  muscles, 
which  undergo  rapid  and  marked  atrophy.  Formerly,  poliomyelitis  was 
seen  chiefly  as  a  sporadic  disease;  but  since  the  year  1905  epidemics  have 
occurred  with  increasing  frequency  in  various  parts  of  the  world,  and 
especially  in  the  United  States  since  1907.  As  it  is  most  frequently 
seen  in  very  young  children,  and  as  it  is  altogether  the  most  common 
form  of  paralysis  at  this  period,  the  old  term  "acute  infantile  paralysis" 
is  perhaps  the  most  appropriate  clinical  designation. 

Etiology. — Fully  eighty  per  cent  of  the  cases  are  seen  in  the  first 
four  years  of  life,  the  greatest  incidence  being  in  the  second  year.  No 
age  is  exempt  and  in  some  epidemics  the  proportion  of  adult  cases  is 
quite  large.  Epidemics  thus  far  observed  have  invariably  occurred  in  the 
warm  mouths;  those  in  the  United  States,  from  July  to  October.  Fully 
four-fifths  of  the  sporadic  cases  also  are  seen  during  these  same  months. 

The  prevalence  of  poliomyelitis  in  an  epidemic  form  began  with 
the  outbreaks  in  Sweden  and  Norway  in  1905  and  1906.  These  Avere 
followed  in  1907  by  the  epidemic  occurring  in  New  York  City  and  vicin- 
ity in  which  there  were  observed  nearly  3,000  cases.  After  that  polio- 
myelitis gradually  spread  over  the  country,  epidemics  occurring  during 
the  next  four  years  in  nearly  all  parts  of  the  United  States.  Large 
outbreaks  were  also  reported  in  other  parts  of  the  world.  The  most 
extensive  epidemic  known  M^as  that  of  New  York  in  1916  in  which  over 
4,000  cases  were  reported  in  a  single  month. 

The  simultaneous  or  successive  occurrence  of  several  cases  in  the  same 


808  DISEASES  OF  THE  NERVOUS  SYSTEM 

family  has  long  suggested  that  the  disease  was  directly  communicable. 
This  has  now  been  established  by  experimental  evidence  and  is  corrob- 
orated by  clinical  observations.  The  disease  may  be  communicated:  (1) 
by  the  typical  acute  paralytic  cases;  (3)  by  mild,  ambulant  or  abortive 
cases;  (3)  by  healthy  carriers,  i.  e.,  persons  who  have  been  in  close  contact 
with  one  suffering  from  an  acute  attack;  (4)  by  chronic  carriers  or  those 
who  have  recovered  from  acute  attacks.  How  long  persons  of  the  last  two 
groups  may  convey  the  disease  is  not  known.  The  virus  has,  however, 
been  demonstrated  on  the  mucous  membranes  of  the  mouth  and  nose 
after  several  months  have  passed.  The  disease,  in  most  circumstances, 
is  feebly  contagious,  and  only  a  small  proportion  of  those  exposed  con- 
tract it.  As  in  the  case  of  cerebrospinal  meningitis,  it  is  much  more 
contagious  when  prevailing  epidemically.  The  transmission  by  healthy 
carriers,  though  very  exceptional,  is  undoubtedly  the  explanation  of  the 
occurrence  of  some  of  the  widely  separated  cases  seen  in  a  community; 
others  of. obscure  origin  may  be  traced  to  abortive  cases.  That  the  virus 
of  poliomyelitis  is  carried  by  insects  has  not  been  established.  At  pres- 
ent we  know  of  no  other  way  of  acquiring  the  disease  than  by  contact 
with  affected  persons  or  with  those  who  serve  as  carriers. 

The  period  of  incubation  of  the  experimental  disease  in  monkeys 
varies  from  four  to  thirty-three  days,  the  average  being  nine  or  ten 
days.  In  man,  also,  it  is  variable,  but  in  most  instances  the  second  case 
in  a  family  has  followed  the  first  one  within  ten  days. 

The  specific  organism  of  this  disease  belongs  to  the  class  of  filtrable 
viruses.  It  passes  through  the  pores  of  the  finest  porcelain  filter.  It 
has  been  isolated  and  cultivated  outside  the  body  by  Flexner  and  N'o- 
guchi,  and  with  a  high-power  microscope  it  can  be  seen  as  very  minute 
globular  bodies.  It  is  present  in  largest  quantity  in  the  diseased  nerve 
structures,  particularly  the  spinal  cord.  In  the  earliest  stages  of  the 
attack  it  is  also  found  in  the  cerebrospinal  fluid,  but  disappears  at 
about  the  time  paralysis  occurs.  It  exists  to  some  extent  in  other  tissues 
of  the  body,  particularly  the  lymph  nodes.  The  disease  can  be  trans- 
mitted to  animals  regularly  and  with  certainty  only  by  inoculation  with 
an  affected  spinal  cord,  in  which  the  virus  persists  for  months  after  the 
acute  attack.  Experiments  and  clinical  evidence  indicate  that  the  usual 
path  of  entrance  is  the  nasal  mucous  membrane.  Osgood  and  Lucas 
have  shown  that  the  virus  persisted  in  the  nasal  mucous  membrane  of 
monkeys,  in  one  instance  for  five  months,  in  another  for  one  and  a  half 
^months,  after  the  acute  attack ;  which  suggests  that  this  may  not  only 
be  an  avenue *of  entrance,  but  possil)ly  a  mode  of  elimination  of  the  in- 
fection, and  indicates  that  the  duration  of  the  infective  period  may  at 
times  be  a  very  long  one. 

Lesions. — As  a  result  of  the  investigations,  particularly  of  Flexner 


ACUTE  POLIOMYELITIS  "809 

and  Lewis  upon  animals,  and  those  of  Harbitz  and  Scheel,  Strauss,  and 
others  upon  the  disease  in  man,  the  pathology  of  acute  poliomyelitis  is 
now  well  known.  This  knowledge  has  greatly  aided  our  clinical  under- 
standing of  the  disease. 

The  lesions  found  in  this  disease  show  in  the  cases  severe  enough  to 
be  fatal  the  effects  of  a  widespread  generalized  infection.  Not  only  are 
the  nervous  tissues  involved,  but  also  ^  the  parenchymatous  organs  and 
lymphoid  structures.  In  the  nervous  system  the  virus  first  attacks  the 
meninges,  especially  o£_the  cord  and  medulla,  setting  up  a  cellular  in- 
flammation of  the  pia,  which  becomes  infiltrated  with  small,  round  cells. 
These  changes  are  most  marked  about  the  blood-vessels.  Besides  this 
the  walls  of  the  vessels  themselves  are  infiltrated  and  their  lumen  nar- 
rowed. The  lesion  also  affects  the  vessels  entering  the  nerve  structures. 
As  a  result  of  the  vascular  lesions  anemia,  edema,  and  hemorrhages  are 
present,  sometimes  small  and  circumscribed,  sometimes  quite  diffuse  and 
extensive.  Thrombosis  seldom  occurs.  But  more  important  still  are 
the  secondary  degenerative  changes  in  the  nerve  cells,  the  site  and  extent 
of  which  are  determined  by  the  vessels  involved  and  the  intensity  of  the 
changes  in  them.  The  lesions  in  the  pons,  medulla,  and  cerebrum,  like 
those  in  the  cord,  are  secondary  to  the  vascular  lesions. 

The  transient  paralysis  in  cases  that  recover  may  be  due  to  edema  or 
to  temporary  vascular  obstruction  from  pressure  outside  the  vessels 
causing  a  local  anemia.  Permanent  paralysis  depends  upon  severe  de- 
generation and  actual  destruction  of  ganglion  cells;  its  extent,  there- 
fore, will  vary  with  the  number  of  the  ganglion  cells  affected.  Any  part 
of  the  central  nervous  system  may  be  affected,  and  the  lesions  are  gen- 
erally more  extensive  than  the  symptoms  would  lead  one  to  expect.  The 
gross  appearances  give  but  little  idea  of  their  severity.  The  process 
often  involves  nearly  the  whole  length  of  the  cord,  being,  however,  gen- 
erally most  marked  in  the  cervical  and  lumbar  enlargements.  The 
changes  are  chiefly  in  the  gray  matter  of  the  anterior  horns,  and  consist 
in  acute  degeneration  of  ganglion  cells,  usually  marked  and  extensive. 
These  cells  in  certain  parts  may  disappear  altogether,  being  replaced  by 
leucocytes.  The  entire  cord,  however,  may  be  involved.  There  is  seen, 
but  to  a  much  less  degree,  infiltration  with  small  round  cells  of  the  pos- 
terior horns,  the  columns  of  Clarke,  and  the  white  matter  of  the  cord, 
everywhere  closely  related  to  the  blood-vessels.  There  are  regularly 
found  changes  in  the  spinal  ganglia  of  a  similar  character  to  those 
described  in  the  cord. 

Lesions  like  those  of  the  cord,  though  generally  less  marked,  are 
seen  in  the  pons,  the  medulla,  the  cerebellum,  and  even  in  the  cerebral 
hemispheres.  They  are,  as  in  the  cord,  especially  related  to  the  pia  and 
the   blood-vessels.      There   is   seen   acute   destruction   of   ganglion    cells 


810  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  areas  of  cell  infiltration  with  lymphocytes.  The  changes  are  espe- 
cially marked  about  the  nuclei  of  the  cranial  nerves,  and  in  the  gray 
matter  about  the  fourth  ventricle.  In  some  cases  the  basal  ganglia 
are  also  involved.  Areas  of  infiltration,  sometimes  quite  difl^use,  may 
be  seen  in  the  cortex,  with  also  some  slight  degeneration  of  ganglion 
cells. 

Thus,  in  the  severe  and  fatal  cases  there  is  present  a  diffuse  inflam- 
mation of  the  entire  cord  and  its  membranes,  also  of  the  medulla,  pons, 
and  basal  ganglia,  with  less  marked  changes  in  the  cerebrum,  always 
accompanied  by  changes  in  the  pia.  In  the  milder  cases  it  is  probable 
that  the  inflammatory  changes  are  limited  to  the  cord,  though  in  some 
patients  dying  later  from  other  causes  Harbitz  and  Scheel  discovered 
changes  in  the  upper  centers,  though  no  symptoms  pointing  to  them 
had  been  present.  From  this  account  of  the  lesions  it  would  appear 
that  we  can  no  longer  distinguish  between  the  lesions  of  acute  polio- 
myelitis, acute  bulbar  paralysis  and  acute  poliencephalitis  inferior.  They 
represent  varying  phases  of  one  and  the  same  disease.  In  recent  acute 
cases  no  changes  are  usually  found  in  the  nerves  except  degeneration  of 
bundles,  corresponding  to  the  degenerated  areas  in  the  cord,  and  prob- 
ably secondary  to  them.  Lesions  in  other  organs  are  often  present,  the 
most  frequent  being  bronchopneumonia  and  acute  parenchymatous  de- 
generation of  the  liver  and  kidneys,  similar  to  what  is  seen  in  other 
severe  general  infections.  The  thymus,  the  solitary  follicles-  of  the  in- 
testine, and  the  mesenteric  glands  may  be  much  swollen. 

In  autopsies  made  upon  cases  of  long  standing  the  aft'ected  part  of 
the  cord,  which  is  often  only  one  lateral  half,  is  smaller  than  normal. 
The  general  changes  are  those  of  a  sclerotic  character.  The  ganglion 
cells  of  the  affected  anterior  horn  have  either  disappeared  altogether,  or 
they  are  few  in  number  and  so  shrunken  as  to  be  hardly  recognizable. 
The  white  matter  also  is  smaller  than  in  the  sound  part  of  the  cord. 
The  anterior  nerve  roots  are  degenerated  quite  to  the  muscles.  The 
affected  muscles  are  atrophied,  and  in  extreme  cases  there  may  be  a 
complete  disappearance  of  muscle  fibers,  their  place  being  taken  by  adi- 
pose and  fibrous  tissue.  In  places  where  the  lesion  is  less  severe  the 
fibers  are  small.  The  affected  limb  is  shorter  and  the  bones  smaller 
than  upon  the  sound  side. 

Symptoms. — ^Cases  of  acute  poliomyelitis  present  a  wide  variety  of 
clinical  symptoms  depending  upon  the  virulence  of  the  infection,  the 
age  of  the  person  attacked,  but  principally  upon  the  part  of  the  nervous 
system  chiefly  involved  in  the  pathological  process.  They  may  be  broadly 
divided  into  four  general  groups:  (1)  the  cerebral  cases;  (2)  the  spinal; 
(3)  the  bulbospinal;   (4)  the  non-paralytic  or  so-called  abortive  cases. 

The  Cerebral  Type. — It  is  only  very  recently  that  acute  polieneepha- 


ACUTE  POLIOMYELITIS  811 

litis,  fully  described  by  Striimpell  in  1885,  has  been  regarded  as  a  mani- 
festation of  this  disease.  Although  some  experimental  evidence  is  still 
wanting,  the  identity  of  the  histological  changes  and  its  association  with 
acute  poliomyelitis  in  epidemics  leave  little  doubt  that  acute  polienceph- 
alitis  is  often  only  the  cerebral  form  of  acute  poliomyelitis.  Such  cases  are 
not  to  be  confounded  with  the  common  forms  of  acute  poliomyelitis  with 
cerebral  symptoms. 

The  onset  is  generally  abrupt,  with  convulsions  which  are  often  re- 
peated over  a  period  of  a  day  or  two.  There  is  usually  vomiting  and 
fever,  which  may  be  high.  The  paralysis  which  follows  after  one  to 
three  days  of  general  symptoms  is  usually  of  the  hemiplegic  type,  the 
face,  arm  and  leg  being  involved.  The  reflexes  are  increased  and  the 
paralysis  is  of  the  spastic  type.  The  face  improves  and  usually  recovers 
completely;  the  leg,  next;  while  the  arm  is  generally  most  affected  and 
the  paralysis  is  likely  to  be  permanent  and  be  followed  by  contractures. 
In  its  late  results  it  resembles  other  forms  of  acute  cerebral  paralysis  in 
early  life. 

The  Spinal  Type. — This  group  includes  the  most  characteristic  form 
of  the  disease  and  is  numerically  the  largest.  In  the  cases  of  moderate 
severity,  the  onset  is  abrupt  and  the  symptoms  may  differ  little  from 
those  seen  in  other  acute  infections.  There  is  usually  vomiting,  which 
is  not  repeated,  more  frequently  constipation  than  diarrhea,  and  fever 
which  is  generally  not  over  103°  P.  Drowsiness,  irritability,  headache 
and  prostration  are  seen  in  most  cases.  After  the  first  day  more  definite 
symptoms,  indicating  involvement  of  the  nervous  system,  are  present — 
general  hyperesthesia,  shooting  pains  in  the  legs,  stiffness  of  the  neck  or 
extremities,  pain  on  motion,  etc.  The  blood  shows  a  moderate  polymor- 
phonuclear leucocytosis  and  the  cerebrospinal  fluid  is  generally  clear, 
but  may  be  slightly  opalescent.  It  shows  a  greatly  increased  number  of 
cells,  which  at  first  may  be  chiefly  polymorphonuclear,  but  very  soon  are 
nearly  all  lymphocytes.  There  is  an  increase  of  globulin.  After  the 
febrile  symptoms  have  lasted  for  from  twenty-four  hours  to  three  days, 
the  paralysis  is  seen.  Exceptionally,  the  early  stage  is  very  short,  and  the 
paralysis  is  noticed  almost  at  the  onset.  In  the  lighter  cases,  the  fever 
may  not  be  over  100°  or  101°  F.,  and  may  last  only  a  day,  with  all  the 
general  and  local  symptoms  correspondingly  mild,  though  the  resulting 
paralysis  may  be  extensive. 

In  the  paralytic  stage  the  loss  of  power  sometimes  comes  on  quickly 
in  a  few  hours;  but  more  often,  rather  gradually,  and  extends  for  from 
two  to  three  days  before  it  is  fully  developed.  The  other  nervous  symp- 
toms usually  continue.  The  posture  is  in  most  cases  dorsal,  with  limbs 
semi-flexed,  but  in  some  cases  with  marked  meningeal  irritation  there 
may  be  a  general  "flexion  of  the  body  with  opisthotonus,  exactly  as  in 


812  DISEASES  OF  THE  NERVOUS  SYSTEM 

cerebrospinal  meningitis.  The  same  rigidity  of  the  neck  and  extremities 
may  also  be  seen.  The  knee  Jerks  are  not  uniform,  at  first  may  be  in- 
creased, but  are  soon  lost  on  the  paralyzed  side  and  sometimes  also  on 
the  sound  side.  Pain  is  present  on  motion,  on  pressure  over  nerve  trunks 
and  sometimes  complained  of  when  the  patient  is  quiet.  Eetention  of 
urine  may  be  so  complete  as  to  require  the  use  of  the  catheter,  but  in 
most  cases  the  child  is  able  to  void,  however,  with  considerable  diffi- 
culty. The  bowels  in  most  of  the  cases  are  constipated.  The  mind  is  usu- 
ally clear,  though  the  child  is  very  sensitive  to  handling,  and  there  may 
be  general  hyperesthesia.  The  duration  of  the  fever  is  on  the  average 
three  or  four  days;  it  is  rare  for  it  to  continue  longer  than  a  week. 
The  temperature  range  is  generally  between  101°  and  103°,  and  the 
fall  to  normal  is  gradual.  Usually  the  height  of  the  temperature  is  in 
proportion  to  the  severity  of  the  infection,  but  it  does  not  measure  the 
danger  of  the  attack,  which  depends  rather  upon  what  part  of  the 
nervous  system  is  involved  most  seriously. 

The  description  above  given  is  that  of  the  type  most  frequently  met 
with,  but  many  other  forms  of  the  disease  are  seen  which  add  much  to ' 
the  difficulty  of  diagnosis.  Certain  cases  present  marked  cerebral  symp- 
toms, chiefly  stupor,  with  very  few  spinal  symptoms.  After  the  usual 
onset,  the  drowsiness  soon  develops  into  deep  stupor,  which  may  last 
for  a  week  or  more.  These  symptoms,  with  the  continuance  of  the  fever, 
the  stiffness  of  the  neck  and  irregularity  of  the  knee  jerks,  form  a  pic- 
ture which  is  almost  indistinguishable  from  tuberculous  meningitis. 
These  cases  belong  to  quite  a  different  group  from  those  described  above 
as  the  cerebral  type.  The  paralysis,  when  it  occurs,  indicates  an  in- 
volvement of  the  cord  at  a  high  level  and  affects,  besides  other  parts, 
one  or  both  arms.  Though  the  symptoms  in  such  cases  are  most  dis- 
turbing, the  cerebral  condition  often  clears  up  rapidly  and  completely. 

Other  types  which  may  be  seen  in  epidemics  are:  (1)  those  in  which 
the  symptoms  of  meningeal  irritation  are  especially  marked,  extreme 
muscular  and  nervous  irritability,  hyperesthesia,  rigidity,  etc.,  a  group  of 
symptoms  strongly  suggesting  cerebrospinal  meningitis;  (2)  cases  in 
which,  with  many  of  the  above  symptoms,  pain  is  especially  prominent; 
(3)  cases  in  which  gastro-intestinal  symptoms  are  particularly  marked; 
both  vomiting  and  diarrhea  may  last  for  several  days  and  their  prom- 
inence may  obscure  the  nervous  symptoms. 

The  Bulbospinal  Type. — The  onset  and  general  symptoms  differ  in 
no  way  from  the  severe  cases  of  the  spinal  type.  It  is  only  after  paralysis 
develops  that  the  characteristic  symptoms  are  seen.  This  group  forms, 
according  to  "Wickman,  about  6  per  cent  of  the  epidemic  cases.  The 
lesions  of  the  bulb  are  generally  more  extensive  than  one  would  expect 
from   the   symptoms.      The  symptoms   of   bulbar   paralysis   are   nearly 


ACUTE  POLIOMYELITIS  813 

always  limited  to  one  side,  whether  they  occur  alone  or  with  paralysis 
of  the  arms  and  legs.  Almost  any  of  the  cranial  nerves  may  be  in- 
volved, altogether  the  most  frequent  being  the  facial.  The  whole  nerve 
is  not  always  affected.  The  facial  paralysis  is  usually  transient,  but 
may  be  permanent.  Ocular  paralyses  are  next  in  frequency,  the  external 
rectus  being  oftenest  affected.  Disturbances  of  speech  are  not  infre- 
quent, but  rarely  persist.  They  are  often  associated  with  disturbances 
of  deglutition,  which,  while  not  common,  may  be  so  severe  as  to  necessi- 
tate feeding  through  a  tube.  With  these  bulbar  symptoms  are  often 
associated  others,  indicating  involvement  of  the  upper  part  of  the  cord, 
such  as  paralysis  of  the  diaphragm,  the  intercostals,  the  neck,  or  the 
upper  extremities.  These  cases  form  the  most  severe  and  fatal  type  of 
acute  poliomyelitis  met  with,  and  it  is  the  type  that  furnishes  most  of  the 
deaths.  The  fatal  result  is  nearly  always  from  respiratory  paralysis  or 
bronchopneumonia. 

Acute  bulbar  paralysis  with  lesions  limited  to  this  part,  though  for- 
merly described  as  a  separate  and  distinct  disease,  is  probably  only  a 
form  of  acute  poliomyelitis. 

Another  rare  clinical  type  is  an  acute  ascending  paralysis  with  symp- 
toms described  as  Landry's  disease.  After  the  usual  onset,  paralysis 
affects  first  the  legs,  then  the  arms,  the  neck  and  finally  the  diaphragm 
and  intercostals,  with  death  from  respiratory  paralysis.  This  extension 
of  the  paralysis  usually  occupies  three  or  four  days,  though  it  is  some- 
times very  rapid,  and  death  may  take  place  on  the  second  or  third  day 
from  the  beginning  of  the  attack. 

Extent  and  Distribution  of  the  Paralysis. — Wickman  gives  the  fol- 
lowing grouping  of  868  epidemic  cases  in  1905 : 

One  or  both  legs 353;  one  or  both  arms 75 

Combinations  6f  arms  and  legs. .  .    152;  legs  and  trunk 85 

Arms  and  trunk 10;  trunk  alone 9 

Ascending  paralysis 32;  descending  paralysis 13 

Spinal  and  cranial  nerves 34;  cranial  nerves  alone.  ...  22 

Whole  body 23;  not  given 60 

'  A  comparison  between  this  and  560  sporadic  cases  we  have  collected 
from  various  authors  is  interesting: 

One  leg 229;  both  legs 176 

Combinations  of  arms  and  legs. .  .     42;  one  arm  only 14 

All  extremities  and  trunk 79 ;  all  others 10 

In  both  series  the  large  proportion  of  cases  in  which  the  legs  are 
involved  is  striking;  also  the  infrequency  Avith  which  the  arms  alone  are 
affected,  and  finally  that  in  the  epidemic  cases  there  is  a  much  larger 


814  DISEASES  OF  THE  NERVOUS  SYSTEM 

number  with  widespread  paralysis  and  with  cranial  nerve  involvement. 
The  latter,  when  occurring  sporadically,  are  generally  classed  under 
some  other  heading  than  acute  poliomyelitis. 

The  paralysis,  when  limited  to  the  leg.  most  frequently  affects  the 
anterior  tibial  group;  next,  the  peroneal,  and  third,  the  quadriceps  ex- 
tensor femoris.  The  paralysis  of  the  upper  extremities  most  often  in- 
volves the  shoulder  group,  the  deltoid  being  the  muscle  which  usually 
suffers  most  severely.  Paralysis  of  the  sphincters  is  very  rare,  though 
bladder  disturbances  are  quite  common. 

The  most  serious  paralysis  is  that  of  the  diaphragm  and  the  inter- 
costals;  either  may  be  involved  alone  and  the  patient  recover,  but  when 
both  are  affected  death  follows.  Diaphragmatic  paralysis  occurs  when 
the  lesion  affects  the  third  to  the  fifth  cervical  segments  of  the  cord. 
It  seldom  occurs  early  and  may  develop  quite  late  in  the  disease.  Though 
this  is  always  a  serious  symptom,  it  may  last  several  days  and  yet  re- 
covery take  place.  When  the  diaphragm  is  paralyzed,  all  the  accessory 
muscles  of  respiration  are  called  into  action ;  the  respiration  is  wholly 
thoracic  and  the  abdominal  wall,  instead  of  protruding,  is  retracted  on 
inspiration. 

Paralysis, of  the  intercostals  is  rare,  except  in  very  severe  cases,  and 
is  usually,  but  not  invariably,  fatal.  It  is  seen  in  association  with  wide- 
spread paralysis  of  arms  and  legs,  and  in  the  rapidly  spreading  cases  of 
ascending  paralysis,  and  in  the  most  severe  infections.  The  respiration 
in  intercostal  paralysis  is  purely  diaphragmatic,  which  is  not  always 
easy  to -recognize,  as  it  is  an  exaggeration  of  the  normal  infantile  type. 
When  both  intercostals  and  diaphragm  are  involved,  we  see  one  of  the 
most  distressing  conditions  seen  in  the  disease,  i.e.,  death  by  respiratory 
paralysis.  A  remarkably  vivid  picture  of  this  is  given  in  the  monograph 
of  Peabody,  Draper  and  Dochez.  The  mind  is  usually  clear,  alert  and 
full  of  apprehension.  Every  breath  drawn  is  with  severe  effort.  Sweat- 
ing is  profuse.  Cyanosis  is  usually  absent.  The  struggle  may  last  for 
several  hours  before  death  takes  place.  Although  life  may  sometimes  be 
prolonged  for  a  considerable  time  by  artificial  respiration,  there  is  prac- 
tically no  hope  of  recovery. 

Paralysis  of  the  abdominal  muscles  is  not  common,  is  usually  of  one 
side,  but  may  affect  both.  It  is  evident  by  a  great  bulging  or  "balloon- 
ing" of  part  of  the  abdominal  wall,  in  coughing,  sneezing,  or  any  forced 
expiration.    It  may  remain  as  a  permanent  paralysis. 

Course  of  the  Disease. — In  those  who  survive  the  acute  stage,  there 
is  a  period  of  a  few  weeks'  duration  in  which  little  change  is  seen.  This 
is  followed  by  spontaneous  improvement,  which  usually  begins  in  the 
muscles  last  affected,  and  reaches  its  limit  in  from  three  to  six  months. 
The  paralysis  remaining  after  this  time  is  likely  to  be  permanent.    By 


ACUTE  POLIOMYELITIS 


815 


the  end  of  six  or  eight  weeks  atrophy  is  present  in  the  paralyzed  muscles. 
The  affected  limb  is  distinctly  smaller  than  its  fellow,  this  being  quite 
apparent  even  in  infants.  Except  in  the  early  stage,  sensory  disturb- 
ances are  absent;  the  knee-jerk  is  lost  in  paraplegic  cases,  and  in  those 
'in  which  the  extensors  of  the  thigh  are  paralyzed.  There  is  arrested 
growth  in  the  whole  limb  (Fig.  135).  It  becomes  much  smaller  and 
shorter  than  its  fellow.  From  paralysis  of  the  shoulder  and  thoracic 
muscles  various  chest  deformities  may  result  (Fig.  126).  The  great 
relaxation  of  the  liga- 
ments at  the  joints  may 
allow  subluxation,  espe- 
cially at  the  knee  and  at 
the  shoulder.  The  circu- 
lation in  the  affected 
limb  is  poor;  it  is  often 
blue  and  cold. 

Very  early  in  the  dis- 
ease the  atrophied  mus- 
cles begin  to  lose  their 
power  to  respond  to  fa- 
radism.  In  the  muscu- 
lar gToups  which  are  to 
be  permanently  par- 
alyzed, the  faradie  re- 
sponse may  be  lost  in  a 
week.  The  muscles  in 
which  recovery  is  to  take 
place  often  preserve  a 
certain  degree  of  con- 
tractility. The  response 
to  the  galvanic  current 
may  be  increased  for  a 

few  months,  and  then  slowly  fail  as  the  muscular  fibers  themselves  degen- 
erate, and  finally  it  may  disappear  altogether.  The  reaction  of  degenera- 
tion is  present  in  the  atrophied  muscles,  but  in  them  alone. 

Non-Paralytic  Cases. — The  terms  "abortive"  or  "ambulant"  are 
sometimes  used  to  designate  cases  of  acute  poliomyelitis  in  which  all  the 
usual  early  symptoms  of  the  disease  are  present,  yet  which  recoTer  with- 
out definite  paralysis  having  developed.  In  some  of  these  cases  there  is, 
however,  a  general  muscular  weakness.  These  represent  instances  of 
infection  in  which  the  nervous  system  either  escapes  altogether,  or  is  so 
slightly  involved  as  to  give  no  definite  symptoms.  That  such  cases  exist 
there  can  be  no  doubt.     It  is  believed  by  many  writers  that  in  number 


Fig.  125. — An  Old  Case  of  Infantile  Spinal  Paraly- 
sis OF  THE  Entire  Left  Lower  Extremity. 
Showing  extreme  atrophy  of  the  thigh  and  leg,  and 
a  very  characteristic  deformity  of  the  foot. 


816 


DISEASES  OP  THE  NERVOUS  SYSTEM 


they  equal  or  possibly  exceed  the  paralytic  cases.  The  evidence  that  they 
are  genuine  cases  of  acute  poliomyelitis  is  not  only  their  frequent  clinical 
■association  in  epidemics  with  frank  cases,  but  has  now,  according  to  Flex- 
ner,  been  definitely  established  by  laboratory  findings,  viz. :  (1)  there  are 
certain  characteristic  changes  in  the  cerebrospinal  fluid — increased  num- 
ber of  cells  chiefly  lymphocytes  and  the  presence  of  globulin;  (2)  there 
has  been  demonstrated  in  the  blood  neutralizing  immunity  principles, 
such  as  are  found  in  persons  suffering  from  typical  attacks,  but  not  pres- 
ent in  normal  blood;  (3)  the  virus  has  been  detected  on  the  nasal  and 

buccal  mucous  membranes  in  such  quan- 
tities as  to  make  possible  the  communi- 
cation of  the  disease  to  monkeys. 

The  recognition  of  non-paralytic 
cases  of  acute  poliomyelitis  has  clarified 
many  points  in  the  spread  of  the  disease. 
Poliomyelitis  may  be  suspected  by  the 
fact  of  the  attack  occurring  in  close  asso- 
ciation with  other  typical  paralytic  cases ; 
but  there  is  nothing  diagnostic  in  the 
clinical  symptoms;  the  absolute  diag- 
nosis rests  upon  the  laboratory  evidence 
above  cited. 

Diagnosis. — The  recognition  of  acute 
poliomyelitis  before  the  occurrence  of 
paralysis  is  impossible  except  by  lumbar 
puncture.  If  this  is  performed  early,  the 
cerebrospinal  fluid  is  found  to  be  clear 
or  slightly  opalescent.  The  number  of 
cells  may  be  as  many  as  1,000  per  c.  mm. 
At  first  these  may  be  nearly  all  polymorphonuclear;  but  soon  they  are 
replaced  by  lymphocytes,  which  generally  form  over  90  per  cent  of  the  , 
cells  seen.  The  test  for  globulin  gives  a  positive  reaction.  By  the  time 
paralysis  appears  the  cells  have  diminished  greatly  in  number  and  soon 
the  fluid  may  show  no  change  by  which  it  can  be  distinguished  from 
the  normal  except  an  increased  number  of  cells  and  an  increased  globulin 
reaction.  The  usual  fluid  found  in  acute  poliomyelitis  resembles  that  of 
tuberculous  meningitis,  which  some  cases  closely  simulate  in  their  clini- 
cal symptoms.  The  v.  Pirquet  skin  test  is  often  a  great  aid  in  diagnosis ; 
but  in  many  instances  one  must  wait  two  or  three  days  for  the  course  of 
the  disease  to  declare  itself,  or  until  tubercle  bacilli  can  be  found  in  the 
cerebrospinal  fluid.  Cases  with  muscular  pains,  general  hyperesthesia, 
rigidity  and  high  fever  may  easily  be  confounded  with  cerebrospinal 
meningitis.     It  can  be  excluded  only  by  lumbar  puncture. 


Fig.  126. — An  Old  Case  of  Infan- 
tile Spinal  Paralysis  of  the 
Left  Arm  and  Shoulder 
Muscles,  with  Resulting 
Lateral  Curvature. 


ACUTE  POLIOMYELITIS  817 

The  later  manifestations  of  the  spinal  type  of  poliomyelitis  are  a 
flaccid  type  of  paralysis  with  marked  atrophy  and  characteristic  electri- 
cal reactions,  hnt  without  sensory  symptoms.  It  may  he  confounded  with 
multiple  neuritis,  or  the  pseudo-paralysis  of  rickets.  Multiple  neuritis 
is  rare  in  children  except  after  diphtheria,  and  is  more  gradual  in  its 
onset.  The  type  of  paralysis  and  the  electrical  reactions  may  be  the 
same  as  in  poliomyelitis.  Certain  birth  palsies,  resulting  from  injuries 
received  during  delivery,  may  resemble  poliomyelitis  when  the  deltoid 
or  shoulder  group  of  muscles  is  involved.  Without  a  clear  history  a  dif- 
ferential diagnosis  may  be  impossible.  The  muscular  weakness  of  rick- 
ets is  general;  there  is  no  reaction  of  degeneration  and  no  history  of 
acute  onset.  Scurvy  is  distinguished  by  the  very  acute  hyperesthesia, 
by  the  swellings,  and  by  hemorrhages  from  the  gums  or  other  mucous 
membranes  together  with  a  history  of  improper  feeding.  The  child 
refuses  to  move  his  legs  only  because  of  pain.  The  cerebral  form  of 
poliomyelitis  gives  a  spastic  paralysis,  usually  hemiplegic  in  type,  which 
may  be  indistinguishable  from  other  forms  of  acquired  cerebral  paralysis. 

Prognosis. — The  dangers  from  poliomyelitis  are  twofold:  that  to  life 
during  the  acute  stage,  and  that  to  muscles  in  the  form  of  permanent 
paralysis  and  disability.  The  mortality  is  much  higher  in  epidemic 
than  in  sporadic  cases.  The  death  rate  in  the  various  large  epidemics 
has  ranged  between  10  and  30  per  cent.  The  danger  to  life  is  least  in 
infants  and  very  young  children.  In  cases  terminating  fatally  death 
usually  occurs  between  the  fourth  and  seventh  days  of  the  disease.  The 
cause  of  death  is  generally  respiratory  paralysis  or  bronchopneu- 
monia. 

It  is  impossible  to  say  in  any  case  of  advancing  paralysis  when  it 
will  be  arrested.  It  rarely  spreads  after  the  seventh  day.  An  important 
question  in  prognosis  is  whether  paralysis  will  be  permanent  or  not. 
Wickmau  reports  recovery  from  paralysis  in  44  per  cent  of  530  epidemic 
cases.  This  is  a  larger  proportion  than  most  writers  give,  and  mucli 
larger  than  we  have  ourselves  observed.  Complete  recovery  from  paral- 
ysis in  20  to  25  per  cent  of  the  cases  is  much  nearer  the  average 
result. 

Significant  symptoms  in  any  given  case  are  the  amount  of  wasting 
and  electrical  reactions.  Muscles  which  soon  lose  completely  their 
faradic  contractility  are  almost  certain  to  waste  rapidly  and  severely. 
The  best  indication  of  coming  improvement  is  the  return  of  farad i(; 
contractility.  If  this  is  completely  lost  for  six  months,  recovery  is  very 
doubtful;  if  faradic  contractility  is  not  lost,  great  and  early  improve- 
ment in  the  paralyzed  muscles  may  be  confidently  predicted.  After  six 
months  but  little  spontaneous  improvement  is  to  be  looked  for,  and  after 
two  years  none  at  all. 


818  DISEASES  OF  THE  NERVOUS  SYSTEM 

Treatment. — The  communicable  character  of  the  disease  being  now 
established,  it  follows  that  all  cases  of  acute  poliomyelitis  should  be  iso- 
lated; when  the  disease  is  epidemic  this  is  imperative.  It  is  not  now 
known  how  long  a  given  case  may  be  infectious.  A  month's  quarantine 
may  be  considered  a  minimum;  but  during  epidemics  a  longer  time 
should  pass  before  an  affected  person  should  be  allowed  to  mingle  with 
other  children.  All  discharges,  especially  those  from  the  mouth  and 
nose,  should  be  disinfected  and  destroyed.  Persons  in  contact  with  ac- 
tive cases  should  use  some  cleansing  nasal  spray  or  mouth  wash  as  the 
only  means  now  known  for  preventing  infection.  The  same  cleansing 
and  disinfection  of  apartments  should  be  practiced  as  after  other  infec- 
tious diseases. 

Since  we  have  as  yet  no  specific  remedy  for  poliomyelitis,  the  treat- 
ment during  the  acute  stage  is  symptomatic  and  to  be  conducted  along 
the  vsame  general  lines  as  other  acute  infections.  Hexamethylenamin 
(urotroijin)  has  been  extensively  used  in  this  disease,  in  doses  of  five  to 
ten  grains  four  times  a  day  to  a  child  of  three  or  four  years,  but  there 
is  no  convincing  proof  that  any  drugs  are  effective  in  aborting  the  dis- 
ease or  preventing  or  arresting  paralysis.  Absolute  rest  is  essential,  even 
in  the  mildest  cases,  and  should  be  continued  for  an  average  period  of 
two  weeks;  longer  when  irritative  symptoms  are  protracted.  Pains  in 
the  affected  limbs  during  the  acute  stage  may  be  lessened  by  the  applica- 
tion of  splints  to  insure  immobilization  and  also  at  times  by  wrapping 
limbs  in  cotton.  There  should  be  as  little  handling  as  possible.  It  is 
important  to  support  the  limbs,  so  as  to  lessen  the  chances  of  deformity. 
There  should  be  placed  at  the  feet  pads  or  sand-bags,  to  prevent  foot- 
drop,  which  otherwise  is  almost  certain  to  occur  in  cases  of  anterior  tibial 
paralysis.  Severe  pain  may  require  the  administration  of  morphin'  or 
codein.  Paralysis  of  respiration  in  the  acute  stage  is  practically  beyond 
heljD.  Feeding  through  the  tube  is  sometimes  necessary  in  bulbar  cases 
for  a  considerable  time,  owing  to  paralysis  of  the  muscles  of  deglu- 
tition. 

When  all  acute  symptoms  have  subsided,  which  is  generally  in  three 
or  four  weeks,  measures  should  be  begun  for  the  development  of  the 
paralyzed  muscles.  The  beneficial  effects  of  electricity  have  been  greatly 
overestimated.  In  many  cases,  however,  it  is  useful,  but  should  never 
be  alone  relied  upon.  Faradism  may  be  used  three  times  a  week  for 
such  muscles  as  respond  to  it ;  for  other  muscles  gahanism  should  be 
employed.  The  pain  and  terror  which  the  use  of  electricity  excites  in 
most  small  children  makes  its  continuance  a  practical  impossibility.  It 
is  far  better  imder  such  circumstances  to  rely  on  other  measures. 

Massage  and  passive  movements  may  be  begun  as  soon  as  hyperes- 
thesia has  gone,  and  may  be  used  at  first  daily  and  soon  twice  a  day  to 


TUMORS  OF  THE  SPINAL  CORD  819 

all  affected  parts.  They  should  he  continued  for  years.  But  still  more 
important  are  active  voluntary  movements  carried  out  hy  the  patient 
himself,  which  should  he  developed  with  great  care  and  systematically 
carried  out  for  an  indefinite  period.  It  is  really  surprising  what  such 
measures  when  intelligently  used  can  accomplish. 

Mechanical  Treatment. — Mechanical  appliances  are  useful  to  prevent 
deformity,  also  to  furnish  support  to  the  limb  in  order  to  enable  the 
child  to  walk.  By  such  means  many  get  about  with  tolerable  comfort 
for  whom  locomotion  without  apparatus  is  impossible  except  with 
crutches.  To  overcome  existing  deformities  in  neglected  cases,  braces  are 
employed  in  conjunction  with  myotomy  or  tenotomy  of  the  various  short- 
ened tendons,  excision  of  portions  of  elongated  tendons,  and  the  produc- 
tion of  artificial  anchylosis  in  cases  of  "flail  joints."  By  these  means  the 
orthopedic  surgeon  is  able  to  give  a  great  deal  of  relief  to  these  unfor- 
tunate and  sometimes  helpless  patients. 


TUMORS  OF  THE  SPINAL  CORD 

Tumors  of  the  cord  are  exceedingly  rare  in  children  and  almost 
unknown  in  infancy.  They  spring  from  the  bone,  from  the  meninges, 
or  from  the  cord  itself.  The  most  common  meningeal  tumors  are  sar- 
comata, fibromata  and  lipomata,  the  last  named  being  found  in  asso- 
ciation with  spina  bifida.  In  the  cord  gliomata,  sarcomata,  solitary 
tubercles  and  gummata  may  be  encountered. 

The  first  and  most  important  symptom  is  pain.  This  may  be  in 
the  extremities  or  in  a  girdle  form  around  the  body.  Associated  with 
the  pain  may  be  a  zone  of  hyperesthesia.  Eventually  there  may  be 
anesthesia.  Motor  symptoms  are  manifested  sooner  or  later.  There 
may  be  contractures  or  tonic  spasm  and  finally  spastic  paralysis  with 
exaggerated  reflexes  and  ankle  clonus.  The  arms  are  seldom  involved. 
Especially  characteristic  is  the  Brown  Sequard  paralysis — a  unilateral 
paralysis  with  a  zone  of  hyperesthesia  upon  the  paralyzed  side  and  with 
anesthesia  upon  the  opposite  side.  Paralysis  of  the  bladder  and  rec- 
tum is  present,  but  is  not  always  an  early  symptom. 

The  diagnosis  of  tumor  is  to  be  made  from  these  general  symptoms, 
in  the  absence  of  injury  or  of  caries  of  the  spine,  which  is  the  most  com- 
mon cause  of  transverse  lesions  of  the  cord  in  childhood.  The  localiza- 
tion of  the  growth  is  to  be  made  according  to  the  rules  of  general  neu- 
rology. This  is  difficult  in  childhood,  because  the  tumors  are  apt  to  be 
diffuse  (gliomata,  sarcomata,  tuberculomata)  and  because  of  the  fre- 
quent inability  to  obtain  the  necessary  cooperation  from  the  child.  The 
general  symptoms  are  also  very  uncertain.     We  have  seen  a  fibroma  of 


820  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  meninges  in  a  five-year-old  child  successfully  removed  by  operation, 
which  caused  no  pain  at  any  time. 

The  prognosis  is  bad.  Few  cord  tumors  in  childhood  are  of  such  a 
character  or  in  such  a  situation  that  they  can  be  removed.  Unless  they 
are  malignant,  or  can  be  removed,  death  results  from  intercurrent  dis- 
ease, from  bed-sores  or  from  ascending  inflammation  of  the  urinary 
tract.  The  treatment  is  surgical.  If  operative  removal  is  impossible, 
nothing  can  be  done  except  to  make  the  patient  comfortable. 


HEREDITARY  ATAXIA— FRIEDREICH'S   ATAXIA 

While  cases  of  Friedreich's  ataxia  are  encountered  with  no  history 
of  a  like  disease  in  relatives,  the  disease  is  especially  likely  to  attack 
several  members  of  a  family  in  one  or  more  generations.  As  many  as 
eight  sufferers  from  the  disease  in  one  generation  have  been  reported, 
and  it  has  been  traced  through  three  generations.  Friedreich's  ataxia 
is  for  this  reason  to  be  classed  among  the  hereditary  degenerative  diseases 
of  the  nervous  system.  Except  for  this  hereditary  influence,  there  is 
no  etiological  factor  known. 

Friedreich's  ataxia  is  an  infrequent  disease,  consisting  of  two  fairly 
distinct  types.  The  type  of  interest  to  pediatrists  occurs  early  in  child- 
hood, usually  between  the  fourth  and  seventh  year.  The  other  type, 
often  known  as  the  Marie  type,  is  seldom  found  before  the  twentieth 
year  and  need  not,  therefore,  concern  us  here. 

The  pathological  changes  are  chiefly  in  the  cord.  These  consist  in  a 
diminution  in  the  circumference  of  the  cord  throughout  its  entire  extent 
and  in  a  degeneration  of  various  tracts,  chiefly  the  posterior  columns. 
The  column  of  Goll  is  affected  throughout,  the  column  of  Burdach  to  a 
greater  or  less  degree,  and  the  crossed  pyramidal  tract  to  a  slight  extent. 
In  addition,  the  cells  of  Clarke's  column  are  degenerated  and  there  is 
a  consequent  degeneration  of  the  direct  cerebellar  tract  and  the  bundle 
of  Growers.     There  is  no  degeneration  in  the  cells  of  the  anterior  horns. 

Symptoms. — Ataxia  is  the  most  striking  and  usually  the  earliest 
symptom.  It  is  first  noticeable  and  is  always  most  marked  in  the  legs. 
There  is  difficulty  in  walking  and  even  in  standing,  but  the  ataxia  of 
the  legs  is  noticeable  in  any  position,  even  when  lying  down.  The  chil- 
dren stand  with  their  legs  wide  apart.  In  some  instances  there  may 
be  a  distinct  Eomberg  symptom,  it  being  impossible  for  them  to  stand  at 
all  with  the  eyes  closed.  The  gait  is  ataxic,  much  like  that  of  locomotor 
ataxia  at  first,  but  later  it  may  be  so  disturbed  that  the  patient  reels 
from  side  to  side  as  if  intoxicated.  Eventually  locomotion  is  impossible 
( s]i('fjally  when  the  muscular  weakness,  M^hich  is  regularly  present,  be- 


PROGEESSIVE  MUSCULAR  WASTING  821 

comes  extreme  with  atrophy.  Early  in  tlie  disease  muscular  weakness  is 
slight.  There  may  be  wobbling  of  the  head  and  there  is  usually  a 
coarse  tremor  of  the  arms  and  hands.  Sensation  is  well  retained  and 
control  over  the  bladder  and  rectum  is  normal.  Exceptionally  there 
are  sharp,  lancinating  pains  in  the  legs.  The  knee  jerks  are  commonly 
absent.  Slow,  scanning,  sometimes  explosive  speech  is  very  frequent  and 
late  in  the  disease  speech  may  be  nearly  impossible.  There  is  often  a 
marked  nystagmus.  A  striking  symptom  is  the  common  deformity  of 
the  foot.  This  may  be  one  of  the  first  symptoms  to  be  noticed.  The 
foot  appears  shortened,  it  is  markedly  arched  and  is  held  in  a  position 
of  slight  equino-varus.  The  great  toe  is  hyper-extended  and  sometimes 
the  terminal  phalanx  is  flexed.  Kypho-scoliosis  develops  with  the  advent 
of  muscular  weakness.  The  intelligence  is  well  retained  for  a  time  but 
suffers  deterioration  in  the  course  of  the  disease.  In  the  form  described 
by  Marie,  there  are  often  exaggerated  reflexes,  optic  nerve  atrophy  and 
paralysis  of  the  extra-ocular  muscles;  but  these  symptoms  are  seen  in 
children  with  the  greatest  infrequency. 

The  course  of  the  disease  is  progressively  downward,  the  ataxia 
becoming  more  marked  and  that  and  the  muscular  weakness  make  walk- 
ing impossible.  The  patient  eventually  becomes  bed-ridden,  in  a  condi- 
tion of  dementia.  But  the  progress  of  the  disease  is  very  slow.  It  may 
last  twenty  or  thirty  years  or  more.  Death  is  usually  due  to  some 
intercurrent  disease  and  is  rarely  the  result  of  asthenia.  Friedreich's 
ataxia  is  incurable.     It  can  only  be  treated  symptomatically. 


DISEASES  ASSOCIATED  WITH  PROGRESSIVE  MUSCULAR  WASTING 

A  number  of  diseases  in  infancy  and  childhood  are  accompanied 
by  muscular  wasting.  This  may  be  secondary  to  disturbances  of  nutri- 
tion, to  some  chronic  infection  or  it  may  result  from  disuse.  Wasting 
is  also  present  with  organic  diseases  of  the  nervous  system,  particularly 
as  the  result  of  some  acute  lesion  such  as  poliomyelitis,  and  also  with 
chronic  crippling  diseases  such  as  spastic  paraplegia,  chronic  meningi- 
tis, etc.  But  there  is  a  group  of  diseases  in  infancy  and  childhood  that 
is  characterized  chiefly  by  progressive  muscular  wasting  with  great 
weakness.  They  develop  insidiously  and  with  but  few  exceptions  progress 
uninterruptedly  to  a  fatal  termination.  They  are  of  great  chronicity 
and  are  practically  incurable.  Many  show  a  marked  hereditary  ten- 
dency. Of  these  diseases,  there  are  a  number  of  more  or  less  clear  cut 
types  that  may  be  recognized  clinically  and  pathologically.  There  are. 
however,  very  many  cases  that  pathologically,  as  well  as  clinically,  have 
the  characteristics  of  two  or  even  more  types.     For  this  reason,  it  has 


822  DISEASES  OF  THE  NERVOUS  SYSTEM 

been  hard  to  classify  these  diseases.  There  has  been  much  difference 
of  opinion  in  regard  to  them  and  there  are  obvious  objections  to  all 
methods  of  classification.  The  lesions  in  some  of  these  cases  are 
chiefly  in  the  cord;  in  others,  in  the  nerves,  and,  in  the  largest  group, 
in  the  muscles.  We  shall  therefore  group  them  as  the  spinal,  the  neural 
and  the  muscular  forms. 

Spinal  Muscular  Atrophy. — The  spinal  forms  are  unusual  in  child- 
hood. Chronic  bulbar  paralysis  and  the  Aran-Duchenne  type  of  spinal 
atrophy  are  so  rare  at  this  age  as  to  be  of  little  importance  to  pediatrists. 
The  other  type  of  central  atrophy  that  has  been  described,  though  infre- 
quently, is 

The  Werdnig-Hoffmann  Type. — This  disease  is  markedly  hereditary; 
several  children  in  a  family  may  be  affected  and  the  disease  has  been 
traced  through  two  or  three  generations.  It  is  not  a  common  disease — 
only  twenty  or  thirty  cases  in  all  have  been  reported.  The  onset  is 
early,  usually  toward  the  end  of  the  first  year.  A  weakness  in  the  thighs 
and  back  develops  in  a  child  that  up  to  that  time  has  been  entirely 
normal.  This  weakness  extends  so  as  to  involve  the  shoulders,  the 
neck,  and,  eventually,  the  arms  and  thighs.  The  legs  and  lower  arms 
are  only  involved  late  in  the  disease,  and  the  hands  and  feet  rarely 
at  all.  There  is  marked  atrophy  of  the  muscles,  particularly  those  of 
the  pelvis  and  shoulders.  The  muscles  show  at  times  fibrillary  con- 
tractions and  there  is  always  loss  of  deep  and  generally  of  superficial 
reflexes.  There  is  a  great  diminution  in  response  to  both  faradic  and 
galvanic  currents.  The  muscles  of  the  face  usually  escape  entirely. 
Bulbar  symptoms  are  very  unusual.  Speech  is  normal  and  the  mentality 
remains  unaffected  to  the  end.  There  is  no  interference  with  sensation. 
The  progress  of  the  disease  is  quite  rapid.  Death  usually  results  in 
two  or  three  years,  from  respiratory  involvement  or  from  pneumonia. 
The  localization  of  the  chief  muscular  paresis  and  atrophy  in  the  pelvic 
and  shoulder  girdles,  the  progressive  character  of  the  disease  and  the 
retention  of  a  clear  mentality,  distinguish  it  from  the  other  diseases 
with  which  it  is  likely  to  be  confounded  which  are  chiefly :  amyatonia 
congenita,  poliomyelitis,  progressive  neural  and  muscular  atrophy  and 
amaurotic  idiocy. 

The  pathological  changes  are  clearly  marked.  There  is  an  atrophy 
of  the  spinal  cord,  with  degeneration  of  the  cells  in  the  anterior  horns 
throughout  its  Avhole  extent  from  the  medulla  to  the  cauda  equina. 
Secondary  to  this  is  a  degeneration  of  the  anterior  roots  of  the  cord 
and  of  the  motor  nerves,  with  great  atrophy  of  the  muscles.  There 
are  no  changes  in  the  pyramidal  tracts. 

The  progress  of  the  disease  is  rapid.  It  is  unbroken  by  periods  of 
remission  and  the  outlook  is  hopeless.    No  treatment  has  any  effect. 


PROGRESSIVE  MUSCULAR  WASTING  823 

Neural  Muscular  Atrophy. — The  existence  of  a  form  of  muscular 
atrophy  dependent  upon  primary  changes  in  the  peripheral  nerves  is 
denied  by  many  authors.  We  have  retained  such  a  classification  for 
the  reasons  that  in  the  peroneal  type  of  muscular  atrophy  there  are 
frequently  severe  lesions  in  the  nerves,  that  the  type  is  generally  clearly 
marked,  and  that  the  disease  runs  a  much  more  benign  course  than 
any  of  the  other  forms  of  muscular  atrophy. 

Peroneal  Type.  (Charcot,  Marie,  Tooth.) — This  form  of  muscular 
atrophy  exhibits  as  marked  familial  tendencies  as  any  other  known 
disease.  Examples  of  it  have  been  met  with  in  five  generations  and 
it  is  seldom  confined  to  one  member  of  a  generation.  Herringham  has 
recorded  a  family  in  which  26  members  had  been  afflicted  with  the 
disease.  The  onset  is  generally  after  the  sixth  year.  It  begins  slowly 
and  symmetrically  in  the  distal  parts  of  the  extremities,  usually  tlie 
legs.  The  extensor  longus  hallucis  and  the  extensor  longus  digitorum 
and  the  tibialis  anticus  are  usually  the  first  muscles  to  waste;  afterward 
the  peroneal  group.  The  localization  of  the  muscular  weakness  causes 
inability  to  flex  the  foot,  which  hangs  down,  causing  an  impediment  to 
walking.  To  overcome  the  impediment  the  knees  must  be  markedly 
flexed,  which  causes  the  "stepping"-  gait.  Double  club  foot  in  the 
position  of  equino-varus,  often  results  from  unopposed  muscular  action 
and  from  attempts  to  walk.  On  this  account  many  of  the  cases  first 
come  to  the  attention  of  orthopedic  surgeons.  It  is  uncommon  for 
the  disease  to  begin  in  the  hands,  but  instances  of  such  a  mode  of 
onset  have  been  reported.  The  atrophy  then  affects  the  small  muscles  of 
tlie  hands.  As  the  disease  progresses  the  legs  and  forearms  gradually 
become  involved  but  the  thighs  and  upper  arms  remain  free.  There  is 
no  hypertrophy  of  muscles  or  pseudo-hypertrophy.  There  may  or  may 
not  be  fibrillary  twitching  of  the  muscles.  Sensation  may  be  normal 
or  there  may  be  complaint  of  paresthesia,  or  of  feelings  of  heat  and 
cold.  Shooting  pains  may  be  felt  but  the  pain  is  never  very  severe 
and  is  frequently  entirely  absent.  Control  of  the  bladder  and  rectum 
is  complete.  There  is  a  diminution  of  response  to  the  faradic  and  also 
galvanic  currents  in  the  affected  muscles  and  in  certain  instances  this 
may  obtain  in  muscles  which  are  apparently  normal. 

The  course  is  an  exceedingly  slow  one  and  usually  not  continuously 
progressive.  In  this  regard  it  differs  greatly  from  the  allied  conditions. 
There  may  be  remissions  of  such  length  that  cure  may  be  said  to  have 
occurred.  The  disease  seldom  results  in  death  and  many  patients  live 
an  active,  self-supporting  life  for  years.  A  return  of  the  affected 
parts  to  a  normal  condition  is  impossible  even  though  complete  arrest 
may  take  place. 

The  nerves  in  the  peroneal  type  of  muscular  atrophy  are  almost 


824  DISEASES  OF  THE  NERVOUS  SYSTEM 

always  the  seat  of  a  marked  interstitial  growth.  Associated  with  the 
neural  change  is  a  degeneration  of  the  posterior  columns  of  the  cord 
and  a  marked  atrophy  of  the  muscles  involved.  Here,  as  in  all  these 
allied  diseases,  exceptions  may  be  found  in  a  preponderant  alter- 
ation in  the  cord  and  muscles  and  an  almost  complete  escape  of  the 
nerves. 

'No  known  treatment  arrests  the  prognosis  of  the  disease.  Electricity, 
massage  and  baths  may  assist  in  retainiDg  muscular  function.  Ortho- 
pedic treatment  (tenotomy,  braces,  etc.)  is  of  marked  aid  in  preserving 
the  ability  to  walk. 

Muscular  Dystrophies.^There  are  certain  well  established  facts  in 
regard  to  the  muscular  dystrophies.  The  changes  are  primarily  in  the 
muscles.  They  are  not  dependent  upon  lesions  of  the  nerves  or  the  cord 
even  though  secondary  degenerations  may  be  present  in  those  situations. 
While  isolated  cases  are  here  and  there  encountered,  muscular  dystrophies 
are  family  diseases.  They  affect  boys  rather  more  often  than  girls.  What 
it  is  that  determines  the  progressive  wasting  of  the  muscles  is  quite  un- 
known. It  appears  to  be  an  inherent  weakness  of  the  muscular  system, 
an  inability  of  the  muscles  to  carry  on  the  fight  for  existence.  They 
fail  to  survive  as  various  parts  of  the  nervous  system  may  fail. 

The  lesions  of  muscular  dystrophy  are  essentially  the  same,  no 
matter  what  the  type.  Ihe  individual  muscle  fibers  waste.  They  become 
ro\nid  instead  of  polygonal  and  eventually  they  disappear,  leaving  the 
sarcolemma  sheath,  with  greatly  increased  nuclei.  Certain  of  the  fibers 
may  actually  hypertrophy  to  several  times  the  size  of  the  normal  fiber, 
l)ut  tliis  is  only  a  temporary  process.  Eventually  the  hypertrophic  fibers 
share  in  the  general  atrophy.  Replacement  of  the  muscle  fibers  by 
connective  tissue  occurs  as  the  atrophy  goes  on,  and  coincident  with  the 
muscular  atrophy  a  deposition  of  fat  takes  place  in  the  muscle.  This 
may  largely  compensate  in  amount  for  the  atrophy  of  true  muscular 
substance  so  that  the  diminution  in  size  of  the  whole  muscle  may  be  very 
gradual.  This  deposition  of  fat  may  even  be  excessi\e  and  thus  the 
pseudo-hypertrophy  is  caused.  Upon  the  relative  amounts  of  the  mus- 
cular tissue,  connective  tissue  and  fat,  depends  the  appearance  of  the 
muscles  as  a  whole.  They  are  lighter  in  color  than  normal,  perhaps  even 
yellow  and  soft.  Eventually,  the  fat  largely  disappears  and  only  firm, 
fibrous  and  contracted  strands  of  connective  tissue  are  left. 

Pseudo-Hypertrophic  Paralysis. — This  is  the  most  frequent  and 
best-known  variety  of  the  muscular  dystrophies.  The  symptoms  as  a 
rule  come  on  early  in  childhood,  nearly  always  before  the  tenth  year, 
and  generally  between  the  second  and  seventh.  The  earlier  symptoms 
relate  to  a  general  weakness  of  the  lower  extremities,  which  is  accom- 
panied by  a  marked  increase  in  the  size  of  certain  muscular  groii]is. 


PROGRESSIVE  MUSCULAR  WASTING 


825 


usually  those  of  the  calves,  but  sometimes  more  of  the  thighs  or  the 
gluteal  regions.  The  enlargement  may  affect  almost  any  muscular  group 
of  the  lower  extremity.  Children  walk  unsteadily,  and  fall  very  easily. 
They  have  special  difficulty  in  rising  from  the  floor  and  in  mounting 
stairs.  The  method  of  rising  in  well-advanced  cases  is  quite  character- 
istic; the  patient  lifts  his  body  until  he 
touches  the  floor  only  with  the  hands 
and  feet;  then  he  proceeds  to  "climb  up 
himself"  by  putting  first  one  hand  upon 
the  knee,  and  then  the  other,  gradually 
moving  his  hands  higher  and  higher  up 
the  thighs  until  the  erect  position  is  at- 
tained. This  is  seen  in  many  of  the 
cases,  but  not  in  all. 

Most  of  these  patients  exhibit,  while 
standing,  a  marked  degree  of  lumbar 
lordosis,  due  to  the  weakness  of  the  ex- 
tensors of  the  hip  and  later  of  the  mus- 
cles of  the  back.  They  stand  with  their 
shoulders  far  back.  This  is  well  shown 
in  Fig.  127.  The  patient  may  be  so 
weak  upon  his  legs  that  the  slightest 
touch  will  cause  him  to  fall,  even  with 
his  apparently  immense  muscular  devel- 
opment. The  small  muscles  are  gener- 
ally weaker  than  those  which  are  en- 
larged. 

With  the  progress  of  the  disease,  the 
muscles  of  the  arms  and  shoulders  be- 
come involved.  Some  of  these  atrophy 
at  once,  others  may  exhibit  pseudo- 
hypertrophy for  a  time.  The  infra- 
spinatus is  the  most  frequently  enlarged, 
next  the  supraspinatus  and  the  deltoid. 
The  pectorals  and  latissimus  dorsi  are 
never  enlarged  but  are  generally  marked- 
ly wasted.  The  weakness  of  the  shoulder, 
muscles  makes  the  characteristic  diffi- 
culty in  picking  the  child  up  by  grasping  him  under  th(?  arms.  They 
slip  through  the  hands.  The  rhomljoids  and  the  levator  angulae  scap- 
ulae, the  biceps  and  the  triceps  gradually  are  involved,  and  later  in  the 
disease  there  is  such  marked  atrophy  with  corresponding  weakness  of  all 
the  aff'ected  groups  that  the  patient  may  Ipe  unable  to  walk  or  even  stand. 


Fig.  127. — Muscular  Pseudo-hy- 
pertrophy. Showing  to  a  mod- 
erate degree  the  large  calves  and 
gluteal  regions  with  a  marked 
lordosis.  (From  a  photograph 
by  Dr.  M.  A.  Starr.) 


826  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  is  absolutely  helpless  with  the  exception  of  the  use  of  his  hands. 
The  knee-jerk  is  at  first  normal,  but  gradually  diminishes  until  it  is 
finally  lost.  The  electrical  reactions  are  normal  until  marked  wasting 
occurs,  when  there  is  a  lessened  response  to  faradism  and  galvanism,  but 
never  the  reaction  of  degeneration.  There  are  no  fibrillary  contractions, 
and  no  sensory  disturbances.  The  progress  of  the  disease  is  generally 
slow,  and  sometimes  irregular.  It  is  often  more  rapid  in  early  childhood, 
and  slower  after  puberty.  Many  of  these  children,  though  apparently 
bright,  are  distinctly  below  the  average  for  their  ages. 

The  prognosis  is  grave,  most  patients  dying  in  from  five  to  ten 
years.  Death  seldom  results  from  the  disease  itself,  but  rather  from 
some  intercurrent  disease,  especially  of  the  lungs.  Nothing  can  be  done 
to  stay  the  course  of  ^luscular  dystrophy.  The  diagnosis  is  generally  easy 
from  the  apparent  liypertrophy  and  actual  weakness  of  the  muscular 
groups.    The  disease{is  incurable. 

The  Juvenile  Form  of  Muscular  Atrophy  {Erh's  Type). — This  is 
much  less  frequent  than  the  form  just  described  and  usually  begins 
somewhat  later  in  li!fe,  between  the  tenth  and  sixteenth  years.  It  is 
characterized  by  progressive  wasting  of  certain  muscular  groups,  espe- 
cially those  about  the  shoulders  and  pelvis,  and  hypertrophy  of  other 
groups.  Of  the  shoulder  and  upper  extremity,  the  muscles  afEected  are 
the  pectorals,  the  trapezius,  the  latissimus  dorsi,  the  serrati,  the  rhomboi- 
dei,  the  muscles  of  the  upper  arm  and  the  subscapularis.  The  deltoid, 
infraspinatus  and  siipraspinatus  for  a  long  time  escape,  and  may  be 
hypertrophied.  The  liand  and  forearm  are  not  involved.  In  the  lower 
extremity,  the  muscles  of  the  pelvis,  thigtis,  and  gluteal  regions  are 
affected,  while  those  |of  the  leg  and  foot  escape  until  late  in  the  disease. 
Weakness  and  atrophy  of  the  muscles  of  the  back  cause  lordosis  of 
great  severity.  In  this  disease  there  are  no  fibrillary  contractions,  no 
reaction  of  degeneration,  and  no  sensory  disturbances.  The  course 
and  result  of  this  form  are  essentially  the  same  as  in  the  preceding 
variety.  It  is  now  regarded  as  the  same  disease  pathologically,  the 
only  difference  being  that  of  localization.  In  the  terminal  stages  dif- 
ferentiation may  be  impossible  and  mixed  cases  that  demonstrate  from 
the  beginning  the  predominant  characteristics  of  both  types  are 
encountered. 

Landouzy-Dejerine  Type. — In  this,  wasting  begins  in  the  muscles 
of  the  face;  the  lips  are  thickened  and  weakened.  They  cannot  be 
firmly  closed,  but  all  the  rest  of  the  facial  muscles  are  markedly  atro- 
phied, giving  a  peculiar  expression  to  the  mouth  known  as  "the  tapir 
mouth."  Speech  may  be  greatly  interfered  with  but  the  muscles  of 
mastication  and  deglutition  are  not  affected.  This  serves  to  differen- 
tiate the  disease  from  bulbar  paralysis.     Later,  the  atrophy  extends  to 


CONGENITAL  MYATONIA  827 

the  shoulders  and  arms,  but  does  not  involve  the  supraspinatus  or 
infraspinatus,  or  the  flexors  of  the  hand  and  forearm.  This  type  is 
sometimes  described  as  beginning  in  the  shoulders,  or  even  in  the  legs. 
The  "description  therefore  corresponds  to  the  juvenile  form  of  Erb, 
with  the  addition  of  the  facial  symptoms,  and  it  is  undoubtedly  a  variety 
of  the  same  disease. 

CONGENITAL  MYATONIA 

{Congenital  Amyotonia — Oppenheim's  Disease) 

This  disease  was  first  described  by  Oppenheim  in  1900.  Its  cause 
is  unknown.  The  symptoms  are  usually  noticed  in  the  early  months, 
sometimes  very  soon  after  birth.  In  some  cases  it  has  been  observed 
even  during  pregnancy  that  fetal  movements  were  less  vigorous  than 
usual.  There  is  a  general  flaccid  paralysis.  That  of  the  lower  extremities 
is  usually  complete;  but  in  the  upper  extremities  feeble  movements  of 
hands  or  arms  may  be  present.  The  intercostal  muscles  and  those  of 
the  neck  are  usually  but  not  always  involved.  The  diaphragm  and 
all  the  muscles  supplied  by  the  cranial  nerves  escape.  There  is  no 
ocular  or  facial  paralysis. 

In  the  well-marked  cases  the  child  lies  completely  helpless  and 
motionless;  the  knee  jerks  are  absent;  but  sensation  is  not  afi'ected  and 
the  mentality  is  normal.  The  electrical  reactions  are  feeble  or  even 
may  be  absent.  Owing  to  involvement  of  the  intercostals  the  respira- 
tion is  usually  labored,  panting  and  diaphragmatic  in  character. 
Secretions  accumulate  in  the  pharynx  and  air  passages  and  choking 
attacks  often  occur.  These  may  result  in  fatal  asphyxia,  or  in  aspira- 
tion pneumonia.  The  pulse  is  normal  and  regular.  There  are  appar- 
ently no  subjective  symptoms.  ,  The  infants  are  usually  well  nourished 
and  may  even  be  very  fat.  In  those  who  live  for  several  months  or~ 
years  the  intelligence  is  apparently  normal  and  control  over  the  sphinc- 
ters complete.  Deformities  of  the  chest  are  often  produced  as  a  conse- 
quence of  the  paralysis  of  the  respiratory  muscles. 

Besides  the  marked  form  of  the  disease,  to  which  the  above  description 
refers,  it  is  now  recognized  that  myatonia  may  occur  in  all  degrees  of 
severity.  In  the  mild  form  there  may  be  only  very  great  weakness  and 
atony  of  the  muscles.  The  ability  to  hold  up  the  head  or  to  walk  may 
then  be  greatly  delayed  though  the  intelligence  may  be  quite  normal. 
These  cases  are  often  confounded  with  rickets ;  but  the  weakness  in 
myatonia  is  permanent.  Owing  to  the  greater  involvement  of  some  mus- 
cular groups,  contractions  of  opposing  groups  may  occur.  This  may 
lead  to  confusion  with  poliomyelitis.     The  milder  forms  of  myatonia 


828  DISEASES  OF  THE  NERVOUS  SYSTEM 

may  be  readily  overlooked  and  may  cause  but  little  interference  with 
function.  Between  these  and  the  severe  forms  of  the  disease  there  are 
seen  all  degrees  of  muscular  weakness. 

The  lesions  are  chiefly  in  the  muscles,  which  show  great  atrophy 
and  degeneration.  They  may  waste  to  fibrous  cords  or  may  largely  be 
replaced  by  connective  tissue  and  fat.  In  several  of  the  cases  the  cells 
of  the  anterior  horns  of  the  cord  have  been  found  reduced  in  number, 
sometimes  almost  absent,  and  the  anterior  nerve  roots  atrophic.  The 
brain  is  normal.  The  nervous  lesions  are  to  be  regarded  as  a  failure  of 
development  rather  than  a  degeneration.  It  is  believed  by  some  that 
they  are  the  primary  condition,  the  lack  of  muscular  development  being 
the  result  of  deficient  innervation. 

Many  of  these  infants  suffering  from  this  disease  die  in  the  first 
year,  most  frequently  from  bronchopneumonia  to  which  they  are  espe- 
cially predisposed  by  reason  of  the  condition  of  the  respiratory  muscles. 
The  duration  of  the  mild  forms  of  the  disease  is  indefinite.  We  have 
seen  a  few  older  children  and  young  adults  with  this  form  of  the  disease. 
In  some  cases  a  slight  improvement  has  taken  place;  but  no  cures  have 
been  reported.  The  condition  is  not  influenced  by  treatment.  The  dis- 
ease usually  either  remains  stationary  or  very  slowly  progresses,  the  child 
dying  of  some  intercurrent  disease. 


CHAPTER  V 

DISEASES  OF  THE  PERIPHERAL  NERVES 
MULTIPLE  NEURITIS 

UxDER  the  term  multiple  neuritis  are  included  those  cases  in  which 
several  nerves  are  involved  in  an  inflammatory  process,  which  may  at 
times  be  general.  In  its  distribution  multiple  neuritis  is  usually  sym- 
metrical, but  it  is  not  necessarily  so. 

Etiology. — The  chief  cause  of  multiple  neuritis  in  children  is  diph- 
theria, although  it  is  occasionally  seen  after  other  infectious  diseases, 
especially  malaria,  typhoid  or  scarlet  fever,  measles,  and  mumps.  In 
diphtheria  the  inflammation  is  due  to  the  direct  action  of  the  toxins 
upon  the  nerve  structures,  since  it  can  be  induced  in  animals  by  injecting 
toxins  into  the  circulation.  There  is  little  doubt  that  in  all  infectious 
diseases  the  inflammation  is  excited  in  a  similar  way.  The  metallic 
poisons,  lead  and  arsenic,  are  rarely  the  cause  of  multiple  neuritis  in 
early  life,  and  the  same  is  true  of  alcohol,  although  a  marked  case  from 


MULTIPLE  NEURITIS  820 

this  cause  has  come  under  our  observation  in  a  child  only  three  years 
old.^  Lastly,  there  are  cases  in  which  the  cause  assigned  is  simply 
exposure  to  cold— those  classed  as  rheumatic. 

Lesions. — Almost  any  nerves  in  the  body  may  be  affected,  although 
the  distribution  varies  somewhat  with  the  cause  of  the  disease.  The 
musculo-spiral  and  the  anterior  tibial  nerves  are  most  frequently  in- 
volved, but  the  inflammation  may  affect  any  of  the  spinal  nerves,  includ- 
ing the  phrenic,  and  occasionally  the  cranial  nerves,  especially  the  pneu- 
mogastric,  hypoglossal,  oculomotor,  and  abducens.  Several  nerves  in 
different  parts  of  the  body  are  usually  affected,  the  lesion  being  in  most 
cases  symmetrical. 

The  affected  nerve  is  sometimes  red  and  swollen,  owing  to  acute 
congestion  and  edema  or  to  a  sero-fibrinous  exudation.  In  other  cases  the 
changes  are  almost  entirely  degenerative.  The  miscroscope  shows  the 
changes  sometimes  to  be  chiefly  interstitial  and  sometimes  chiefly  paren- 
chymatous. There  is  an  exudation  of  cells  into  the  sheath,  between  the 
sheath  and  the  nerve  fibers,  and  even  between  the  nerve  fibers  themselves. 
The  myelin  breaks  up  into  granules,  and  in  places  luay  completely  dis- 
appear. The  late  changes  are  those  of  subacute  or  chronic  degeneration 
of  the  nerve  fibers. 

With  these  changes  in  the  nerves  there  are  associated^  in  some  cases, 
inflammatory  and  degenerative  changes  in  the  ganglion  cells  of  the 
spinal  cord,  although  they  are  much  less  severe  than  are  the  lesions  in 

^This  case  was  in  many  respects  a  remarkable  one.  The  boy  completely 
emptied  a  decanter  containing  twelve  ounces  of  whisky,  but  almost  immediately 
vomited  the  greater  part  of  it.  He  soon  after  showed  the  symptoms  of  alcoholic 
intoxication,  and  in  a  few  hours  became  comatose,  in  which  condition  he  con- 
tinued for  twelve  hours.  After  this  he  gradually  lost  power  in  his  legs,  and  at 
the  end  of  a  week  was  unable  to  walk  at  all.  He  had  convulsions,  and  after  this 
there  developed  the  usual  symptoms  of  meningitis  at  the  convexity,  with  which 
he  was  admitted  to  the  Babies'  Hospital,  three  weeks  after  drinking  the  whisky. 
The  child  was  then  unconscious  and  there  was  present  incomplete  paralysis,  af- 
fecting all  four  extremities,  with  anesthesia  of  the  arms.  The  active  inflamma- 
tory symptoms  continued  for  six  weeks  longer,  during  which  time  there  were 
repeated  convulsions,  continuous  stupor,  fever,  gradually  increasing  deformities, 
marked  atrophy,  loss  of  reflexes,  and  great  diminution  in  the  faradic  contractility 
of  all  the  paralyzed  muscles;  in  the  thighs,  left  leg,  and  abdominal  muscles  there 
were  no  responses  to  a  strong  current,  but  there  was  nowhere  the  reaction  of 
degeneration.  The  child  was  at  death's  door  for  three  or  four  weeks.  Three 
months  after  the  attack  the  first  signs  of  improvement  were  observed  in  the 
cerebral  symptoms.  Shortly  afterward  he  began  to  use  his  hands,  and  at  the 
end  of  six  weeks  he  was  walking  alone  and  talking  freely.  The  improvement  was 
very  rapid,  and  eight  weeks  from  the  date  of  the  first  change  for  the  better,  and 
five  months  from  the  time  of  taking  the  whisky,  he  was  as  well  as  ever.  The 
diagnosis  was  multiple  alcoholic  neuritis,  with  a  convexity  meningitis.  (Fig.  128 
is  from  a  photograph  taken  while  the  symptoms  were  at  their  height.) 
28 


830  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  nerves.     However,  they  were  once  regarded  as  the  explanation  of 
some  of  these  cases,  particularly  of  diphtheritic  paralysis. 

Symptoms.- — The  onset  of  multiple  neuritis  is  in  most  cases  a  gradual 
one,  it  being  usually  from  two  to  four  weeks  before  the  paralysis 
reaches  its  height.  Very  exceptionally  the  onset  may  be  abrupt,  with 
fever,  and  marked  paralysis  in  a  few  days.  It  is  characteristic  of  this 
disease  that  both  motor  and  sensory  symptoms  are  present,  and  that  they 
are  the  same  in  their  distribution.  The  symptoms  are  usually  symmet- 
rical. There  is  first  noticed  a  general  weakness  in  the  affected  muscles, 
which  slowly  increases  to  complete  paralysis.  As  the  extensor  groups 
of  the  hands  and  feet  are  apt  to  be  aifected,  there  are  wrist-drop  and 
foot-drop  (Fig.  128).     The  paralysis  may  begin  in  the  feet  and  hands. 


Fig.  128. — Alcoholic  Neuritis,  showing  Chabacteristic  Dropping  of  thb  Feet. 
This  position  of  the  lower  extremities  was  maintained  for  over  a  month.  Boy  three 
years  old. 

and  gradually  extend  until  it  involves  not  only  the  four  extremities,  but 
even  the  muscles  of  the  trunk  and  the  neck,  although  this  is  rare.  The 
child' may  then  be  absolutely  helpless,  unable  to  sit  up,  or  even  to  support 
his  head.  In  such  cases  the  head  seems  loosely  attached  to  the  body,  and 
rolls  about  on  the  shoulders  like  a  ball.  Weakness  of  the  spinal  muscles 
leads  to  deformities  (Fig.  129)  which  may  be  mistaken  for  Pott's 
disease,  even  by  experienced  observers.  In  most  of  the  muscular  groups 
the  paralysis  is  incomplete.  The  symptoms  which  relate  to  the  phrenic 
and  the  cranial  nerves  will  be  described  with  Diphtheritic  Paralysis,  for 
they  are  rarely  seen  in  any  other  form.  It  is  characteristic  of  multiple 
neuritis  that  the  bladder  and  rectum  escape. 

The  sensory  symptoms  are  marked  only  in  the  early  stage  of  the 
disease,  while  the  paralysis  is  increasing;  they  improve  so  much  more 
rapidly  than  the  motor  symptoms,  that  they  may  be  altogether  wanting 
at  the  time  that  the  paralysis  is  at  its  height.  In  some  cases  they  are 
so  slight  as  to  be  overlooked.     There  is  usually  pain  along  the  course 


MULTIPLE  NEURITIS 


831 


of  the  affected  nerves,  which  is  sharp  and  neuralgic  in  character,  and 
generally  associated  with  acute  tenderness  of  the  nerve  trunks  and  of 
the  muscles.  Often  there  is  a  general  hyperesthesia  in  the  early  part 
of  the  attack,  followed  by  partial  anesthesia.  The  sensations  of  touch, 
pain,  temperature,  and  the  muscular  sense  are  all  about  equally  affected. 

Ataxia  is  not  uncommon,  and  may 
be  a  more  striking  symptom  than  the  loss 
of  power.  All  the  reflexes  are  diminished 
or  lost,  especially  the  knee-jerk,  as  the 
legs  are  usually  most  affected.  Some- 
times, particularly  after  diphtheria, 
there  is  loss  of  the  knee-jerk,  when  there 
is  no  other  symptom  of  neuritis.  In  the 
severe  cases  muscular  tremor  is  fre- 
quently present. 

Atrophy  is  a  prominent  symptom  of 
neuritis,  and  it  is  evident  early  in  the 
disease,  often  being  quite  as  rapid  as  in 
poliomyelitis.  The  electrical  reactions 
are  altered — every  grade  of  reduction  in 
the  responses  being  seen,  from  a  slight 
diminution  in  the  reaction  to  faradism 
to  the  complete  reaction  of  degeneration. 
Vasomotor  symptoms,  such  as  edema  of 
the  affected  parts,  glossiness  of  the  skin, 
etc.,  are  often  present.  Deformities 
from  muscular  contraction  occur  early; 
they  may  be  severe,  and  in  some  cases, 
permanent. 

Course  and  Prognosis.— The  usual 
course  of  the  disease  is  for  the  symptoms 
gradually  to  increase  for  three  or  four 
weeks  and  then  improve,  sometimes  rap- 
idly, but  more  often  slowly,  the  case 
usually  going  on  to  complete  recovery  in 
the  course  of  a  few  months.  Exception- 
ally the  paralysis  may  be  permanent.  The  sensory  symptoms  always  dis- 
appear before  the  motor  ones.  Multiple  neuritis  may  prove  fatal,  from 
paralysis  of  the  heart  or  the  muscles  of  respiration,  or  death  may  be  due 
to  asphyxia  from  the  entrance  of  food  or  foreign  bodies  into  the  air 
passages,  owing  to  anesthesia  of  the  epiglottis  and  paralysis  of  the  mus- 
cles of  deglutition.  Death  sometimes  follows  from  complications,  espe- 
cially pneumonia.    The  electrical  reactions  are  of  much  prognostic  value 


Fig.  129.  —  Multiple  Neuritis 
AFTER  Diphtheria  in  a  Child 
Four  Years  Old.  The  posi- 
tion of  the  head  and  spine  is  due 
to  partial  paralysis  of  the  trunk 
and  neck.  The  legs  were  also 
affected. 


832  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  regard  to,  the  persistence  of  the  paralysis.  If  the  reaction  of  degenera- 
tion is  present  the  paralysis  is  certain  to  last  many  months,  and  some 
muscles  are  sure  to  he  permanently  affected.  Where  there  is  simply  a 
diminution  in  the  faradic  responses,  even  though  accompanied  by 
marked  atrophy,  complete  recovery  may  be  expected,  although  it  is  often 
slow. 

Diagnosis. — The  diagnostic  features  of  multiple  neuritis  are  the  com- 
bination of  motor  and  sensory  symptoms  with  the  same  distribution,  the 
occurrence  of  atrophy,  and  the  diminution  in  the  electrical  responses, 
even  the  reaction  of  degeneration.  The  gradual  onset  and  the  wide- 
spread distribution  of  the  paralysis  are  also  characteristic.  If  all  four 
extremities  are  paralyzed,  it  is  altogether  the  most  probable  disease ;  and 
if  to  this  is  added  paralysis  of  the  neck  and  spinal  muscles,  the  diagnosis 
is  almost  certain.  The  facts  that  the  paral3^sis  is  often  incomplete,  and 
that  it  involves  parts  distant  from  each  other,  are  also  important. 
Neuritis  may  be  mistaken  for  poliomyelitis,  for  Landry's  paralysis,  or 
for  Pott's  paraplegia ;  an  important  diagnostic  point  from  the  last  men- 
tioned is  the  condition  of  the  reflexes — being  greatly  exaggerated  in 
Pott's  paraplegia,  while  they  are  diminished  or  lost  in  multiple 
neuritis. 

Treatment. — As  this  disease  tends  in  the  great  majority  of  cases  to 
spontaneous  recovery,  it  is  difficult  to  estimate  the  value  of  any  method 
of  treatment.  Causes,  such  as  lead,  arsenic,  alcohol,  and  malaria,  are  to 
be  sought  and  reiuoved  as  the  first  step.  During  the  acute  stage  the  pain 
may  be  so  severe  as  to  require  relief,  which  is  best  accomplished  by  the 
application  of  heat.  In  using  counter-irritation  much  care  is  necessary, 
for  troublesome  ulceration  may  follow.  After  the  acute  stage  has  passed, 
or  at  the  end  of  three  or  four  weeks,  electricity  should  be  begun,  faradism 
being  used  if  the  muscles  respond  to  a  moderate  current,  otherwise  gal- 
vanism. This  should  be  continued  daily  until  recovery.  >Stryebnin  is 
much  used  in  these  cases,  but  it  is  doubtful  whether  it  has  any  specific 
influeuce,  although  as  a  tonic  it  is  valuable.  Other  tonics,  such  as  iron, 
quinin.  and  cod-liver  oil.  should  also  be  given.  Massage  is  also  bene- 
ficial. The  special  treatment  of  cardiac  and  respiratory  paralysis  will  be 
discussed  in  the  following'  article. 


DIPHTHERITIC  PARALYSIS 

This  is  not  only  the  most  frequent  variety  of  multiple  neuritis,  bul 
it  has  some  peculiarities  Avhich  make  a  separate  consideration  of  it 
desirable. 

Frequency. — According  to  the  statistics  of  various  observers,  paraly- 


DIPHTPTERTTTC  PARALYSIS  833 

sis,  including  all  varieties,  occurs  after  diphtheria  in  from  5  to  15  per 
cent  of  the  cases.  Sanne  gives  11  per  cent  in  2,4-48  cases;  Lennox 
Browne,  14  per  cent  in  1,000  cases  (in  neither  of  these  groups  did  the 
patients  receive  antitoxin) ;  the  Eeport  of  the  Collective  Investigation 
by  the  American  Pediatric  Society,  9.7  per  cent  of  3.384  cases  which 
were  treated  by  antitoxin.  The  most  recent  figures  are  those  of  J.  D. 
Eolleston.  He  encountered  some  form  of  paralysis  in  20.7  per  cent 
of  2,300  cases,  all  personally  observed  by  him. 

There  can  be  little  doubt  that  since  the  introduction  of  treatment 
with  antitoxin  more  cases  of  post-diphtheritic  paralysis  are  observed 
tlian  in  the  pre-antitoxin  days.  The  undoubted  explanation  of  the  fre- 
quency with  which  paralysis  is  seen  after  antitoxin  treatment  is  that 
patients  now  live  long  enough  to  develop  paralysis,  when  without  anti- 
toxin the  same  patients  would  have  died  during  the  early  stage  of  the 
disease. 

Neuritis  is  more  likely  to  follow  severe  than  mild  cases.  Its  occur- 
rence after  some  very  mild  attacks  shows  how  great  is  the  susceptibility 
of  the  nervous  tissues  to  the  action  of  the  poison.  But  the  great /deter- 
mining factor  is  the  duration  of  the  action  of  unneutralized  toxin  upon 
the  nerves.  The  frequency  of  neuritis  is  in  direct  relation  to  the 
length  of  time  elapsing  before  the  administration  of  antitoxin.  Eolles- 
ton's  figures  upon  this  point  are  illuminating.  When  antitoxin  was 
given  on  the  first  day  of  the  disease,  3.6  per  cent  of  the  ca^es  subse- 
quently developed  paralysis;  on  the  second  day,  14.09  per  cent;  on  the 
thirrl  day,  21.4  per  cent;  on  the  fourth  day,  26.9  per  cent;  on  the 
fifth  day,  26.3  per  cent;  on  the  sixth  day,  27.1  per  cent.  Ko  better 
proof  of  the  protection  of  the  nervous  system  by  antitoxin  can  be 
adduced. 

Time  of  Occurrence. — During  the  second  week,  and  sometimes  even 
during  the  latter  part  of  the  first  week,  the  early  paralysis  occurs,  usu- 
ally affecting  the  palate.  The  most  frequent  and  most  characteristic 
paralysis — that  affecting  the  throat,  eyes,  extremities,  and  respiration — 
begins  at  a  later  period,  usually  not  before  four  or  five  weeks  after  the 
throat  has  cleared  ofi^,  and  sometimes  even  later  than  this. 

Extent  and  Distribution  of  the  Paralysis. — Eoss  gives  the  following 
statistics  of  171  collected  cases  of  diphtheritic  paralysis:  palate  affected 
in  128;  eyes  in  77,  in  54  of  which  the  muscles  of  accommodation  were 
involved;  lower  extremities  in  113;  upper  extremities  in  60;  trunk  or 
neck  in  58;  muscles  of  respiration  in  33.  In  the  477  cases  reported 
by  Eolleston  the  paralysis  was  distributed  as  follows:  palate,  331  (74 
per  cent)  ;  ciliary  muscles,  236  (53  per  cent)  ;  extra-ocular  muscles,  80 
(18  per  cent)  ;  pharynx,  36  (11  per  cent)  ;  diaphragm,  16  (3.6  per 
cent). 


834  DISEASES  OF  THE  NEEVOUS  SYSTEM 

Symptoms. — In  the  great  majority  of  cases  the  throat  is  affected,  and 
usually  the  paralysis  is  first  noticed  there.  It  may  involve  the  palate 
alone,  or  the  muscles  of  the  pharynx  or  larynx  in  addition.  The  muscles 
of  the  extremities  or  of  the  eye  are  often  next  attacked.  In  severe  cases 
there  may  also  be  involved  the  muscles  of  the  trunk  and  neck,  and  some- 
times the  diaphragm.  Paralysis  of  the  throat  and  diaphragm  distin- 
guishes diphtheritic  paralysis  from  other  forms  of  multiple  neuritis. 
Whatever  the  extent  or  situation  of  the  paralysis,  the  knee-jerk  is  nearly 
always  lost.  The  symptoms  in  the  extremities  and  the  trunk  do  not  differ 
from  those  of  multiple  neuritis  from  other  causes.  The  throat  paralysis 
shows  itself  by  a  nasal  voice  and  by  regurgitation  of  fluids  through  the 
nose,  sometimes  by  difficulty  in  swallowing  or  by  the  entrance  of  food 
into  the  larynx,  owing  to  anesthesia  of  the  epiglottis  and  paralysis  of 
the  muscles  of  deglutition.  There  may  be  difficulty  in  protruding  the 
tongue  or  in  articulation.  Facial  paralysis  is  rare.  On  the  part  of  the 
eye  there  is  most  frequently  seen  inability  to  read,  owing  to  paralysis  of 
the  muscles  of  accommodation;  there  may  be  dilatation  of  the  pupils, 
rarely  strabismus  or  ptosis. 

Respiratory  paralysis  may  be  due  to' involvement  of  the  phrenic  or 
the  intercostal  nerves,  more  frequently  the  former.  Extensive  paralysis 
of  other  parts — the  throat,  extremities,  or  trunk — usually  precedes.  The 
first  warning  is  generally  in  the  form  of  occasional  attacks  of  dyspnea, 
sometimes  accompanied  by  cough.  Gradually  these  attacks  increase  in 
frequency  and  severity.  The  voice  is  reduced  to  a  whisper.  As  the 
diaphragm  is  usually  affected,  the  breathing  is  entirely  thoracic.  The 
respiratory  movements  are  rapid,  but  irregular,  shallow,  and  ineffectual. 
There  is  cyanosis,  also  great  subjective  as  well  as  objective  dyspnea. 
The  anxiety,  distress,  and  apprehension  of  the  patient  are  sometimes 
terrible.  There  is  a  constant  dread  of  impending  suffocation,  and  the 
respiratory  movements  are  continued  only  by  the  patient's  constant 
efforts,  otherwise  they  would  cease  altogether.  After  a  few  hours  these 
severe  symptoms  may  subside,  to  return  after  a  short  respite.  There 
may  be  several  such  attacks  during  two  or  three  days,  in  each  of  which 
death  seems  imminent.  Unfortunately,  this  is  the  most  frequent  termi- 
nation. Of  thirty-three  such  cases  collected  by  Eoss,  only  eight  recov- 
ered. Associated  with  these  respiratory  symptoms  others  may  be  present. 
There  may  be  attacks  of  abdominal  pain,  vomiting,  and  disturbance  of 
the  heart's  action — usually  an,  irregular  or  intermittent  pulse,  which 
may  be  either  unnaturally  slow  or  very  rapid.  In  many  cases  the  heart 
continues  to  beat  normally,  even  though  the  respiration  is  so  much 
disturbed. 

The  premonitory  symptoms  of  cardiac  paralysis  are  an  irregular  or 
intermittent  pulse,  often  slow,  but  becoming  very  rapid  from  even  the 


DIPHTHERITIC  PARALYSIS  835 

slightest  exertion.  It  is  always  weak  and  compressible.  The  first  sound 
of  the  heart  is  feeble  and  may  be  reduplicated.  Heart  block,  the  disas- 
sociation  of  auricular  and  ventricular  contraction,  has  been  reported. 
As  the  symptoms  increase  there  is  marked  pallor,  coldness  of  the  ex- 
tremities, great  restlessness,  anxiety,  precordial  distress,  and  perhaps 
orthopnea.  Within  twenty-four  hours  from  the  beginning  of  such 
symptoms  death  usually  occurs.  In  other  cases  it  may  come  suddenly 
without  any  warning,  or  with  a  warning  so  slight  as  to  be  overlooked. 
At  such  times  it  often  follows  some  muscular  exertion,  such  as  getting 
out  of  bed,  walking  across  the  room,  or  so  slight  an  effort  as  sitting  up 
suddenly  in  bed.  Fits  of  temper  or  other  excitement  have  at  times 
produced  it. 

It  is  by  no  means  certain  that  cardiac  paralysis  is  due  to  a  lesion 
of  the  cardiac  nerves.  Toxic  myocarditis  appears  to  be  a  more  im- 
portant factor  in  producing  the  fatal  result. 

Death  in  diphtheritic  paralysis  is  usually  due  either  to  cardiac  or 
respiratory  paralysis.  Of  171  cases  of  all  varieties  collected  by  Eoss, 
45  were  fatal,  while  of  Rolleston's  477  cases,  85  were  fatal.  Death 
can  be  ascribed  to  the  paralysis  in  only  a  small  proportion  of  cases. 
It  results  usually  from  cardiac  fa-ilure  which  is  due  to  myocarditis 
and  not  to  true  neuritis.  Cardiac  failure  was  the  cause  of  death 
in  80  of  Eolleston's  85  fatal  cases.  The  prognosis  of  diphtheritic 
paralysis  is  grave  because  it  indicates  that  a  serious  form  of  diplitheria 
has  been  present  and  usually  that  antitoxin  has  been  given  late.  The 
pharyngeal  and  diaphragmatic  paralyses  may  of  themselves  be  fatal, 
the  former  by  causing  aspiration  pneumonia. 

Treatment. — Cases  of  paralysis  of  the  trunk  or  extremities  are  to  be 
managed  like  others  of  multiple  neuritis.  In  severe  forms  of  throat 
paralysis  feeding  by  a  stomach  tube  should  be  employed,  on  account  of 
the  danger  of  the  entrance  of  food  into  the  air  passages.  It  must  in 
most  cases  be  continued  for  several  days.  The  tube  may  be  passed 
either  through  the  mouth  or  the  nose. 

The  great  mortality  attending  the  myocarditis  occurring  with  diph- 
theritic paralysis  shows  how  unsuccessful  is  treatment  in  most  of  the 
cases;  still,  no  doubt  there  are  instances  where  life  may  be  saved  by 
judicious  treatment.  In  cases  of  threatened  cardiac  failure  the  drug 
most  to  be  depended  upon  is  morphin,  hypodermically ;  this  should  be 
used  every  two  or  three  hours  in  sufficient  doses  to  keep  the  patient 
under  its  influence  while  threatening  symptoms  are  present.  I'he 
patient  shoukl  be  kept  absolutely  quiet,  not  even  being  allowed  to  turn 
in  bed.  In  respiratory  paralysis  the  general  reliance  is  upon  atropin  or 
strychnin  used  hypodermically  in  full  doses,  and  faradization  of  the  respi- 
ratory muscles,  particularly  the  diaphragm. 


836 


DISEASES  OF  THE  NERVOUS  SYSTEM 


FACIAL  PARALYSIS 


Peripheral  paralysis  of  the  face  occurring  as  a  result  of  injury  in- 
flicted during  delivery  has  already  been  described.  There  remain  to  be 
considered  here  cases  which  arise  from  causes  that  operate  at  a  later 
period.  The  facial  nerve  may  be  affected  in  any  one  of  three  situations — 
after  its  exit  from  the  cranium,  in  the  bony  canal,  and  within  the 
cranium. 

In  the  first  situation,  the  principal  cause  of  neuritis  is  exposure  to 
cold,  the  "rheumatic"  cases;  but  it  occasionally  occurs  as  a  complica- 
tion of  mumps  and  disease  of  the 
lymph  glands  of  this  region.  The 
nerve  is  affected  just  after  it  has 
escaped  from  the  stylomastoid  fora- 
men, and  all  the  branches  given  off 
beyond  its  exit  are  involved.  There 
is  paralysis  of  the  muscles  of  the 
forehead,  those  about  the  eye,  cheek, 
nose,  and  mouth.  The  affected  side 
of  the  face  is  smooth,  there  is  inabil- 
ity to  wrinkle  the  forehead,  contract 
the  eyebrows,  close  the  eye  complete- 
ly, raise  the  nostril,  whistle,  or  blow. 
The  mouth  is  drawn  to  the  healthy 
side  (Fig.  130).  If  the  paralysis  is 
complete,  there  may  be  diflficulty  in 
drinking  or  in  articulation.  In  par- 
tial paralysis  the  symptoms  may  not 
be  noticeable  while  the  face  is  at 
rest.  There  are  no  sensory  symptoms.  The  electrical  reactions  resemble 
those  of  other  forms  of  neuritis;  there  is  diminution  in  the  response  to 
the  faradic  current,  which  is  more  or  less  marked  according  to  the  sever- 
ity of  the  lesion,  and  there  may  be  the  reaction  of  degeneration. 

In  the  bony  canal,  the  facial  nerve  is  usually  involved  as  a  result 
of  disease  of  the  ear.  In  children  this  is  much  more  frequent  than 
from  the  other  causes  just  mentioned.  While  it  occasionally  occurs 
with  acute  otitis,  it  generally  accompanies  the  chronic  form  witli  caries 
of  the  petrous  bone,  which  in  our  experience  is  very  often  tuberculous. 
In  addition  to  the  paralysis  there  is  present  or  there  is  a  history  of  a 
discharge  from  the  ear,  and  generally  there  is  some  deafness  upon  the 
side  affected.  The  facial  symptoms  are  usually  the  same  as  in  the  cases 
first  described.    However,  when  the  nerxe  is  affected  between  the  stape- 


FiG.  130. — Facial  Paralysis  of  Right 
Side  from  Middle-ear  Disease  in 
a  Child  Two  and  a  Half  Years 
Old. 


FACIAL  PARALYSIS  837 

dius  and  the  geniculate  ganglion,  there  is  a  disturbance  of  the  sense 
of  taste,  and  of  the  secretion  of  saliva.  Facial  paralysis  may  also  occur 
as  a  result  of  injury  to  the  nerve  during  the  mastoid  operation. 

At  the  base  of  the  brain  the  trunk  of  the  nerve  may  be  involved  in 
cerebral  tumor,  basilar  meningitis,  and  in  fracture  of  the  skull.  In 
any  of  these  conditions  the  auditory  nerve  also  is  likely  to  be  affected. 
A  not  infrequent  cause  of  central  paralysis  is  poliomyelitis.  Facial 
paralysis  occurs  in  the  cerebral  form  with  hemiplegia,  or  more  com- 
monly it  is  associated  with  paralysis  from  a  spinal  lesion.  Occasionally 
the  facial  nerve  alone  may  be  involved.  The  whole  nerve  may  be  affected 
or  only  one  of  its  branches. 

Prognosis. — The  result  is  greatly  modified  by  the  causes  in  the  differ- 
ent cases.  In  those  which  are  due  to  cold,  spontaneous  recovery  usu- 
ally occurs  in  the  course  of  a  few  weeks  or  months.  In  those  depend- 
ing upon  disease  of  the  ear,  the  outlook  is  not  so  favorable,  and  though 
there  may  be  improvement,  it  is  not  rare  for  some  paralysis  to  be 
permanent.  In  the  third  group  of  cases,  facial  paralysis  is  only  one  of 
the  symptoms,  and  the  result  depends  entirely  upon  the  nature  of  the 
cause.  In  poliomyelitis  the  prognosis  is  good  though  in  some  cases  a 
certain  degree  of  paralysis  may  remain. 

Diagnosis. — Facial  paralysis  is  easily  recognized.  It  is  important  to 
separate  the  peripheral  paralysis  from  that  due  to  a  lesion  above  the 
pons,  as  in  cases  of  ordinary  hemiplegia.  In  the  latter  group  only  the 
lower  half  of  the  face  is  affected,  the  muscles  of  the  forehead  and  those 
about  the  eye  escaping,  and  the  electrical  reactions  are  unchanged. 

Treatment. — This  is  essentially  the  same  as  in  other  cases  of  neuritis. 
In  cases  due  to  ear  disease  the  primary  lesion  should  receive  appropriate 
treatment. 


SECTION  VIII 

DISEASES  OF  BLOOD,  LYMPH  NODES,   DUCTLESS   GLANDS, 
BONES,  AND  JOINTS 

CHAPTEE  I  • 

DISEASES  OF  THE  BLodo 

There  are  several  particulars  in  which  the  -blood  of  infancy  and 
early  childhood  differs  from  that  of  older  persons. 

Specific  Gravity. — This  has  no  constant  relation  to  the  number  of 
white  or  red  corpuscles,  but  varies  with  the  amount  of  hemoglobin.  The 
highest  specific  gravity  is  seen  in  the  blood  of  the  newly  born.  During 
the  first  two  weeks  of  life  it  sinks  rapidly  to  its  lowest  point,  where  it 
remains  until  about  the  end  of  the  second  year;  after  this  time  it  rises 
gradually  until  about  puberty.  The  average  specific  gravity  during 
childhood  is  1.050  to  1.055. 

Hemog^lobin. — The  percentage  of  hemoglobin  is  highest  in  the  blooi 
of  the  newly  born,  and  falls  rapidly  during  the  first  few  days  after  birth. 
Throughout  childhood  it  is  considerably  lower  than  in  adult  life.  The 
hemoglobin  is  lowest  between  the  third  month  and  the  second  year; 
after  the  second  year  it  gradually  increases  up  to  puberty.  The  usual 
range  in  young  children,  as  measured  by  the  adult  standard,  is  between 
sixty-five  and  eighty-five  per  cent,  seventy-five  per  cent  being  a  low  limit 
in  healthy  children. 

Red  Corpuscles. — The  number  of  red  corpuscles  is  highest  in  the 
newly  born.  At  this  time  it  is  from  4,350,000  to  6,500,000  in  each  cubic 
millimeter.  In  infancy  it  is  from  -4,000,000  to  5,500,000 ;  in  later  child- 
hood, from  4,000,000  to  4,500,000  (Hayem).  In  size  a  much  greater 
variation  is  seen  in  the  red  cells  of  the  newly  born  than  in  those  of  older 
children  and  adults.  In  the  blood  of  the  fetus  there  are  present  nucle- 
ated red  corpuscles  or  normoblasts  (Plate  XII,  A).  These  diminish 
in  number  toward  the  end  of  pregnancy.  They  are  always  found  in 
the  blood  of  premature  infants,  but  in  infants  born  at  term  they  are 
seen  only  in  small  numbers  and  disappear  after  a  few  days.  In  later 
infancy  their  presence  is  always  pathological. 

Normal  White  Cells. — The  following  varieties  are  found  in  health: 

830 


840  DISEASES  OF  THE  BLOOD 

1.  Lympliocijtes. — These  are  small  cells  about  the  size  of  a  red  blood 
cell.  The  protoplasm  is  small  in  amoimt,  forming  merely  a  narrow  rim 
about  the  nucleus ;  it  stains  with  basic  dyes  rather  more  deeply  than  does 
the  nucleus.  The  nucleus  is  relatively  large,  is  centrally  situated,  and 
shows  at  times  one  or  two  nucleoli.  The  protoplasm  may  have  a  reticu- 
lar structure.  These  cells  form  in  adults  from  twenty-two  to  twenty- 
five  per  cent  of  the  white  corpuscles,  but  in  young  children  they  are  often 
as  high  as  fifty  or  sixty  per  cent  (Plate  XII,  B,  10). 

3.  Large  Mononuclear  Leucocytes  and  Transitional  Forms. — These 
cells  are  two  or  three  times  the  size  of  ordinary  red  cells  (Plate  XII,  D, 
10).  The  oval  nucleus  is  not  so  centrally  situated  as  in  the  lymphocytes, 
and  stains  feebly  but  rather  more  deeply  than  the  protoplasm,  which  is 
poorly  stained  by  basic  dyes.  The  protoplasm  is  homogeneous  and  rela- 
tively large  in  amount. 

The  transitional  forms  occasionally  contain  a  few  feebly  staining  neu- 
trophilic granules ;  their  nuclei  are  bent  or  curved  and  stain  more  deeply. 

0.  Polymorphonuclear  Neutrophiles. — These  are  smaller  than  the 
large  lymphocytes  (Plate  XII,  B  and  C,  8).  The  nucleus  consists  of 
three  to  four  parts,  usually  connected  by  narrower  portions,  and  stains 
darkly.  The  protoplasm  stains  with  acid  dyes  and  shows  a  great  num- 
ber of  granules  which  stain  only  with  neutral  dyes.  In  adults  these 
cells  form  about  seventy  per  cent  of  the  white  cells;  but  in  children 
they  are  less  numerous,  the  increase  in  the  lymphocytes  being  at  the 
expense  of  the  neutrophiles. 

4.  EosinopJiiles. — These  are  about  the  same  size  as  the  neutrophiles 
(Plate  XII,  C,  9) ;  they  have  deeply  staining  nuclei,  usually  divided 
into  two  parts.  The  protoplasm  has  many  large  granules  that  stain 
deeply  with  acid  dyes,  and  often  a  narrow  outer  layer  stains  more 
deeply  than  the  rest.  They  form  from  one  to  two  per  cent  of  the  total 
number  of  white  cells. 

5.  Mast  Cells. — They  are  only  occasionally  found,  their  proportion 
being  about  0.5  per  cent  of  the  white  cells;  they  are  polymorphonuclear 
cells  whose  granules  stain  only  with  basic  dyes,  not  at  all  with  tri-acid; 
often  they  are  metachromatic  (Plate  XII,  C,  12). 

Patholog^ical  White  Cells. — Of  these  there  are  three  principal  forms: 

1.  Myelocytes,  neutrophilic. — They  have  neutrophilic  granules  and  a 
single  rounded  nucleus  (Plate  XII,  C,  11).  Ehrlich's  myelocytes  differ 
from  those  of  Cornil  in  that  the  cells  as  a  whole  are  smaller,  the  nuclei  are 
more  centrally  situated  and  stain  more  deeply. 

2.  Myelocytes,  eosinophilic. — These  resemble  the  polyuuclear  eosino- 
philes,  except  for  the  round,  undivided  nucleus. 

3.  Myelocytes,  basophilic. — These  are  similar  to  the  mast  cells,  dif- 
fering only  in  the  form  of  the  nucleus. 


PLATE  XII 


C. 


Drawn  by  Dr.  F.  C.  Wood 


A.     Blood  of  an  Eight-Months'  Fetus. 
C.     von  Jaksch's  Anemia. 

1.  Red  cells,  normal. 

2.  Red  cells,  normoblasts. 

3.  Red  cells,  megaloblasts. 

4.  Red  cells,  showing  mitosis. 

5.  Red  cells,  poikilocytes. 

6.  Red  cells,  granular  degeneration. 


D. 

Simple  Anemia. 

Acute  Lymphatic  Leukemia. 


7.  Red  cells,  polychromatophilia. 

8.  White  cells,  polynuclear  neutrophiles. 

9.  White  cells,  eosinophiles. 

10.  White  cells,  lymphocytes. 

11.  White  cells,  myelocytes. 

12.  White  cells,  mast  cells. 


SECONDARY  ANEMIA  841 

These  myelocytes  all  represent  immature  forms,  originating  in  the 
bone  marrow.  Pathologically,  these  may  be  immature  forms  of  the 
leucocytes,  or  these  may  undergo  acute  or  chronic  degeneration,  with 
swelling  and  fragmentation,  nuclear  changes,  hydropic  degeneration, 
etc. 

The  number  of  leucocytes  in  the  blood  of  the  newly  born,  according 
to  Eieder,  is  at  birth  from  14,200  to  37,400  per  cubic  millimeter;  from 
the  second  to  the  fourth  day,  from  8,700  to  13,400 ;  after  the  fourth  day, 
from  13,400  to  14,800.  The  normal  variations  in  infancy  are  from  9,000 
to  18,000,  and  in  later  childhood  from  8,000  to  13,000. 


SECONDARY  ANEMIA 

This  consists  in  an  impoverishment  of  the  blood,  especially  the  red 
cells,  and  a  corresponding  diminution  in  the  specific  gravity,  and  in 
a  greater  proportional  decrease  in  the  amount  of  hemoglobin.  It 
occurs  apart  from  disease  of  the  blood-making  organs.  Infancy  and 
childhood  are  themselves  strong  predisposing  causes  of  anemia  on 
account  of  the  great  demands  made  upon  the  blood  in  the  rapid  growth 
of  the  body. 

Etiology. — The  causes  of  anemia  embrace  a  wide  range  of  patho- 
logical conditions.  A  child  born  of  a  delicate  mother  or  of  one  suffering 
from  tuberculosis  or  syphilis  may  show  a  marked  anemia  at  birth. 
It  sometimes  occurs  in  the  first  two  or  three  months  of  life  in  a  severe 
form  without  any  discoverable  cause.  It  may  follow  any  severe  hemor- 
rhage or  occur  in  any  of  the  blood  dyscrasiae — purpura,  scurvy,  etc. 
It  accompanies  any  prolonged  infection  with  or  without  suppuration, 
also  nephritis,  many  forms  of  gastro-intestinal  disease  and  malignant 
growths.  It  is  especially  marked  in  general  sarcomatosis.  Certain  of 
the  specific  infections,  notably  diphtheria,  malaria,  tuberculosis  and 
rheumatism,  produce  a  marked  degree  of  anemia  as  one  of  their  effects. 
It  is  found  with  great  severity  with  some  of  the  intestinal  parasites, 
particularly  varieties  of  the  tape-worm  and  hook-worm.  Anemia  is  at 
times  due  to  mineral  poisons — lead,  mercury  or  potassium  chlorate. 

Much  more  frequent  in  young  children  than  any  of  the  above  are 
the  anemias  due  to  improper  feeding,  rickets,  and  unhygienic  surround- 
ings. How  important  these  causes  are  and  how  severe  a  grade  of 
anemia  may  be  produced  by  them,  is  not  usually  appreciated.  The 
physician  is  often  led  to  suspect  some  serious  organic  or  constitutional 
disease  when  none  exists,  and  to  overlook  such  common  conditions  and 
obvious  causes  as  those  mentioned.  Anemia  is  seen  when  lactation  is 
unduly  prolonged.    It  is  a  frequent  result  of  an  exclusive  diet  of  milk  or 


842  DISEASES  OF  THE  BLOOD 

infant  foods  into  the  second  or  third  year.  Older  children  who  drink 
tea  and  coffee  and  eat  largely  of  indigestible  food,  pastry,  cake,  etc.,  are 
frequently  anemic.  Lack  of  fresh  air,  confinement  to  overheated  rooms 
and  the  crowding  of  young  children  in  hospitals  and  institutions,  are 
common  and  important  causes  of  anemia. 

Symptoms. — Anemic  children  usually  exhibit  many  symptoms  of 
malnutrition.  Their  tissues  are  flabby;  they  are  generally  below  average 
weight  and  suffer  from  digestive  disturbances  and  chronic  constipation. 
The  associated  nervous  symptoms  are  many;  headaches,  indefinite  pains, 
insomnia  or  disturbed  sleep,  general  irritability  and  a  high  degree  of 
nervousness.  There  is  easy  fatigue,  shortness  of  breath  on  exertion, 
and  sometimes  fainting  attacks.  The  peripheral  circulation  is  poor; 
the  hands  and  feet  are  often  cold.  The  pulse  may  be  slightly  irregular. 
Murmurs  may  be  heard  over  the  base  of  the  heart  or  the  large  vessels, 
and  so  loud  even  in  infancy  as  to  be  mistaken  for  organic  disease. 
A  venous  hum  may  be  heard  in  the  neck.  Epistaxis  is  not  uncommon. 
There  may  be  enuresis.  Edema  is  rare  in  older  children,  but  in 
severe  anemias  of  infancy  it  is  sometimes  marked.  In  a  certain  number 
of  cases,  even  of  moderate  severity,  the  spleen  is  much  enlarged.  Pallor 
of  the  skin  and  mucous  membranes  is  present  in  most  cases,  but  is  not 
an  accurate  guide  as  to  the  degree  of  anemia.  This  can  only  be  deter- 
mined by  an  examination  of  the  blood. 

The  Blood. — There  is  a  reduction  of  the  number  of  red  cells  and  to 
a  still  greater  degree  in  the  hemoglobin.  In  a  case  of  moderate  severity 
the  red  cells  are  from  3,500,000  to  4,000,000,  and  the  hemoglobin  from 
fifty  to  sixty  per  cent.  In  severe  cases  the  red  cells  may  fall  to  2,000,000 
or  2,500,000  or  even  lower,  and  the  hemoglobin  to  twenty  or  thirty 
per  cent.  These  figures  are  not  uncommon.  Occasionally  there  is  seen 
a  reduction  of  the  hemoglobin  to  as  low  as  fifteen  per  cent  and  of  the 
red  cells  to  1,500,000.  The  red  cells  are  pale.  There  is  usually  poikilo- 
cytosis  and  anisocytosis ;  and,  especially  in  infancy,  a  few  normoblasts 
and  megalocytes  may  be  found  (Plate  XII,  B). 

There  is  generally  a  slight  leucocytosis.  The  differential  count  of 
the  white  cells  shows  an  increase  in  the  lymphocytes,  chiefly  the  small 
variety;  the  polymorphonuclear  cells  are  relatively  reduced  in  number. 

Prognosis. — The  course  and  termination  of  anemia  depend  upon  its 
cause.  If  this  is  one  that  can  be  removed,  as  in  cases  depending  upon 
improper  feeding  and  surroundings,  very  rapid  improvement  often  takes 
place  and  prompt  recovery.  In  the  most  severe  cases  death  may  occur, 
rarely  from  the  anemia,  usually  from  some  complicating  disease. 

In  making  a  prognosis  in  a  given  case  the  general  symptoms  and  the 
cause  of  the  anemia  are  much  more  important  than  the  examination  of 
the  blood.     If  the   digestive  organs  are  in  good  condition  and  good 


CHLOKOSIS 


843 


surroundings  can  be  secured,  even  though  the  hemoglobin  and  red  cells 
are  very  greatly  reduced,  the  prognosis  is  good.  But  in  unfavorable 
surroundings  and  with  a  greatly  disordered  digestion,  the  outlook  is 
more  serious. 

Typical  blood  examinations  of  a  moderate  and  of  a  severe  case  of 
secondary  anemia  in  a  young  child  are  as  follows : 


Severe  Anemia 

Hemoglobin 20  per  cent. 

Red  blood  cells 2,500,000 

White  cells 12,000 

Polymorphonuclear 30  per  cent. 

Small  mononuclear 45  per  cent. 

Large  mononuclear 25  per  cent. 

Other  forms 5  per  cent. 


Moderate  Anemia 

Hemoglobin 50  per  cent. 

Red  blood  cells 4,000,000 

White  cells 10,000 

Polymorphonuclear 40  per  cent. 

Small  mononuclear 25  per  cent- 

Large  mononuclear 20  per  cent. 

Other  forms 5  per  cent. 


The  treatment  of  all  the  forms  of  anemia  will  be  considered  together 
at  the  close  of  the  chapter. 

CHLOROSIS 

Chlorosis  usually  occurs  in  young  girls  about  the  time  of  puberty. 
It  is  characterized  by  a  peculiar  greenish-yellow  tint  of  the  skin, 
and  is  not  accompanied  by  emaciation.  The  changes  in  the  blood 
consist  in  a  very  great  reduction  in  the  hemoglobin  without  a  corre- 
sponding diminution  in  the  red  corpuscles. 

Etiology. — The  exact  cause  of  chlorosis  is  not  yet  understood.  The 
disease  rarely  occurs  in  males;  it  is  usually  seen  in  girls  between  the 
fourteenth  and  seventeenth  years,  and  more  often  in  blondes  than  in 
brunettes.  Heredity  appears  to  be  a  factor  in  some  cases.  Other  causes 
are  occupations  deleterious  to  health,  such  as  employment  in  factories 
or  confinement  in  ill-ventilated  rooms;  insufficient  food  or  clothing; 
psychical  disturbances,  like  grief,  care,  or  fright;  excessive  mental  or 
physical  strain,  and  disorders  of  menstruation — although  the  latter  are 
perhaps  more  frequently  a  result  than  a  cause  of  the  disease. 

Lesions. — Chlorosis  is  not  a  fatal  disease.  In  the  few  cases  with 
chlorosis  that  have  died  of  other  diseases  the  lesions  noted  have  been 
dilatation  of  the  right  heart  with  hypertrophy  of  the  left  ventricle, 
a  small  aorta,  small  uterus  and  ovaries,  and  occasionally  round  ulcer  of 
the  stomach.  Under  the  microscope  there  may  be  found  a  very  marked 
degree  of  fatty  degeneration  of  the  heart  muscle,  and  sometimes  of  the 
inner  coat  of  the  blood-vessels. 

Symptoms. — The  general  symptoms  of  chlorosis  are  very  much  like 
those  of  simple  anemia.  There  are  observed  shortness  of  breath  upon 
exercise,  palpitation,  syncope,  attacks  of  vertigo,  disturbances  of  diges- 


844  DISEASES  OF  THE  BLOOD 

tion,  amenorrhea,  and  almost  invariably  constipation.  The  appetite  is 
capricious,  it  being  a  peculiarity  of  these  patients  to  crave  all  sorts  of 
indigestible  articles.  Instead  of  the  usual  pallor  of  anemia,  the  skin 
has  a  yellowish-green  tint,  from  which  the  term  "green-sickness"  has 
arisen.  Occasionally  patches  of  pigmentation  are  seen.  Anemic  cardiac 
murmurs  may  be  heard  in  various  situations,  most  frequently  a  systolic 
murmur  at  the  base  of  the  heart,  and  usually  loudest  over  the  pulmonic 
area.  There  may  be  a  venous  hum  in  the  neck.  In  some  marked  cases 
there  is  evidence  of  slight  cardiac  dilatation,  especially  of  the  right 
heart,  and  there  may  be  hypertrophy  of  the  left  ventricle.  The  pulse  is 
weak  and  soft,  edema  of  the  feet  is  frequent,  and  sometimxcs  there  is 
slight  albuminuria.  In  some  cases  there  is  fever.  Nervous  disturbances, 
such  as  vague,  indefinite  pains,  attacks  of  migraine,  supra-orbital  neu- 
ralgia, various  hysterical  manifestations,  and  chorea,  are  common.  Ulcer 
of  the  stomach  is  sometimes  seen  as  a  complication. 

The  Blood. — The  specific  gravity  is  reduced  in  proportion  to  the  loss 
of  hemoglobin.  The  characteristic  feature  of  chlorosis  is  a  loss  of  hemo- 
globin which  is  out  of  proportion  to  the  reduction  in  the  red  cells.  The 
hemoglobin  in  an  ordinary  case  is  frequently  as  low  as  thirty-five  or 
forty  per  cent,  while  the  red  cells  may  be  3,500,000  to  4,000,000,  or  even 
higher. 

Morphologically  the  cells  are  pale  with  a  wide  central  clear  area. 
Poikilocytosis  may  be  present,  but  is  not  marked;  rarely  normoblasts 
may  be  found.  The  presence  of  megalocytes  is  disputed.  The  leuco- 
cytes are  usually  unchanged  in  number  and  proportion,  but  the  lympho- 
cytes may  be  relatively  increased. 

Prognosis. — The  course  of  the  disease  is  essentially  a  chronic  one, 
often  lasting  for  a  year.  Eelapses  are  quite  frequent.  These  cases 
regularly  recover  when  proper  treatment  can  be  carried  out. 

Diagnosis. — A  probable  diagnosis  is  in  most  cases  easily  made  from 
the  etiology,  the  functional  derangement  of  the  heart,  the  color  of  the 
skin,  and  a  positive  diagnosis  always  by  an  examination  of  the  blood. 

PSEUDO-LEUKEMIC  ANEMIA  OF  INFANCY 
(Von  Jaksch  Disease) 

This  form  of  anemia  was  first  described  by  von  Jaksch  in  1889, 
and  is  by  him  believed  to  be  peculiar  to  infants  and  young  children. 
It  is  characterized  by  marked  leucocytosis,  marked  reduction  in  the 
number  of  red  cells  and  in  the  hemoglobin,  a  great  enlargement  of  the 
spleen,  and  sometimes  a  moderate  enlargement  of  the  liver  and  the 
lymphatic  glands.  This  disease  is  not  to  be  confounded  with  pseudo- 
leukemia or  Hodgkin's  disease. 


PSEUDO-LEUKEMIC  ANEMIA  845 

The  existence  of  pseudo-leukemic  anemia  as  a  distinct  disease  is 
denied  by  most  authorities  on  diseases  of  the  blood,  who  regard  it  as 
a  symptom-complex.  They  hold  that  the  reported  cases  can  be  classed 
either  as  severe  secondary  anemia,  pernicious  anemia,  or  leukemia. 

Etiology. — Of  the  cases  thus  far  recorded  the  majority  have  been 
between  the  ages  of  seven  and  twelve  months.  Of  twenty  cases  collected 
by  Monti  and  Berggriin,  sixteen  showed  evidences  of  rickets  and  one 
was  syphilitic.  The  exact  cause  of  the  disease  is  still  unknown,  and 
its  essential  nature  is  a  matter  of  some  doubt. 

Lesions. — The  most  characteristic  change  is  found  in  the  spleen, 
which  is  very  much  enlarged,  often  forming  an  abdominal  tumor  of 
considerable  size.  It  is  firm,  hard,  and  there  may  be  evidences  of  peri- 
splenitis. The  microscope  shows  a  simple  hyperplasia..  Enlargement  of 
the  liver  is  less  ■  constant,  it  being  normal  in  more  than  half  the  cases. 
There  is  no  relation  between  the  size  of  the  spleen  and  that  of  the  liver. 
The  hepatic  cells  are  unchanged.  Enlargement  of  the  lymph  glands  has 
been  noted  in  about  half  the  reported  cases,  the  swelling  affecting  the 
cervical,  axillary,  or  inguinal  glands;  but  it  is  rarely  great.  It  is  due 
to  simple  hyperplasia.  Inconstant  changes  in  the  bone-marrow  have 
been  described. 

Symptoms. — The  Blood. — The  main  features  noted  are  the  follow- 
ing (Plate  XII,  C)  : 

The  specific  gravity  is  lowered,  the  usual  range  being  between  1.035 
and  1.044.  The  reduction  of  the  hemoglobin  is  very  great;  in  many 
of  the  cases  it  has  been  as  low  as  twenty-five  per  cent,  and  in  a  few  below 
twenty  per  cent. 

The  red  cells  are  always  diminished;  they  are  frequently  below 
2,000,000.  There  is  also  great  inequality  in  their  size  and  shape.  Nu- 
cleated red  cells  are  found  in  considerable  numbers;  as  a  rule,  these  are 
chiefly  normoblasts,  but  when  the  anemia  becomes  more  severe,  it  is 
usually  the  megaloblasts  that  predominate.  The  leucocytes  vary  from 
20,000  to  50,000.  They  may  show  an  increase  in  the  mononuclear  or  in 
the  polymorphonuclear  forms.  The  eosinophiles  are  usually  increased, 
but  not  to  the  extent  to  suggest  leukemia.  All  varieties  of  cell  degenera- 
tion are  found. 

The  general  symptoms  of  the  disease  develop  slowly  and  with  the 
usual  signs  of  anemia.  In  some  cases  the  infants  continue  to  be  plump 
and  well  nourished.  Pallor  is  usually  very  marked.  Enlargement  of 
the  spleen  is  so  great  that  it  can  hardly  be  overlooked  if  the  abdomen  is 
examined.  The  glandular  enlargements  are  not  marked,  and  in  many 
cases  are  wanting  altogether. 

The  course  of  the  disease  is  essentially  chronic.  Cases  have  been  seen 
in  which  pseudo-leukemia   developed  from  an   ordinary  severe  simple 


846  DISEASES  OF  THE  BLOOD 

anemia  in  the  course  of  a  few  weeks.  The  symptoms  and  blood  changes 
generally  come  on  slowly  in  the  course  of  weeks  or  months,  and  some- 
times remain  nearly  stationary  for  as  long  a  period  as  several  months, 
and  then  slowly  improve.  In  other  cases  they  grow  gradually  worse.  In 
the  cases  going  on  to  recovery  there  is  noticed  improvement  in  the 
general  symptoms  coincident  with  a  diminution  in  the  size  of  the  spleen, 
a  reduction  in  the  number  of  leucocytes,  an  increase  in  the  red  cells,  the 
hemoglobin,  and  the  specific  gravity,  and  a  gradual  disappearance  of 
the  nucleated  red  cells. 

Prog^nosis. — In  Monti's  list  of  twenty  cases,  four  proved  fatal;  one 
recovered,  in  which  the  proportion  of  leucocytes  to  the  red  cells  had 
been  one  to  twelve.  The  prognosis  should  be  guarded,  for,  although 
improvement  may  take  place,  many  patients  die  from  intercurrent 
disease, 

PERNICIOUS  ANEMIA 

This  is  the  most  severe  form  of  anemia  known.  Its  cause  and 
essential  nature  are  as  yet  very  imperfectly  understood.  It  is  charac- 
terized by  quite  uniform  blood  changes  and  by  the  general  symptoms 
of  a  very  marked  anemia,  and  it  tends  to  go  on  from  bad  to  worse, 
terminating  fatally  in  the  great  proportion  of  cases. 

Etiology. — Pernicious  anemia  is  a  rare  disease  in  childhood,  and 
especially  rare  in  infancy.  Its  essential  cause  is  quite  unknown.  In  a 
few  instances  intestinal  parasites,  particularly  tapeworms,  have  produced 
in  children  an  anemia  indistinguishable  from  pernicious  anemia. 

Lesions. — There  is  found  a  very  high  grade  of  anemia  in  all  the 
internal  organs,  fatty  degeneration  of  the  heart  and  blood-vessels,  and 
sometimes  also  of  the  liver  and  kidneys,  with  numerous  capillary  hemor- 
rhages in  the  various  organs.  A  striking  post-mortem  change  consists 
in  the  deposit  of  iron  in  the  hepatic  cells.  This  is  found,  however, 
with  other  severe  forms  of  anemia.  Its  distribution  is  peculiar  and 
unlike  that  seen  in  most  other  diseases.  The  bone  marrow  is  also 
markedly  altered  in  that  the  red  cells  may  be  of  the  megaloblastic  in- 
stead of  the  normoblastic  type.  In  aplastic  anemia  there  may  be  a 
yellow  bone  marrow  instead  of  the  normal  red  bone  marrow  of  child- 
hood. 

Symptoms. — The  Blood. — The  specific  gravity  of  the  blood  in  per- 
nicious anemia  is  constantly  and  considerably  reduced,  and  its  coagula- 
bility is  feeble.  The  hemoglobin  is  always  reduced;  usually  it  is  as 
low  as  from  twenty  to  thirty  per  cent.  The  red  cells  are  always  much 
diminished  in  number  and  to  a  degree  greater  than  the  reduction  in 
the  hemoglobin.     Their  number  is  seldom  greater  than  2,000,000,  and 


PERNICIOUS  ANEMIA  847 

• 
frequently  less  than  1,000,000.     Megalocytes  are  present,  often  in  great 

numbers,  and  a  preponderance  of  them  is  regarded  essential  to  the 
diagnosis.  Microcytes  are  rare.  It  is  characteristic  of  pernicious  ane- 
mia that  owing  to  the  relatively  high  hemoglobin  content  the  red  cells 
have  a  high  color  index  and  stain  well,  usually  deeper  than  in  normal 
blood.  A  striking  feature  of  these  cases  is  the  presence  of  extreme 
poikilocytosis.  Nucleated  red  cells  are  also  present,  megaloblasts  in 
greater  numbers  than  normoblasts.  The  red  cells  do  not  readily  collect 
to  form  rouleaux.  The  blood  platelets  are  greatly  reduced  and  frequently 
almost  absent. 

The  total  number  of  leucocytes  is  markedly  diminished,  but  the  lym- 
phocytes may  be  relatively  increased.  An  occasional  myelocyte  may  l)e 
found. 

The  general  symptoms  are  those  of  a  most  intense  anemia.  There 
is  marked  pallor  of  the  skin  and  mucous  membranes,  with  great  weak- 
ness and  prostration.  Various  accidental  heart  murmurs  are  heard. 
There  may  be  dyspnea.  There  may  or  may  not  be  emaciation.  The  late 
symptoms  are  hemorrhages  from  the  nose  and  other  mucous  membranes, 
subcutaneous  ecchymoses  with  dropsy  of  the  feet  and  ankles,  and  some- 
times of  the  large  serous  cavities  of  the  body,  but  without  albuminuria. 
In  many  cases  fever  is  present.  This  may  be  so  high  as  to  lead  to  the 
suspicion  of  some  acute  infectious  process. 

The  course  of  the  disease  is,  as  a  rule,  more  rapid  than  in  adults, 
the  duration  being  in  most  cases  but  a  few  months;  it  is  marked  by 
periods  of  exacerbation  and  remission.  During  the  exacerbations  all  the 
symptoms  are  intensified,  and  as  a  rule  some  fever  is  present.  During 
the  remissions  marked  improvement  may  take  place  in  all  the  symptoms 
and  an  increase  in  the  hemoglobin  and  red  cells  occurs.  In  general,  the 
progress  of  the  disease  is  downward  and  sometimes  the  rate  is  very  rapid. 
The  only  exceptions  are  the  cases  in  which  the  disease  depends  upon 
some  intestinal  parasite,  when  improvement  and  even  recovery  may 
occur. 

Treatment  of  the  Different  Forms  of  Anemia. — In  secondary  anemia 
the  thing  of  the  first  importance  is  to  discover  and  treat  the  primary 
condition  upon  which  the  anemia  depends.  In  infancy,  special  atten- 
tion should  be  given  to  diet  and  hygiene.  A  mixed  diet  composed  of 
fruits,  beef  juice,  eggs  and  green  vegetables  should  be  substituted  for 
one  consisting  mainly  or  exclusively  of  milk.  Also  important  is  an 
abundant  supply  of  fresh  air.  The  whole  manner  of  life  of  these 
patients  must  be  carefully  studied  and  managed  according  to  the  direc- 
tions laid  down  in  the  chapter  upon  Malnutrition,  with  which  condition, 
especially  in  infancy,  a  very  large  number  of  these  cases  are  associated. 
The  general  treatment  referred  to  is  often  more  important  than  the 


848  DISEASES  OF  THE  BLOOD 

administration  of  the  preparations  of  iron,  which,  however,  should  never 
be  omitted. 

The  preparations  of  iron  especially  adapted  to  infants  are  the  albu- 
minate, bitter  wine,  sweet  wine,  saccharated  carbonate,  malate,  and 
citrate.  The  dose  should  be  regulated  according  to  the  age  of  the  child. 
Older  children  may  take  the  same  preparations  as  adults,  especially 
reduced  iron  and  Blaud's  pills.  Much  benefit  is  seen  from  combining 
arsenic  with  iron,  or  from  alternating  the  two.  In  addition  to  these 
remedies,  cod-liver  oil  should  be  given  if  the  condition  of  the  digestive 
organs  will  permit. 

In  chlorosis  more  decided  results  are  seen  from  the  use  of  iron  than 
in  any  other  form  of  anemia.  Blaud's  pills  are  here  the  favorite  form 
of  administration,  and  are  advantageously  combined  with  small  doses 
of  nux  vomica  and  aloin  to  overcome  the  tendency  to  constipation. 
Arsenic  is  useful  in  these  cases  also.  Great  benefit  in  chlorosis  results 
from  change  of  air  and  change  of  scene,  thus  removing  the  patient 
from  all  sources  of  nervous  excitement  or  disturbance.  The  general  con- 
dition, diet,  and  habits  of  life  should  also  receive  careful  attention, 
particularly  the  condition  of  the  bowels. 

It  is  important  that  the  administration  of  iron  should  be  continued 
for  some  time  after  the  disappearance  of  all  symptoms,  on  account  of 
the  tendency  to  relapse. 

In  the  pseudo-leukemic  anemia  of  infants,  arsenic  is  decidedly  the 
most  valuable  drug,  but  should  be  given  in  combination  with  iron. 
Fowler's  solution  is  the  best  preparation  for  infants;  the  dose  should 
rarely  be  more  than  one  drop,  which  should  be  repeated  four  or  five 
times  daily  after  feeding,  and  continued  for  a  long  time.  The  general 
treatment  of  these  patients  is  the  same  as  in  cases  of  simple  anemia. 
When  rickets  is  present  cod-liver  oil  and  phosphorus  should  be  added. 

In  pernicious  anemia,  arsenic  offers  a  much  better  prospect  of  im- 
provement than  does  iron.  Beginning  with  small  doses,  the  amount 
should  be  gradually  increased  up  to  the  point  of  tolerance,  very  much 
as  in  cases  of  chorea. 

In  every  case  of  anemia  the  most  careful  attention  should  be  given 
to  the  general  condition,  particularly  guarding  against  exposure  to  cold 
and  dampness.  The  feeble  circulation  of  these  patients  renders  them 
peculiarly  susceptible.  Caution  should  also  be  given  against  much  mus- 
cular exercise. 

In  cases  of  secondary  anemia  transfusion  is  a  remedy  of  the  greatest 
value.  In  acute  anemia  following  loss  of  blood  its  effects  are  little 
short  of  marvelous.  In  the  primary  anemias  and  in  pernicious  anemia  its 
effects  are  much  less  evident  and  in  the  great  majority  of  cases  only  tem- 
j)orary  improvement  is  seen. 


LEUKEMIA  849 


LEUKEMIA 


This  is  a  disease  in  which  the  essential  feature  is  a  great  increase 
in  the  number  of  leucocytes,  with  a  moderate  reduction  in  the  number  of 
red  corpuscles,  and  the  presence  in  the  blood  of  cell  forms  not  found 
in  health. 

Etiology. — Leukemia  is  a  rare  disease  in  childhood,  but  it  is  seen 
even  in  early  infancy.  Its  greater  frequency  in  males  holds  good  even 
in  childhood.  In  a  small  number  of  cases  heredity  has  been  noted. 
Leukemia  may  follow  syphilis,  rickets,  malaria,  or  even  simple  anemia, 
or  it  may  occur  apparently  as  a  primary  disease  in  children  previously 
healthy.     The  cause  is  unknown. 

Lesions. — The  essential  lesions  of  leukemia  are  found  in  the  spleen, 
the  lymphatic  glands,  and  the  bone-marrow.  In  some  cases  the  most 
important^  changes  are  in  the  lymphatic  glands,  giving  rise  to  the 
lymphatic  form  of  leukemia.  Any  of  the  external  glands  of  the  body 
may  be  aifected — the  cervical,  axillary,  and  the  inguinal,  or  the  mesen- 
teric, tracheobronchial,  the  tonsils,  and  even  the  lymph  nodules  of 
the  tongue,  pharynx,  and  intestines.  The  changes  in  the  glands  are 
generally  those  of  a  simple  hyperplasia.  The  liver  is  enlarged  in  most 
of  the  cases,  chiefly  from  an  infiltration  with  lymphoid  tissue,  which 
may  be  diffuse  or  may  occur  in  patches.  Less  frequently  similar  lym- 
phoid masses  are  seen  in  other  organs.  Lesions  may  be  present  in 
almost  any  of  the  viscera  due  to  secondary  infections.  In  lymphatic 
leukemia  the  changes  in  the  spleen  and  marrow  may  be  slight.  Changes 
of  a  severe  form  in  the  spleen  and  marrow  are,  however,  usually  seen 
together,  giving  rise  to  what  is  known  as  the  splenomyelogenous  form 
of  the  disease.  The  spleen  is  usually  enormously  enlarged,  sometimes 
filling  half  the  abdominal  cavity.  In  the  early  stage  it  is  soft,  vascular, 
and  of  a  dark-red  color;  in  the  late  stages'  it  is  firm  and  hard.  There 
may  be  perisplenitis.  On  section,  light-gray  patches  of  lymphoid  tissue 
may  be  seen  scattered  throughout  the  organ,  and  in  some  instances 
there  may  be  wedge-shaped  infarctions.  The  microscope  shows  thicken- 
ing of  the  trabeculae  and  deposits  of  lymphoid  tissue,  especially  about 
the  arteries. 

Symptoms. — In  acute  lymphatic  leukemia,  which  in  our  experience, 
is  the  most  common  form  of  leukemia  in  early  life,  the  symptoms  are 
so  severe  and  the  progress  so  rapid  as  to  suggest  an  acute  infection.  It 
is  often  preceded  by  some  other  infection  such  as  pneumonia,  multiple 
abscesses  or  inflammation  of  the  tonsils.  The  onset  may  be  abrupt  with 
severe  symptoms — fever,  general  and  articular  pains  and  great  prostra- 
tion, but  not  much  that  is  definite ;  or  it  may  be  more  gradual  Avith  only 


850  DISEASES  OF  THE  BLOOD 

local  symptoms  for  several  weeks.  The  swelling  of  the  external  lym- 
phatic glands  may  be  the  first  thing  noticed;  this  is  most  marked 
usually  in  the  cervical  region,  but  the  axillary,  inguinal,  femoral  and 
epitrochlears  may  also  be  involved.  The  individual  glands  may  be  no 
larger  than  an  almond,  but  often  reach  the  size  of  a  walnut.  There  is  no 
redness  and  seldom  tenderness.  The  glandular  swelling  is  usually 
progressive;  the  spleen  and  liver  soon  become  large  and  hemorrhages 
often  occur.  These  may  be  subcutaneous  in  the  form  of  small  petechiae 
or  larger  purpuric  areas,  or  there  may  be  bleeding  from  the  nose,  the 
bowels,  the  bladder,  or  blood  may  be  vomited.  The  mouth  often  is  the 
seat  of  disease  resembling  scurvy.  In  fact,  these  symptoms  may  domi- 
nate the  clinical  picture.  The  gums  are  much  swollen  and  bleed  easily; 
there  may  be  sloughing  in  the  gums,  tonsils  or  buccal  mucous  mem- 
brane. The  submaxillary  glands  are  swollen  and  there  is  much  local 
pain  and  discomfort.  The  general  symptoms  at  this  stage  are  usually 
severe.  The  temperature  is  nearly  always  somewhat  elevated  and  it 
may' be  as  high  as  103°  or  104°  F. ;  there  is  marked  dyspnea  and  great 
muscular  weakness ;  the  pulse  is  rapid  and  feeble  and  the  loss  of  weight 
usually  marked. 

■  The  blood  picture  varies  greatly  in  the  different  cases  and  in  the 
same  case  at  different  stages  of  the  disease.  The  constant  feature  is 
the  great  relative  increase  in  the  lymphocytes,  which  usually  form  from 
90  to  98  per  cent  of  the  white  cells,  and  a  corresponding  reduction  in  the 
polymorphonuclear  cells.  The  lymphocytes  are  chiefly  of  the  large 
variety  and  many  of  them  are  degenerated  so  that  they  stain  with 
difficulty.  The  total  leucocytes  in  the  early  stage  may  not  be  increased 
and  there  may  even  be  a  leucopenia — 3,000  or  4,000.  Sometimes  the  total 
leucocytes  fall  greatly  toward  the  end  of  the  disease ;  but  generally  they 
are  increased,  numbering  from  50,000  to  150,000;  the  red  cells  are  uni- 
formly reduced  in  number  to  from  1,000,000  to  3,000.000  and  the  hemo- 
globin to  twenty  or  thirty  per  cent  or  even  lower.  The  coagulability  of 
the  blood  is  diminished.  The  course  of  this  form  of  the  disease  is  usually 
rapid.  It  may  last  only  three  or  four  weeks,  and  rarely  more  than  two  or 
three  months.  Death  is  due  to  hemorrhages,  to  exhaustion,  or  to  some 
acute  intercurrent  infection. 

Other  cases  run  a  less  acute  course  and  may  be  marked  by  irregular 
and  prolonged  attacks  of  fever  which  in  some  cases  may  be  high  and  last 
for  months,  but  with  few  other  symptoms  except  enlargement  of  the 
lymphatic  glands.  The  blood  picture  varies  much  from  time  to  time, 
the  constant  feature  being  the  high  percentage  of  lymphocytes  and  a 
moderate  degree  of  anemia.  The  total  leukocyte  count  may  be  low  for 
a  long  period  but  a  marked  relative  increase  in  the  lymphocytes  is  a 
constant  feature.     The  chronic  form  of  lymphatic  leukemia  does  not 


LEUKEMIA  851 

differ  greatly  from  that  in  the  adult  but  in  our  experience  is  very  uncom- 
mon in  children. 

In  the  splenomyelogenous  form  of  the  disease  the  progress  is  usually 
less  acute  and  resembles  that  seen  in  the  adult,  but  its  course  is  always 
more  rapid  in  early  life.  In  the  case  reported  by  Knox,  death  occurred 
two  weeks  after  the  first  symptoms.  In  most  of  the  cases  the  early 
symptoms  are  latent.  A  sudden  and  alarming  hemorrhage  is  some- 
times the  first  thing  to  call  attention  to  the  serious  condition.  In 
other  cases  there  are  only  the  symptoms  of  general  weakness  and  anemia. 
Sometimes  the  splenic  tumor  is  the  first  thing  noticed.  In  the  early 
part  of  the  disease  the  usual  symptoms  of  anemia  are  present — digestive 
disturbances,  shortness  of  breath,  weak  and  rapid  pulse.  Hemorrhages 
may  occur  as  an  early  or  late  symptom;  they  are  most  frequently  from 
the  nose,  but  severe  hemorrhages  may  occur  from  the  stomach,  the 
mouth,  the  intestines,  or  there  may  be  ecchymoses  upon  the  skin.  The 
enlargement  of  the  spleen  may  be  sufficient  to  form  an  abdominal 
tumor,  so  as  to  attract  the  attention  even  of  the  parents.  The  swelling 
of  the  liver  is  not  so  great.  The  lymphatic  glands  are  enlarged  only  to 
a  moderate  degree,  and  in  many  cases  this  symptom  is  absent  alto- 
gether. They  are  painless,  movable,  and  usually  several  groups  are 
affected. 

The  late  symptoms  are  dropsy  of  the  feet  or  general  anasarca, 
hemorrhages,  diarrhea,  headaches,  general  weakness,  and  attacks  of 
syncope.  Fever  is  quite  constant  in  the  late  stages  of  the  disease, 
and  the  temperature  may  be  from  101°  to  103°  F.  The  urine  may 
contain  albumin  and  casts.  Vision  is  sometimes  disturbed  by  the 
formation  of  leukemic  plaques  in  the  retina.  It  is  rare  that  there  are 
any  symptoms  referable  to  the  bones,  although  expansion  and  tender- 
ness-of  the  flat  bones  have  been  observed. 

In  the  splenomyelogenous  form  the  white  cells  may  be  from  100,000 
to  500,000,  but,  especially  under  the  influence  of  arsenic,  a  marked 
temporary  diminution  may  occur,  so  that  their  number  may  be  scarcely 
above  the  normal;  both  Ehrlich's  and  Cornil's  myelocytes  are  present, 
and  the  presence  of  a  large  number  of  these  is  pathognomonic.  The 
number  of  polymorphonuclear  neutrophiles  is  greatly  increased,  al- 
though their  proportion  is  diminished.  The  eosinophiles  are  very  much 
increased  in  number,  mononuclear  forms  being  present.  The  number 
of  lymphocytes  is  increased,  but  they  vary  according  to  the  type  and 
stage  of  the  disease;  basophilic  (mast)  cells,  both  mononuclear  and  poly- 
morphonuclear, are  present  in  considerable  number,  this  being  the  most 
reliable  diagnostic  sign. 

Prognosis. — The  prognosis  of  leukemia  of  all  varieties  in  children  is 
very  bad,  nearly  all  cases  terminating  fatally  within  a  few  weeks  or 


852  DISEASES  OF  THE  BLOOD 

months  from  the  first  definite  S3anptoms.  The  iisnal  causes  of  death 
are  exhaustion,  hemorrhages,  and  bronchopneumonia.     . 

Diagnosis. — The  general  s5anptoms  are  likely  to  he  misleading,  espe- 
cially fever,  dyspnea  and  prostration.  The  buccal  symptoms  frequently 
suggest  scurvy.  A  rapid  general  enlargement  of  the  external  lymphatic 
glands  always  is  suspicious,  but  without  a  blood  examination,  a  diagnosis 
is  impossible.  The  chief  reliance  is  to  be  placed  in  cases  of  lymphatic 
leukemia  upon  the  great  relative  increase  in  the  lymphocytes  and  reduc- 
tion in  the  polymorphonuclears  more  than  upon  the  total  number  of 
leucocytes;  in  other  cases  the  diagnosis  rests  upon  the  enormous  increase 
in  the  leucocytes,  and  especially  upon  the  presence  of  numerous  mast 
cells  and  neutrophile  and  eosinophile  myelocytes. 

Treatment. — Leukemia  is  little  influenced  by  treatment.  The  re- 
ported cures  must  be  taken  with  some  allowance,  for  most  of  these  were 
published  before  leukemia  was  sharply  differentiated  from  simple  anemia 
with  leucocytosis.  Temporary  improvement  in  some  cases  has  followed 
the  use  of  arsenic  in  full  doses.  Hemorrhages  may  be  relieved  at 
times  by  calcium  lactate.  Benzol  is  often  of  distinct  value  in  the  treat- 
ment of  chronic  splenomyelogenous  leukemia.  Its  effect  is  to  diminish 
markedly  the  number  of  white  cells,  especially  those  developed  from  the 
bone  marrow.  The  total  number  of  leucocytes  m.ay  be  reduced  from  a 
hundred  thousand  or  more  to  less  than  ten  thousand.  In  giving  benzol, 
care  should  be  observed  that  the  reduction  does  not  take  place  too 
rapidly.  As  the  effect  is  continuous  for  a  time  after  the  drug  is  omitted, 
no  more  should  be  given  after  the  total  number  of  cells  is  15,000  or 
20,000.  Benzol  may  be  given  in  capsules  beginning  with  seven  or 
eight  grains  (gram  0.5)  once  a  day.  The  dose  may  be  increased  gradu- 
ally, depending  upon  its  effect,  but  should  not  exceed  thirty  to  thirty- 
five  grains  (gram  2.5). 

.Coincident  with  the  fall  in  the  number  of  white  cells  there  is 
usually  a  marked  increase  in  the  red  cells  and  a  great  amelioration  of 
the  patient's  condition.  This  is  unfortunately  not  permanent  though 
it  may  last  for  many  months.  Subsequent  courses  of  treatment  with 
benzol  bring  less  improvement,  or  may  be  without  influence.  Striking 
improvement  has  followed  transfusion,  but  this  is  usually  only  tem- 
porary. In  the  great  .majority  of  cases  the  disease  goes  on  to  a  fatal 
termination  in  spite  of  the  measures  employed. 


HEMOPHILIA 

Hemophilia  is  an  hereditary  disease,  in  which  there  is  a  tendency 
to  profuse  or  even  uncontrollable  bleeding  from  slight  wounds.     The 


HEMOPHILIA  853 

hemorrhage  may  even  be  spontaneous.  Persons  so  affected  are  known  as 
"bleeders." 

Etiology. — The  hereditary  tendency,  of  the  disease  is  very  strongly 
marked,  and  it  has  often  been  traced  through  seven  or  eight  generations. 
Males  are  much  more  frequently  affected  than  females,  the  proportion 
being  about  twelve  to  one.  In  the  matter  of  inheritance,  the  disease 
is  most  often  transmitted  through  the  mother,  who,  however,  usually 
escapes  herself.  Patients  suffering  from  hemophilia  may  have  nothing 
else  about  them  that  is  abnormal.  It  has  no  connection  with  either 
purpura  or  scurvy.  Howell,  from  his  extensive  studies  upon  hemophilia, 
has  come  to  the  conclusion  that  it  is  due  to  a  relative  preponderance  of 
antithrombin.  The  antithrombin  may  be  normal  in  amount  or  abso- 
lutely increased  but  on  account  of  the  absolute  diminution  in  the  pro- 
thrombin there  is  always  a  relative  increase  in  the  factors  that  delay 
the  coagulation  of  blood. 

Symptoms. — The  first  manifestations  of  hemophilia  are  not  often 
seen  before  the  second  year.  The  hemorrhages  of  the  newly  born  have 
no  relation  to  this  condition.  The  discovery  of  the  disease  is  generally 
quite  accidental.  The  first  hemorrhage  may  be  traumatic  or  spon- 
taneous. In  traumatic  hemorrhages  there  may  be  very  severe  bleeding 
after  so  slight  a  wound  as  the  drawing  of  a  tooth;  sometimes  a  large 
hematoma  forms  between  the  muscles  as  the  result  of  a  moderate  con- 
tusion. 

The  following  is  the  relative  frequency  of  spontaneous  hemorrhages 
in  334  cases  collected  by  Grandidier :  Bleeding  from  the  nose  in  169, 
mouth  in  43,  intestines  in  36,  stomach  in  15,  urethra  in  16,  lungs  in 
17.  There  may  be  hemorrhage  from  the  skin  or  from  any  mucous 
membrane  of  the  body.  The  attacks  of  spontaneous  hemorrhage  are 
often  periodical,  and  may  be  accompanied  by  arthritic  symptoms  resem- 
bling rheumatism.  There  are  hemorrhages  into  the  joints  in  some  in- 
stances with  severe  resulting  deformity. 

The  severity  of  the  hemorrhages  varies  much  in  the  different  cases. 
From  a  slight  wound  a  patient  may  bleed  until  he  is  exsanguinated, 
and  even  until  death  occurs.  Such  a  result  from  the  first,  hemorrhage, 
however,  is  rare.  In  some  cases  the  disposition  to  bleed  is  outgrown  in 
later  life.  Grandidier  states  that,  of  153  boys,  over  one-half-  died  be- 
fore reacliing  the  seventh  year.  It  is  striking  that  when  the  disease  af- 
fects females  there  is  no  tendency  to  excessive  bleeding  at  menstruation 
or  parturition. 

Treatment. — The  indications  at  the  time  of  bleeding  are,  to  arrest 
the  hemorrhage  by  the  use  of  the  ordinary  surgical  means — especially 
compression.  Calcium  lactate  and  gelatine  may  be  used  as  described 
in  the  hemorrhages  of  the  newly  born;  but  little  benefit  is  to  be  ex- 


854  DISEASES  OF  THE  BLOOD 

pected  from  drugs.  In  all  marked  cases  transfusion  should  be  practiced. 
Its  effects  are  sometimes  very  striking.  In  convalescence  after  attacks 
of  hemorrhage,  iron  and  general  tonics  should  be  given.  In  all  patients 
who  are  bleeders  everything  which  might  by  any  means  excite  hemor- 
rhage should  be  avoided. 

PURPURA 

The  term  purpura  is  used  to  designate  a  condition  in  which  there  is 
a  tendency  to  spontaneous  hemorrhages  beneath  the  skin,  from  the 
various  mucous  membranes,  and  in  some  cases  into  the  internal  organs. 
The  term  purpura  simplex  is  applied  to  those  cases  in  which  the  hemor- 
rhages are  limited  to  the  skin;  purpura  hemorrhagica  to  those  in  which 
there  is  in  addition  bleeding  from  the  mucous  membranes  or  visceral 
hemorrhages.  It  is  impossible  to  draw  a  line  sharply  between  these  two 
classes  of  cases,  as  the  chief  difference  between  them  seems  to  be  one  of 
degree.  Purpura  is  sometimes  known  as  morbus  maculosis  or  as  Werl- 
hofs  disease. 

Symptomatic  Purpura. — This  occurs  in  quite  a  variety  of  conditions, 
the  hemorrhages  generally  being  limited  to  the  skin,  but  not  always  so. 
These  cases  may  be  grouped  in  the  following  classes : 

1.  Infectious. — This  form  of  purpura  is  very  constantly  seen  in 
malignant  endocarditis,  in  the  hemorrhagic  forms  of  the  various  erup- 
tive fevers — measles,  scarlet  fever,  variola,  vaccinia,  and  typhus — also  in 
epidemic  meningitis  and  occasionally  in  diphtheria,  pyemia,  and  sep- 
ticemia. The  occurrence  of  hemorrhages  in  these  cases  appears  to  de- 
pend upon  an  altered  condition  of  the  blood-vessels,  which  is  a  direct 
result  of  the  infection,  and  it  is  a  bad  prognostic  sign. 

2.  Cachectic. — Purpura  occurs  late  in  the  course  of  many  protracted 
and  exhausting  diseases,  especially  in  infancy.  It  is  most  frequently 
met  with  in  bronchopneumonia,  empyema,  tuberculosis,  ileocolitis,  in 
both  the  tuberculous  and  the  simple  forms  of  meningitis,  and  in  malig- 
nant disease.  It  also  occurs  from  apparently  similar  causes  in  several 
of  the  diseases  of  the  blood,  particularly  in  leukemia  and  pernicious 
anemia.  In  most  cases  of  cachectic  purpura  the  hemorrhagic  spots  are 
small,  not  very  abundant,  and  occur  either  upon  the  abdomen  or  the 
lower  extremities.  This  form  is  quite  common  in  hospital  practice,  and 
is  almost  invariably  indicative  of  a  fatal  result.  In  cachectic  purpura 
the  hemorrhages  are  usually  limited  to  the  skin. 

3.  Toxic. — Certain  drugs,  such  as  phosphorus,  quinin,  potassium 
chlorate,  and  sometimes  others,  may  in  rare  cases  produce  hemorrhages 
when  long  continued  or  in  large  doses.  The  hemorrhage  of  jaundice 
may  also  be  considered  in  this  group. 


PURPURA  855 

4.  Mechanical  hemorrhages,  such  as  those  occurring  in  pertussis  or 
epilepsy,  are  sometimes  classed  with  purpura.  In  convalescence  from 
protracted  illness  there  are  sometimes  seen,  when  patients  first  stand  or 
walkj  purpuric  spots  on  the  lower  extremities.  They  may  occur  after  the 
confinement  of  a  limb  in  bandages  or  splints.  In  both  these  cases  the 
cause  is  partly  mechanical  and  partly  due  to  the  weakened  condition  of 
the  blood-vessels. 

5.  Neurotic. — These  cases  are  occasionally  seen  in  diseases  of  the 
spinal  cord  and  sometimes  in  hysteria  in  young  adults,  but  very  rarely 
in  children. 

Primary  Purpura. — This  occurs  in  children  of  all  ages,  being  not 
uncommon  in  infancy.  Hemorrhages  of  the  newly  born  have  not  gener- 
ally been  included  in  this  class.  The  age  at  which  primary  purpura  is 
most  frequently  seen  is  from  two  to  ten  years.  The  sexes  are  about 
equally  affected;  of  Steffen's  56  cases,  27  were  males  and  29  females. 
The  disease  may  occur  in  children  who  are  cachetic,  rachitic,  or  anemic, 
and  in  those  whose  surroundings  are  poor,  but  it  has  not,  like  scurvy,  any 
close  relation  to  diet.  It  may  follow  any  acute  disease,  being  associated 
most  frequently  with  derangements  of  the  stomach  and  bowels.  Quite 
often  the  disease  develops  abruptly,  without  any  assignable  cause,  in  chil- 
dren previously  healtliy. 

Lesions. — The  external  hemorrhages  may  occur  upon  any  part  of 
the  body.  There  are  smaller  or  larger  ecchymoses  or  an  infiltration 
of  the  tissues  >vith  Ijlood,  which  undergoes  gradual  absorption  with  the 
usual  changes.  With  the  hemorrhages,  various  forms  of  inflammation 
of  the  skin  may  be  associated,  especially  erythema  and  urticaria,  with 
sometimes  more  or  less  edema.  Hemorrhages  from  the  mucous  mem- 
branes are  more  frequent,  because  of  the  feebler  resistance  of  the  tissues. 
There  are  seen  ecchymoses  upon  the  visible  mucous  membranes  vt^hich 
resemble  those  upon  the  skin.  At  autopsy  they  are  occasionally  seen 
in  the  trachea  or  bronchi,  but  more  often  in  the  digestive  tract.  In 
the  colon,  and  occasionally  in  the  small  intestine,  ulcers  may  be  found; 
but  they  are  rarely,  if  ever,  seen  in  the  stomach.  They  may  be  super- 
ficial or  deep,  and  have  even  been  known  to  cause  perforation. 

Intracranial  hemorrhages  are  rare,  and  are  usually  meningeal. 
These  may  be  sufficient  to  cause  severe  symptoms.  We  have  seen  an  in- 
stance in  an  infant  six  months  old  of  extensive  meningeal  hemorrhage 
covering  a  large  part  of  the  brain.  In  Steffen's  article  several  such  cases 
are  mentioned.  Pulmonary  hemorrhages  are  not  frequent.  Ecchymoses 
may  be  found  beneath  the  pericardium ;  but  endocarditis  and  pericarditis 
are  extremely  rare,  probably  occurring  only  in  the  rheumatic  cases.  The 
spleen  is  occasionally  enlarged,  but  by  no  means  uniformly  so,  and  it 
may  be  the  seat  of  hemorrhages. 


85G  DISEASES  OF  THE  BLOOD 

While  hematuria  is  one  of  the  most  frequent  of  the  visceral  hemor- 
rhages, severe  nephritis  is  rare.  Acute  degeneration  of  the  renal  epithe- 
lium of  the  tubes  is  quite  common.  There  may  be  punctiform  hemor- 
rhages, and  occasionally  larger  ones  beneath  the  capsule  or  in  the  mucous 
membrane  of  the  pelvis  of  the  kidney.  The  suprarenal  capsules  may  be 
the  seat  of  extensive  and  even  fatal  hemorrhage.  There  may  be  effusions 
of  a  sero-sanguineous  fluid  into  any  of  the  large  serous  cavities,  most 
frequently  into  the  peritoneum.  The  articular  lesions  of  purpura  may 
be  of  a  rheumatic  character,  with  which  purpura  occurs  as  a  complica- 
tion; or  there  may  be  hemorrhages  into  the  tissues  about  the  joint,  or 
even  into  the  joint  itself — usually  the  knee  or  elbow. 

The  blood  shows  the  changes  of  secondary  anemia — a  moderate  reduc- 
tion in  the  hemoglobin  and  the  red  corpuscles  with  occasional  irregulari- 
ties in  size  and  the  appearance  of  nucleated  red  cells.  In  the  most 
severe  cases  there  is  a  moderate  degree  of  leucocytosis.  Duke  has  demon- 
strated a  constant  and  marked  diminution  in  the  blood  platelets. 

Pathogenesis. — Why  it  is  that  under  certain  circumstances  the  blood- 
vessels will  not  hold  their  contents,  it  is  difficult  to  understand.  There 
have  been  described  by  Cassel,  Eiehl,  Wilson,  and  others,  changes  in  the 
small  blood-vessels,  usually  a  form  of  endarteritis,  but  the  lesions  are 
not  constant.  Howell  has  found  no  changes  in  the  factors  of  the  blood 
that  influence  coagulation.  They  are  present  in  normal  quantity  and 
proportion.  Henoch  has  suggested  the  vaso-motor  origin  of  purpura, 
in  which  there  is  first  a  paralytic  distention  of  the  small  vessels,  followed 
by  stasis,  hemorrhage,  or  edema.  In  certain  forms,  as  in  malignant 
endocarditis,  it  is  well  established  that  the  cause  is  an  infectious  throm- 
bosis. Although  the  bacteriological  examinations  made  thus  far  in  pur- 
pura have  not  been  conclusive,  there  is  reason  to  believe  that  infection 
is  the  essential  factor  in  some  forms  of  the  disease,  particularly  in  the 
cases  characterized  by  sudden  onset,  high  temperature,  and  cerebral 
symptoms,  and  which  run  a  rapidly  fatal  course.  There  are,  no  doubt, 
now  included  under  this  term  jDurpura  several  diseases  quite  distinct 
from  one  another. 

The  Clinical  Types. — 1.  The  Ordinary  Form. — In  the  mild  cases  the 
hemorrhage  is  confined  to  the  skin  (purpura  simplex),  or  it  is  accom- 
panied by  slight  bleeding  from  the  mucous  membranes.  There  is  usually 
some  general  indisposition  of  an  indefinite  character  for  a  day  or  two 
before  the  purpuric  spots  are  noticed;  most  frequently  a  disturbance  of 
digestion  with  vomiting,  diarrhea,  and  sometimes  slight  fever.  The 
hemorrhages  appear  as  small  petechiae,  varying  in  size  from  a  pin's 
head  to  a  pea,  usually  first  upon  the  lower  extremities.  There  may  be 
only  a  few  widely  scattered  spots  or  the  body  may  be  covered.  The 
color  is  first  a  bright  red,  then  purple,  gradually  fading  in  the  course 


PURPURA  857 

of  a  few  days.  New  spots  come  as  the  old  ones  disappear,  so  that  the 
amount  of  eruption  may  not  diminish.  They  do  not  disappear  upon 
pressure. 

The  course  of  these  cases  is  generally  favorable,  recovery  taking 
place  in  from  one  to  four  weeks.  Eelapses  are,  however,  very  frequent, 
and  such  attacks  may  come  at  intervals  of  a  few  weeks  or  months  for  a 
considerable  period.  One  must  be  guarded  in  giving  an  absolutely  favor- 
able prognosis  in  any  case  of  purpura,  for  it  occasionally  happens 
that  in  a  patient  who  for  several  days  has  had  symptoms  of  mild  pur- 
pura, there  suddenly  develop  those  of  the  most  severe  type  with  a  rapidly 
fatal  termination. 

2.  The  Severe  Form. — Such  cases  are  characterized  by  hemorrhages 
from  the  mucous  membranes  (purpura  hemorrhagica)  from  the  outset. 
These  may  even  appear  before  the  spots  upon  the  skin.  In  severe  at- 
tacks the  j)etechial  spots  are  more  likely  to  appear  suddenly,  and  large 
ecchymoses,  varying  in  size  from  a  pea  to  the  palm  of  the  hand,  are  more 
frequent.  There  may  be  bleeding  from  the  nose,  gums,  mouth,  or 
pharynx,  and  ecchymoses  may  be  seen  upon  these  mucous  membranes, 
also  upon  the  conjunctivae.  Vomiting  of  blood  and  bloody  discharges 
from  the  bowels  are  quite  frequent  symptoms.  The  urine  may  contain 
enough  blood  to  give  it  a  bright-red  color.  Less  frequently  there  are 
seen  hemorrhages  of  the  retina  or  choroid  and  from  the  female  genitals. 
In  one  of  our  cases  there  was  almost  continuous  bleeding  from  one  ear. 
Cutaneous  ecchymoses  are  increased  by  slight  injuries,  such  as  the 
pressure  from  a  bandage  or  from  scratching.  Epistaxis  may  be  copious 
enough  to  necessitate  plugging  of  the  nares.  The  amount  of  blood  vom- 
ited is  not  often  large ;  its  source  may  be  the  stomach,  the  mouth,  or  the 
pharynx.  The  blood  in  the  stools  is  usually  dark  colored,  but  there  may 
be  some  bright-red  blood  even  when  there  are  no  ulcers  present.  In  one 
of  our  cases  so  much  blood  was  lost  by  the  bowels  as  to  produce  the  symp- 
toms of  a  very  marked  cerebral  anemia.  In  certain  cases  the  gastro- 
intestinal symptoms  are  very  prominent,  and  there  may  be  slight  icterus. 
The  discharge  of  blood  from  the  stomach  or  intestine  may  be  accom- 
panied by  very  severe  attacks  of  colic  and  tenesmus.  In  some  of  these 
cases  there  are  pains  and  slight  swelling  of  the  joints.  Eenal  symptoms 
are  generally  present.  The  attacks  of  abdominal  pain  with  purpura  and 
the  discharge  of  blood  may  come  on  paroxysmally  every  few  days  for  a 
period  of  several  weeks.  They  have  been  ascribed  to  thrombosis  of  the 
intestinal  vessels.     This  is  sometimes  known  as  "Henoch's  purpura." 

Constitutional  symptoms  are  present  in  most  of  the  severe  cases. 
There  is  usually  fever,  from  101°  to  103°  F.,  and  sufficient  prostration 
to  keep  the  patient  in  bed.  If  the  amount  of  blood  lost  is  large,  there 
are  the.  usual  symptoms  of  severe  anemia.     The  loss  of  blood  may  be 


858  DISEASSS  OF  THE  BLOOD 

sufficient  to  cause  death,  particularly  in  infants.  Cerebral  symptoms 
may  depend  upon  anemia  or  upon  meningeal  hemorrhage.  They  are 
not  frequent  in  this  form  of  the  disease.  Edema,  especially  of  the  face 
and  feet,  may  exist  without  albuminuria,  and  albuminuria  may  be  pres- 
ent in  cases  in  which  there  is  no  renal  hemorrhage. 

In  some  of  the  cases  beginning  with  severe  general  symptoms,  and 
occasionally  when  the  onset  is  mild,  the  patients  after  a  few  days  pass 
into  a  typhoid  condition  with  low  delirium,  great  prostration,  weak  and 
irregular  pulse,  dry,  cracked  tongue,  and  high  temperature.  Such  cases 
are  almost  always  fatal.  They  are  not  to  be  confounded  with  ordinary, 
typhoid  fever  complicated  by  purpura. 

The  course  varies  much  in  the  different  cases.  It  lasts  from  one  to 
six  weeks,  the  symptoms  slowly  subsiding,  but  often  showing  a  strong 
tendency  to  recurrence.  The  prognosis  depends  upon  the  age  of  the 
patient,  the  extent  of  the  hemorrhage,  and  the  presence  or  absence  of 
septic  symptoms. 

3.  The  Hyperacute  Form  (purpura  fulminans). — This  is  a  rare 
form,  especially  in  young  children.  Its  development  is  usually  sudden, 
with  a  chill,  vomiting,  marked  prostration,  and  high  temperature.  The 
purpuric  spots  come  out  with  great  rapidity,  and  in  the  course  of  a 
few  hours  or  a  day  they  may  be  very  extensive.  In  addition  to  the 
ordinary  subcutaneous  hemorrhages,  bloody  vesicles  may  form  upon  the 
skin.  In  many  cases  the  hemorrhages  are  limited  to  the  skin,  th€  mu- 
cous membranes  and  the  viscera  escaping  altogether.  There  is  no  ten- 
dency to  gangrene.  Cerebral  symptoms  are  invariably  present  and  usu- 
ally prominent;  there  may  be  delirium,  dulness,  stupor,  and  finally 
coma.  The  spleen  is  apt  to  be  enlarged..  The  urine  is  nearly  always 
albuminous.  This  form  of  purpura  has  all  the  characteristics  of  a  gen- 
eral infectious  disease,  and  it  is  almost  invariably  fatal. 

4.  The  Cxangrenous  Form. — Sloughing  is  not  common  in  purpura, 
but  it  is  most  often  seen  in  the  mucous  membranes.  Osier  refers  to  two 
cases  affecting  the  uvula.  We  once  saw  a  slough  which  caused  perfora- 
tion of  the  soft  palate.  Wickham  Legg  reports  a  case  with  gangrene  of 
the  prepuce.  Gangrene  of  the  skin  is  even  less  frequent,  although  cases 
have  been  reported  even  in  young  children.  Charron's  patient  was  only 
three  years  old,  and  several  others  in  children  are  collected  in  Gimard's 
monograph  upon  this  subject.  The  gangrene  may  involve  the  skin  only, 
or  the  subcutaneous  tissues,  and  even  the  muscles.  It  has  been  seen 
upon  the  upper  and  lower  extremities,  and  even  upon  the  face,  and  may 
extend  over  quite  a  large  surface.  In  some  of  the  milder  forms  of  pur- 
pura, gangrene  results  from  some  slight  injury,  such  as  a  blow,  the  pres- 
sure from  a  bandage,  or,  in  the  nose,  from  the  pressure  of  a  tampon. 
These  cases  are  almost  invariably  fatal.     Those  in  which  the  sloughing 


PURPURA  859 

is  confined  to  small  areas  of  the  mucous  membrane  of  the  mouth  often 
recover. 

5.  The  Eheumatic  Form. — The  term  "rheumatic  purpura"  (peliosis 
rheumatica)  is  applied  to  cases,  not  so  common  in  children  as  in  older 
patients,  in  which  subcutaneous  hemorrhages,  and  sometimes  bleeding 
from  the  mucous  membranes,  are  associated  with  painful  joint  swell- 
ings. These  are  to  be  regarded  as  cases  of  rheumatism  complicated  by 
purpura.  The  joints  most  frequently  affected  are  the  knee  and  the 
ankle.  The  arthritic  symptoms  are  usually  less  severe  than  in  attacks 
of  acute  rheumatism.  There  may  be  present  erythema  exudativum  or 
erythema  nodosum  or  urticaria.  Usually  there  are  throat  symptoms 
and  fever,  and  frequently  edema  of  the  face  and  eyelids  with  albu- 
minuria. The  spleen  may  be  enlarged.  The  usual  duration  is  from  one 
to  three  weeks,  and  although  relapses  may  occur,  the  cases  usually 
recover. 

Joint  symptoms,  particularly  articular  pains,  are  not  infrequent  in 
the  course  of  milder  attacks  of  purpura  without  the  febrile  symptoms 
mentioned.  In  severe  cases  extravasations  of  blood  have  been  reported 
as  occurring  in  the  tissues  about  the  joints,  and  even  in  the  joints  them- 
selves, these  being  cases  of  true  arthritic  purpura.  It  is  probable  that 
in  the  past  some  cases  of  scurvy  have  been  included^in  this  group. 

Diagnosis. — The  rapid  acute  cases  may  be  confounded  with  the  hem- 
orrhagic forms  of  the  various  eruptive  fevers.  The  ordinary  subacute  or 
passive  forms  are  chiefly  to  be  differentiated  from  scurvy.  The  diag- 
nosis is  not  difficult,  and  the  mistake  need  not  be  made  if  the  essential 
features  of  scurvy  are  borne  in  mind — its  dietetic  cause,  bleeding  gums, 
hyperesthesia,  and  deep  rather  than  subcutaneous  hemorrhages  which 
are  usually  near  the  joints. 

Prognosis. — This  depends  very  much  upon  the  form  of  the  disease. 
Of  128  cases  of  all  varieties  occurring  in  children  in  Steffen's  collection, 
there  were  40  deaths.  In  12  cases  of  severe  primary  purpura  reported 
by  Grimard,  there  were  3  deaths  and  9  recoveries.  Purpura  simplex  is 
rarely  fatal;  cases  of  purpura  hemorrhagica  usually  recover  unless 
marked  febrile  symptoms  are  present.  The  forms  classed  as  typhoid, 
gangrenous,  and  purpura  fulminans  are  almost  invariably  fatal.  The 
tendency  to  relapse  exists  in  all  varieties. 

Treatment. — The  treatment  of  symptomatic  purpura  should  have 
reference  to  the  cause  of  the  disease.  The  mild  cases  of  primary  pur- 
pura usually  recover  promptly  under  a  tonic  plan  of  treatment.  The 
more  severe  cases  require  confinement  in  bed,  absolute  quiet,  and  care  to 
avoid  exposure  and  even  the  slightest  injury  or  extra  pressure  upon  any 
part.  Drugs  do  not  seem  greatly  to  influence  the  course  of  the  disease. 
Those  most  frequently  employed  are  epinephrin,  hydrastis,  hamamelis. 


860  DISEASES  OF  THE  LYMPH  NODES 

aromatic  sulphuric  acid,  the  vegetable  acids,  ergot,  and  gallic  acid. 
Whether  or  not  it  is  true,  as  claimed  by  some,  that  all  hemorrhagic 
diseases  are  related  to  scurvy,  the  striking  improvement  seen  in  this 
disease  from  the  use  of  fresh  fruit  and  vegetables  suggests  their  employ- 
ment in  purpura.  In  some  cases  very  decided  benefit  seems  to  follow 
their  use  in  the  acute  stage,  but  more  particularly  in  convalescence.  For 
hyperacute  and  gangrenous  cases,  little  can  be  done  except  to  treat  the 
symptoms.  Surgical  means  of  arresting  the  hemorrhage  are  rarely  suc- 
cessful.   In  all  severe  cases  transfusion  should  be  tried. 


CHAPTEE  II 
DISEASES  OF  THE  LYMPH  NODES  {LYMPHATIC  GLANDS) 

It  is  characteristic  of  infancy  and  childhood  that  the  lymphoid  tis- 
sues— tonsils,  adenoids,  external  and  internal  lymph  glands,  and  many 
smaller  lymph  nodules  throughout  the  body — are  prone  to  swelling  and 
hyperplasia.  In  robust  children  infectious  processes  of  the  nose,  pharynx, 
or  bronchi  cause  acute  swelling  of  the  lymph  nodes  in  the  neighborhood, 
which  rapidly  subside  when  the  cause  is  removed.  In  others,  in  whom 
this  vulnerability  of  the  lymphoid  tissues  exists,  the  hyperplasia  in  the 
lymph  nodes  is  out  of  proportion  to  the  exciting  cause  and  continues 
after  the  cause  has  ceased  to  operate.  Certain  children  have  at  birth  an 
excessive  development  of  lymphoid  tissue,  particularly  in  the  region  of 
the  throat  in  the  form  of  enlarged  tonsils,  adenoid  vegetations  of  the 
pharynx,  etc. 

The  influence  of  heredity  in  causing  this  condition  is  too  often  seen 
to  be  passed  over  as  a  coincidence.  Frequently  the  parents,  during  child- 
hood, suffered  from  the  same  condition,  and  often  every  member  of  a 
large  family  of  children  is  affected.  They  may  be  in  other  respects 
healthy,  reared  amid  good  surroundings,  and  show  no  evidence  of  any 
other  constitutional  disease.  Any  disease  in  the  parents  in  consequence 
of  which  children  are  born  with  tissues  having  less  than  normal  re- 
sistance, may  be  regarded  in  the  light  of  a  remote  cause. 

The  condition  is  seen  in  perfection  in  children  reared  in  institutions 
and  in  crowded  tenements.  It  is  more  common  in  cities  than  in  the 
country.  Anything  which  produces  malnutrition  or  lowers  the  general 
vitality  of  the  tissues  may  be  ranked  as  a  cause.  Eickets  is  often  asso- 
ciated. 

During  infancy,  the  lymphoid  structures  most  frequently  affected  arc 
tliose  connected  with  the  srastro-enteric  and  the  bronchial  mucous  mem- 


ANATOMICAL  CONNECTIONS 


861 


branes;  in  later  childhood  it  is  those  which  are  connected  with  the 
pharynx  and  tonsils. 

The  degree  of  enlargement  of  the  lymph  nodes  which  is  sometimes 
found  in  the  difEerent  situations  has  often  led  to  misinterpretation. 
They  have  often  been  connected  with  pathological  conditions  or  clinical 
symptoms  with  which  they  have  really  nothing  to  do. 

As  age  advances  we  usually  see  retrograde  changes  in  the  different 
groups  of  glands  unless  they  become  the  seat  of  tuberculous  infection. 
Those  connected  with  the  digestive  tract  generally  begin  to  diminish 
after  the  second  year,  and  by  the  fifth  or  sixth  year  the  enlargement  has 
almost  disappeared;  while  the  tonsils,  adenoid  growths  of  the  pharynx, 
and  enlarged  cervical  glands  are  usually  stationary  after  the  seventh  or 
eighth  year,  and  frequently  undergo  quite  a  marked  atrophy  about  the 


Name  of  the 
Group. 


Number  and  Situation. 


Organs  or  Areas  from  which  they 
Receive  Lymphatics. 


9 
10 


Suboccipi- 
tal. _ 
Mastoid. 


PpTotid. 


Submaxil- 
lary. 

Supra- 
hyoid. 

Superficial 
cervical. 


Deep  cervi- 
cal, upper 
set. 


Deep  cervi- 
cal, lower 
set. 

Sub-hyoid. 


Retrophar- 
yngeal 


29 


One   or   two;  at   nape  of 

neck. 
Four  or  five  small  ones ;  in 

mastoid  region. 

Five  to  ten ;  on  the  surface 
and  in  the  substance  of 
the  parotid  gland. 

Twelve  to  fifteen;  along 
base  of  jaw,  beneath 
cervical  fascia. 

One  or  two ;  median  hne  be- 
tween chin  and  hyoid 
bone. 

Five  or  more ;  along  exter- 
nal jugular  vein,  beneath 
platysma,  but  superfi- 
cial to  the  sternomas- 
toid. 

Ten  to  sixteen;  about  bi- 
furcation of  common 
carotid  and  along  inter- 
nal jugular  vein.  They 
are  just  above  upper  bor- 
der of  the  thyroid  carti- 
lage and  on  a  level  with 
the  hyoid  bone. 

A  chain  in  the  supraclavic- 
ular fossa. 


A  few  small  glands  below 
hyoid  bone  and  near  me- 
dian hne. 

Two  small  glands  in  front 
of  spine  and  upon  pre- 
vertebral muscles. 


Scalp,  posterior  portion. 

Receive  efferent  vessels  from  group  1, 
and  through  them  from  part  of 
scalp. 

Scalp,  frontal  and  parietal  portions; 
orbit,  posterior  part  of  nasal  fossa, 
upper  jaw,  posterior  and  upper 
part  of  pharjTix. 

Mouth,  lower  lip,  gums. 


Chin  and  middle  portion  of  lower  lip. 


Auricle,  part  of  scalp,  skin  of  face 
and  neck,  and  some  efferent  ves- 
sels from  groups  1  and  2. 


Lower  part  of  pharynx,  larynx,  pal- 
ate, tonsils  and  part  of  tongue, 
part  of  nasal  fossa,  deep  muscles  of 
head  and  neck,  and  from  inside  the 
cranium.  Receive  also  efferent 
vessels  from  groups  3  and  4. 


Connect  with  axillary  group  by  a 
chain  along  axillary  artery;  also 
with  glands  of  mediastinum  and 
with  groups  7  and  9. 

Communicate  with  group  8,  and  may 
connect  below  with  chain  of  bron- 
chial glands. 

Pharynx  and  part  of  nasal  fossa. 


862  DISEASES  OF  THE  LYMPH  NODES 

time  of  puberty.  The  presence  of  these  enlarged  lymph  nodes  and  the 
catarrhal  condition  of  the  mucous  membranes  "n'ith  which  they  are  asso- 
ciated, are  important  in  relation  to  all  acute  infectious  diseases  which 
affect  these  mucous  membranes.  They  bring  about  an  increased  sus- 
ceptibility to  scarlet  fever,  measles,  diphtheria,  and  most  of  all  to  tuber- 
culosis. 

In  the  table  on  the  preceding  page  are  given  the  situation  and  drain- 
age areas  of  the  various  groups  of  lymph  nodes  of  the  head  and  neck 
which  play  so  important  a  role  in  infancy  and  childhood. 


SIMPLE  ACUTE  ADENITIS 

This  is  an  acute  inflammation  of  the  lymph  nodes  which  in  infancy 
frequently  terminates  in  suppuration.  A  certain  amount  of  inflamma- 
tion of  the  lymph  nodes  occurs  in  children  in  all  acute  processes  affect- 
ing the  mucous  membranes,  especially  when  they  are  severe  or  prolonged. 
Those  in  connection  with  the  various  internal  organs  are  considered  with 
the  diseases  of  those  organs.  Acute  inflammation  of  the  external  nodes 
is  of  sufficient  frequency  to  require  separate  consideration.  While  this  is 
probably  always  secondary  to  some  pathological  process  in  the  skin  or 
mucous  membranes,  the  primary  condition  may  be  so  slight  as  to  be 
overlooked,  and  the  adenitis  may  be  the  more  important  condition  or  may 
even  assume  the  appearance  of  a  primary  disease.  It  is  particularly  in 
infants  that  this  is  seen,  and  it  depends  upon  the  unusually  active  ab- 
sorption and  upon  the  susceptibility  of  the  lymphoid  tissues, at  this  age. 
The  cervical  glands  are  frequently  affected,  occasionally  those  of  the 
axillary  and  inguinal  regions. 

Etiology. — Acute  adenitis  occurs  in  children  of  all  ages  in  connection 
with  diphtheria,  scarlet  fever,  measles,  and  epidemic  catarrh.  In  such 
cases  it  is  often  severe,  and  after  scarlet  fever  not  infrequently  terminates 
in  suppuration.  "With  the  simple  acute  catarrhal  processes  of  the  phar}Tix 
and  rhinopharynx  adenitis  also  occurs,  but  it  is  usually  mild  and  rarely 
ends  in  suppuration.  In  infancy,  on  the  other  hand,  acute  adenitis 
from  simple  catarrh  is  not  only  very  common  but  often  severe,  and 
frequently  terminates  in  suppuration.  Ulcerative  stomatitis,  carious 
teeth,  eczema  of  the  scalp  or  traumatism,  may  excite  adenitis  in  chil- 
dren of  all  ages.  Axillary  adenitis  may  result  from  vaccination ;  ingui- 
nal adenitis,  from  balanitis  or  vulvovaginitis. 

Of  109  cases  of  acute  adenitis  from  our  records,  not  including  any 
associated  with  diphtheria,  measles,  or  scarlet  fever,  more  than  three- 
fourths  occurred  in  the  first  two  years,  and  half  of  them  in  the  first  year 
of  life.     This  susceptibility  of  infants  is  very  striking.     The  disease 


SIMPLE  ACUTE  ADENITIS 


863 


occurs  frequently  in  those  who  were  previously  healthy,  and  often  when 
the  evidences  of  disease  of  the  mucous  membrane  are  slight.  This  is 
true  not  only  of  the  cases  of  cervical  adenitis,  but  also  of  others  in  which 
the  inguinal  glands  are  involved.  The  inflammation  is  usually  asso- 
ciated with  the  streptococcus  or  staphylococcus,  occasionally  with  the 
pneumococcus  or  influenza  bacillus. 

Lesions. — The  changes  taking  place  in  the  glands  are  acute  conges- 
tion, with  swelling,  edema,  and  active  hyperplasia  of  the  lymphoid  ele- 
ments. The  process  may  terminate  in  resolution  or  in  suppuration 
according  to  the  intensity  of  the  infection  and  the  susceptibility  of  the 
tissues.  When  severe  enough  to  cause  suppuration,  the  adenitis  is  ac- 
companied by  considerable  inflam- 
mation of  the  surrounding  cellular 
tissue. 

In  the  series  of  109  acute  cases 
to  which  reference  has  been  made, 
not  including  the  specific  infectious 
diseases,  96  were  cervical,  9  were  in- 
guinal, and  4  axillary;  sixty-two  per 
cent  terminated  in  suppuration,  the 
latter  being  nearly  all  in  infancy. 
Suppurative  otitis  was  present  in 
sixteen  per  cent  of  the  cases.  Sup- 
purative retropharyngeal  adenitis 
(retropharyngeal  abscess)  was  asso- 
ciated in  several  cases. 

In  infancy  the  disease  is  usually 
unilateral,  or,  if  bilateral,  the  glands 
of  one  side  are  more  severely  affected 
than  those  of  the  other.  Suppura- 
tion is  nearly  always  of  one  side,  and  usually  the  abscess  starts  in  a 
single  gland. 

Symptoms. — The  symptoms  and  course  of  the  adenitis  of  the  specific 
infectious  diseases  belong  to  their  clinical  history.  Suppuration  is  in- 
frequent, except  after  scarlet  fever. 

The  typical  cases  of  acute  adenitis  are  those  which  occur  in  infancy. 
There  are  present  the  symptoms  of  the  original  disease — usually  acute 
catarrh  of  the  nose  or  rhinopharynx,  mouth,  or  ear,  which  may  not  be 
severe,  and  sometimes  is  overlooked.  The  glands  most  frequently  af- 
fected are  the  deep  cervical  group.  The  tumor  appears  Just  below  the 
angle  of  the  jaw  at  the  anterior  border  of  the  sternomastoid  muscle 
(Fig.  131).  The  swelling  during  the  acute  catarrh  is  not  rapid  or  great, 
but  continues  after  the  original  process  has  subsided  until  it  reaches  the 


Fig.  131. — Acute  Suppurative  Ade- 
nitis IN  AN  Infant  One  Year  Old. 
Showing  the  most  frequent  situation 
of  the  tumor  in  the  cervical  region. 


864 


DISEASES  OF  THE  LY]MPH  NODES 


size  of  a  walnut  or  a  hen's  egg.  In  the  most  acute  cases  there  is  marked 
inflammation  of  the  periglandular  cellular  tissue,  with  pain,  tenderness, 
and  extra  heat.  If  suppuration  occurs,  it  is  generally  evident  in  the 
latter  part  of  the  second  week,  but  sometimes  it  may  be  as  late  as  the 
third  or  even  the  fourth  week.  In  the  axillary  or  inguinal  region  (Fig. 
132)  the  symptoms  of  adenitis  are  essentially  the  same  as  in  the  neck. 
In  the  inguinal  cases  the  degree  of  catarrh  of  the  mucous  membrane  is 
often  very  slight. 

Most  cases  run  their  course  with  slight  fever  and  few  general  symp- 
toms ;  but  in  young  infants  the  constitutional  symptoms  are  often  severe 
and  the  physician  may  be  in  doubt  whether  the  local  process  is  sufficient 

to  explain  them.  The  temperature 
may  be  from  102°  to  104°  F.  for- 
several  days,  with  considerable  pros- 
tration, which  is  much  increased  if 
there  is  complicating  otitis.  After 
suppuration,  if  freely  opened  at  the 
proper  time,  the  al)scess  heals  rap- 
idly and  permanently,  a  sinus  being 
rare.  Occasionally  the  infection  ex- 
tends from  one  gland  to  another, 
uud  a  succession  of  these  glandular 
abscesses  occurs. 

In  the  non-suppurative  cases  the 
swelling  may  be  even  greater  than 
in  those  which  suppurate;  but  it  is 
less  difiiuse  and  apparentl}^  limited 
to  the  gland.  It  subsides  slowly  in 
the  course  of  from  four  to  eight 
weeks,  often  leaving  a  small  tumor  which  may  1)e  apparent  for  several 
months.  In  susceptible  children  recurrent  attacks  of  acute  inflammation 
may  lead  to  chronic  enlargement  Avhich.may  last  indefinitely.  Thesr 
glands  do  not  become  cheesy,  except  from  subsequent  tuberculous  in- 
fection. 

The  acute  cases  in  infancy  in  which  suppuration  occurs,  appear  to 
recover  about  as  promptly  and  quite  as  completely  as  those  terminating 
in  resolution,  although  in  the  former  the  constitutional  symptoms  arc 
more  severe. 

Diagnosis. — This  is  usually  easy  if  it  is  remembered  that,  with  the 
exception  of  the  specific  infectious  diseases,  and  occasionally  local  causes 
like  eczema  of  the  scalp,  carious  teeth,  etc.,  acute  suppurative  adenitis 
is  essentially  a  disease  of  infancy.  It  is  often  mistaken  for  mumps 
when  the  SAvelling  is  severe,  but  on  close  examination  there  is  but  little 


Fig.  132. — Acute  Suppurative  Ade- 
nitis (inguinal)  in  an  Infant 
Three  Months  Old. 


SIMPLE  CHRONIC  ADENITIS  8C.1 

resemblance  between  the  conditions.  The  disease  is  usually  acute,  and 
has  little  in  common  with  the  slow  suppuration  seen  in  later  childhood 
from  the  breaking  down  of  tuberculous  glands.  In  the  occasional  eases 
seen  in  wliich  the  disease  runs  a  slower  course  a  diagnosis  from  the  tu- 
berculous form  may  be  aided  by  a  tul)erculin  test. 

Treatment. — Prophylaxis  requires  that  in  all  acute  catarrhs  the 
mucous  memljrane  should  be  kept  as  clean  as  possible  by  the  use  of  nasal 
or  pharyngeal  sprays,  or  by  careful  syringing  with  simple  solutions  like 
Dobell's  or  Seller's,  or  a  simple  saline. 

In  the  stage  of  acute  inflammation  very  hot  applications  or  an  ice- 
bag  may  be  used  for  the  relief  of  pain.  It  is  very  doubtful  whether 
either  of  these  means  has  much  influence  in  preventing  suppuration.  If 
abscess  forms,  incision  should  be  deferred  until  pointing  has  taken  place. 
If  this  plan  is  followed,  refilling  is  rare.  A  simple  incision  with  proper 
aseptic  treatment  is  all  that  is  required.  Curetting  may  be  done  if  there 
is  much  broken-down  tissue  present,  luit  it  is  not  usually  necessary.  In 
most  of  the  cases  the  abscess  promptly  heals  and  a  perfect  cure  takes 
place.  Benefit  is  seldom  seen  from  painting  with  iodin  or  from  inunc- 
tions of  iodin  ointment  or  the  oleate  of  mercury.  If  adenitis  is  second- 
ary to  carious  teeth,  eczema,  or  ulcerative  stomatitis,  these  conditions 
should  receive  appropriate  treatment.  Such  cases  do  not  usually  sup- 
purate, but  subside  rapidly  when  the  primary  cause  is  removed. 


SIMPLE  CHRONIC  ADENITIS 

This  consists  in  a  simple  hyperplasia  of  the  lymph  nodes  which  is 
non-syphilitic  and  non-tuberculous.  There  are  considered  here  only  the 
external  glands,  but  those  of  the  cavities  of  the  body  are  affected  in^a 
similar  way,  in  diseases  of  the  mucous  membranes  with  which  they  are 
connected. 

Simple  chronic  adenitis  is  not  so  frequent  as  the  acute  form  in 
infants,  and  it  is  less  common  after  the  third  year.  It  may  follow  one  or 
more  attacks  of  acute  adenitis,  or  it  may  result  from  subacute  or  chronic 
inflammations  of  the  skin  or  of  the  various  mucous  membranes,  infection 
from  which  causes  the  acute  form.  Chronic  enlargement  of  the  glands 
of  the  neck  is  very  common  with  adenoids,  diseased  tonsils  and  with 
pediculosis  of  the  scalp. 

Symptoms. — The  glands  upon  both  sides  of  the  neck  are  usually 
involved,  and  more  often  a  group  than  a  single  gland.  The  degree  of 
swelling  is  not  generally  great,  being  much  less  than  in  acute  adenitis, 
and  usually  less  than  in  the  tuberculous  form.  There  are  no  constitu- 
tional symptoms.     Hypertrophy  of  the  tonsils  and  adenoid  growths  of 


866  DISEASES  OF  THE  LYMPH  NODES 

the  pharynx  are  frequently  associated.  There  is  no  tendency  to  suppura- 
tion or  caseation.  The  swelling  usually  increases  slowly  for  one  or  two 
months,  then  remains  stationary  for  about  the  same  length  of  time,  after 
which  it  slowly  subsides.  A  subacute  course  is  more  frequent  than  a 
very  chronic  one. 

Diagnosis. — These  cases  are  especially  to  be  distinguished  from  the 
much  more  frequent  cases  of  tuberculous  adenitis.  The  most  important 
points  for  differentiation  are,  that  they  occur  most  frequently  in  children 
under  two  years,  a  period  when  tuberculous  adenitis  is  not  very  com- 
mon; some  definite  exciting  cause  is  usually  present;  caseation  and  sup- 
puration do  not  occur;  the  glands  do  not  become  adherent  to  the  skin 
or  to  the  deeper  tissues;  they  usually  enlarge  more  rapidly  than  do  the 
non-caseating  tuberculous  glands;  and  they  are  influenced  to  a  greater 
degree  by  constitutional  treatment.  The  children  do  not  usually  respond 
to  the  tuberculin  test. 

Treatment. — Operative  measures  are  not  called  for  in  simple  ade- 
nitis. Local  causes  usually  found  in  the  pharynx,  nasopharynx,  or  mouth 
should  be  removed  if  possible.  Pediculosis  should  be  treated.  Often 
more  can  be  accomplished  by  removal  to  a  climate  in  which  the  child's 
catarrhal  symptoms  are  relieved  than  by  all  else.  Little  benefit  is  seen 
from  local  applications.  The  most  useful  internal  remedies  are,  the 
syrup  of  the  iodid  of  iron  (twenty  drops  three  times  a  day  to  a  child  of 
four  years),  and  arsenic  (two  or  three  drops  of  Fowler's  solution  three 
times  a  day).  Cod-liver  oil  should  be  given  continuously  except  during 
warm  weather, 

SYPHILITIC  ADENITIS 

It  is  quite  rare  that  a  marked  degree  of  glandular  enlargement  is 
seen  as  a  symptom  of  hereditary  syphilis;  indeed,  it  is  so  rare  that  it  is 
often  forgotten  that  chronic  multiple  glandular  enlargements  are  ever 
due  to  this  disease.  In  the  few  examples  that  have  come  under  our  ob- 
servation, this  has  been  a  late  symptom  of  hereditary  syphilis.  The 
glandular  enlargements  were  cervical  and  multiple,  and  the  degree  of 
swelling  was  often  marked.  They  may  be  associated  with  disease  of  the 
bones  or  of  the  mucous  membrane  of  the  throat  or  of  the  nose,  or  with- 
out signs  of  such  disease.  The  diagnosis  of  syphilis  rests  upon  the  asso- 
ciation of  other  late  manifestations  of  the  disease — keratitis,  periostitis, 
deformities  of  the  teeth,  the  Wassermann  reaction,  and  the  prompt  im- 
provement under  antisyphilitic  treatment.  Li  their  local  appearance 
they  resemble  tuberculous  glands. 


TUBERCULOUS  ADENITIS  867 

TUBERCULOUS  ADENITIS 

(Scrofula) 

Tuberculous  disease  of  the  lymph  glands  of  the  cavities  of  the  body 
is  discussed  elsewhere;  only  that  of  the  external  glands  is  here  consid- 
ered. This  condition  presents  some  striking  peculiarities :  it  is  not  com- 
mon in  infancy,  although  one  of  the  most  frequent  forms  of  tuberculosis 
in  older  children;  it  often  exists  as  the  only  apparent  tuberculous  lesion 
in  the  body.  In  the  great  majority  of  cases  it  is  the  cervical  glands 
which  are  affected. 

Etiology. — The  age  at  which  tuberculosis  of  the  cervical  lymph 
glands  is  most  often  seen  is  from  three  to  ten  years.  In  tuberculosis  in 
infancy,  the  external  glands  are  not  usually  involved,  while  the  bronchial 
glands  are  almost  invariably  the  seat  of  infection. 

The  cervical  glands  become  involved  as  the  result  of  a  descending 
infection  from  the  rhinopharynx  or  of  an  ascending  infection  from  the 
bronchial  glands.  The  descending  infection  is  altogether  the  most  com- 
mon one.  The  tonsils  and  less  commonlj  the  adenoid  tissue  of  the  rhino- 
pharynx  become  tuberculous  from  the  sputum  coughed  up  from  the 
lungs  or  from  organisms  received  into  the  mouth  from  outside.  From 
the  foci  in  the  pharynx  the  path  is  direct  to  the  cervical  glands.  Local 
pathological  conditions  that  affect  the  tonsils  and  adenoid  tissue  and  so 
favor  the  development  of  tuberculosis  are  chronic  pharyngitis,  disease 
of  the  tonsils  and  carious  teeth.  Attacks  of  grippe,  measles  and  scarlet 
fever,  frequently  play  the  role  of  exciting  causes.  The  question  often 
arises  whether  the  process  is  at  first  a  simple  one  and  later  becomes  tuber- 
culous, or  whether  it  is  a  tuberculous  one  from  the  beginning.  Our  own 
belief  is  that  in  practically  all  cases  the  process  is  a  tuberculous  one  from 
the  outset. 

Of  97  cases  of  tuberculous  adenitis  in  children  studied  by  Park  and 
Krumwiede,  51  showed  the  human  type  of  bacillus  and  46  the  bovine 
type.  The  proportion  of  cases  of  bovine  infection  was  much  higher  in 
children  under  five  years  of  age  than  in  those  who  were  older  (61  and  38 
per  cent  respectively).  These  findings  showing  the  frequency  of  bovine 
infection  are  in  striking  contrast  to  those  obtained  by  them  in  other 
forms  of  tuberculosis  in  children  and  point  unmistakably  to  food  or 
mouth  infection,  most  probably  tuberculous  milk,  as  a  cause. 

Lesions. — It  has  already  been  stated  that  in  the  great  majority  of 
cases  tlie  cervical  lymph  nodes  are  involved,  and  generally  they  are  the 
only  ones  affected.  In  155  cases  of  tuberculous  glands  in  the  series  re- 
ported by  Treves,  those  of  the  neck  were  the  seat  of  disease  in  145  and 


868  DISEASES  OF  THE  LYMPH  NODES 

the  only  seat  in  131 ;  those  of  the  axilla  were  involved  in  17,  but  alone 
only  in  4;  the  groin  in  8,  and  alone  in  6.  The  nodes  first  affected  are 
most  frequently  the  upper  set  of  the  deep  cervical  group;  sometimes, 
however,  it  is  the  superficial  nodes  of  the  submaxillary,  or  the  parotid 
group,  and  occasionally  the  submental  or  the  pre-auricular.  The  chain 
of  deep  cervical  nodes  which  is  involved,  follows  the  carotid  artery,  and 
often  extends  some  distance  below  the  clavicle.  These  deep  nodes  are 
sometimes  connected  with  the  bronchial  group,  but  it  is  much  more  fre- 
quent to  trace  them  upward  to  the  tonsils  which  in  a  very  large  propor- 
tion of  the  cases  are  tuberculous. 

The  process  in  all  tuberculous  glands  is  essentially  a  chronic  one, 
but  pathologically  the  cases  may  be  divided  into  two  groups,  correspond- 
ing somewhat  to  the  forms  of  disease  seen  in  the  lungs.  In  one  group 
the  process  is  more  rapid,  and  tends  to  early  caseation  and  softening; 
the  products  of  inflammation  are  mainly  cellular,  and  the  amount  of 
fibrous  tissue  is  small.  In  another  group  the  course  is  slower,  and  fibrous 
tissue  predominates,  caseation  and  softening  being  late  or  absent. 

In  the  first  group  the  glands  in  the  early  stage  are  swollen,  of  a  pale 
pink  color,  and  homogeneous;  later  they  become  more  firm,  and  show, 
as  the  first  gross  evidence  of  tuberculous  deposits,  small  grayish-white 
spots,  which  are  generally  numerous  and  scattered  through  the  affected 
gland ;  these  spots  enlarge,  and  may  coalesce  to  form  one  large  gray 
mass,  involving  nearly  the  whole  gland.  Subsequently  there  is  caseation 
and  then  softening,  usually  beginning  in  the  center  of  the  caseous  area. 
Inflammation  within  the  gland  is  followed  by  that  of  the  surrounding 
tissues,  which  may  result  in  adhesions  or  in  the  formation  of  a  peri-glan- 
dular abscess.  The  first  change  in  the  gland  is  the  production  of  epithe- 
lioid and  giant  cells,  about  which  there  is  a  zone  of  small  round  cells; 
cheesy  degeneration  then  begins  in  the  center.  The  caseous  masses  may 
become  encapsulated  by  tlie  production  about  them  of  fibrous  tissue;  or 
softening  may  occur  at  one  or  more  foci,  and  an  abscess  form.  Such  an 
abscess  contains  curdy  material,  but  very  little  true  pus,  the  contents 
being  chiefly  detritus  from  the  broken-down  node.  Tubercle  bacilli  are 
usually  more  numerous  in  the  early  stages  of  the  process,  but  are  often 
difficult  of  detection  in  broken-down  tissues,  and  the  curdy  pus  is  some- 
times sterile.  As  the  glands  soften,  the  process  gradually  extends  from 
the  center  to  the  surface,  and  they  become  adherent  to  the  surrounding 
structures — blood-vessels,  nerves,  or  the  fascia — they  fuse  together  and 
form  large  knotty  masses,  and  when  they  ultimately  break  down  they 
lead  to  the  formation  of  an  abscess  in  the  cellular  tissue,  finally  involv- 
ing the  skin.  In  the  form  of  suppuration  which  occurs  in  and  about 
tuberculous  nodes,  an  important  part  is  often  played  by  other  bacteria, 
usually  the  staphylococcus  or  the  streptococcus. 


TUBERCULOUS  ADENITIS  869 

In  the  second  group  of  cases,  where  the  process  goes  forward  more 
slowly,  the  changes  are  not  quite  the  same,  the  essential  difference  being 
that  the  amount  of  fibrous  tissue  is  much  greater.  These  nodes  are  not 
so  vascular;  they  are  tough  and  hard,  appearing  like  small  fibrous 
tumors.  The  capsules  are  greatly  thickened,  and  under  the  microscope 
is  seen  fibrous  tissue  arranged  in  concentric  layers,  often  inclosing  small 
caseous  masses.  These  nodes  less  frequently  form  adhesions  to  the  sur- 
rounding tissues,  and  consequently  are  freely  movable,  while  suppura- 
tion is  quite  exceptional.  Although  the  separate  tumors  are  much 
smaller  than  in  the  first  group,  the  glandular  mass  is  often  a  large  one, 
because  of  the  number  of  glands  involved. 

It  is  seldom  in  either  group  of  cases  that  the  process  is  limited  to  a 
single  node  or  even  to  two  or  three  nodes.  Very  often  an  entire  chain  is 
involved. 

Tuberculous  infection  of  the  lymph  nodes  may  terminate  in  resolu- 
tion, encapsulation,  calcification,  or  suppuration.  The  inflammation  may 
subside  before  caseation  has  taken  place  and  the  inflammatory  products 
undergo  absorption.  After  caseation  has  occurred  the  masses  may  be- 
come encapsulated  and  contract  to  small  fibrous  nodules.  Calcification 
of  the  glands  in  this  location  is  rare.-  In  other  cases  caseation  is  fol- 
lowed by  breaking  down,  liquefaction,  and  an  external  abscess.  The 
course  which  the  local  disease  takes  will  depend  upon  the  intensity  of  the 
infection  and  the  general  vigor  and  resistance  of  the  child.  There  is 
seen  in  most  cases  a  tendency  of  the  inflammation  to  subside  spon- 
taneously about  the  time  of  puberty.  Cure  has  sometimes  followed  an 
attack  of  intercurrent  disease,  such  as  erysipelas  of  the  face,  and  even 
scarlet  fever. 

Symptoms. — In  the  early  part  of  the  disease  there  are  no  symptoms 
but  the  glandular  swelling,  and  this  usually  begins  gradually.  In  many 
cases  both  sides  are  involved,  but  as  the  disease  progresses  the  advanced 
changes  are  usually  confined  to  one  side.  In  other  cases  the  first  swell- 
ing noticed  is  an  acute  one,  but,  unlike  other  acute  enlargements,  it  does 
not  subside,  but  persists.  The  symptoms  m  most  cases  are  characterized 
by  remissions  and  exacerbations ;  the  glands  increase  for  a  time  and  then 
remain  stationary  or  even  diminish,  to  take  a  new  start  from  the  stimu- 
lus of  some  fresh  infection  of  the  mucous  membrane  with  which  the 
glands  are  associated,  such  as  an  attack  of  measles  or  influenza,  or  sim- 
ply from  a  deterioration  in  the  patient's  general  health.  During  exacer- 
bation the  glands  may  be  painful  and  tender  and  show  the  usual  signs 
of  local  inflammation. 

The  whole  course  of  the  disease  varies  from  several  months  to  as 
many  years.  As  a  rule  the  younger  the  patient  the  more  rapid  its  prog- 
ress.   Treves  gives  three  and  a  half  years  as  the  average  duration  when 


870  DISEASES  OF  THE  LYMPH  NODES 

suppuration  occurs,  but  in  infancy  the  glands  sometimes  break  down  in 
two  or  three  months.  The  glands  first  affected  are  usually  those  situ- 
ated near  the  bifurcation  of  the  common  carotid  artery.  Such  tumors 
usually  make  their  appearance  just  in  front  of  the  sternomastoid  muscle 
— sometimes  behind  it — and  at  the  level  of  the  upper  border  of  the 
larynx  or  the  hyoid  bone.  In  the  more  rapid  cases  the  tumors  usu- 
ally attain  a  considerable  size  in  three  or  four  months,  sometimes  in 
half  that  time.  The  usual  size  reached  is  from  that  of  an  almond  to  an 
English  walnut.  At  first  the  tumors  are  movable  and  preserve  their 
distinct  outline;  later  they  become  adherent,  first  to  the  deeper  tissues 
and  to  each  other,  finally  to  the  skin,  and  there  is  formed  an  irregular 
nodular  mass  in  which  it  is  sometimes  difficult  to  make  out  the  individ- 
ual glands.  As  the  process  approaches  the  surface  there  are  small  spots 
of  softening ;  then  there  is  distinct  fluctuation ;  the  skin  becomes  discol- 
ored and  finally  gives  way,  and  there  is  a  discharge  of  thick,  curdy  pus, 
which  may  continue  for  an  indefinite  time,  until  the  whole  of  the  broken- 
down  gland  has  been  thrown  off.  This  course  is  repeated  with  each  suc- 
cessive gland  which  breaks  down.  In  cases  progressing  more  slowly  the 
glands  become  adherent  chiefly  to  one  another,  and  suppuration  is  less 
frequent. 

In  what  proportion  of  tuberculous  lymph  nodes  suppuration  occurs, 
it  is  difficult  to  say.  liike  other  tuberculous  lesions  in  the  body,  this  one 
is  much  more  frequent  than  was  once  supposed ;  formerly,  if  glands  did 
not  break  down  in  a  few  years,  they  were  usually  regarded  as  non-tuber- 
culous. We  now  know  that  a  large  number  of  tuberculous  glands  do  not 
break  down  for  many  years  and  some  never  do.  Two  forms  of  suppura- 
tion occur  in  connection  with  tuberculous  glands — one  an  abscess  of  the 
gland  proper,  the  other  outside  of  and  usually  over  it.  In  a  typical  case 
of  the  first  variety,  the  gland  is  distinctly  outlined  and  often  superficial, 
there  is  very  little  inflammation,  the  spot  of  softening  and  fluctuation  is 
small,  and  the  pus  discharged  is  always  curdy.  In  the  second  variety  the 
abscess  is  preceded  by  a  more  diffuse  swelling,  and  the  outline  of  the 
gland  may  not  be  made  out;  the  signs  of  inflammation  are  more  marked, 
the  area  of  fluctuation  is  larger,  and  the  pus  is  more  like  that  of  any 
ordinary  abscess.  Often  the  two  varieties  are  combined;  as  when  a 
gland  beneath  the  deep  fascia  breaks  down  and  there  is  formed  directly 
over  it  an  abscess  in  the  cellular  tissue,  which  communicates  through  a 
narrow  opening  with  the  gland  beneath.  In  such  cases  the  sinus  con- 
tinues open  for  a  very  long  time,  until  the  whole  of  the  gland  has  been 
discharged.  If  healing  occurs  before  this,  the  cicatrix  soon  breaks  down. 
When  abscesses  are  allowed  to  open  spontaneously,  large,  irregular, 
and  usually 'very  intractable  ulcers  form.  The  skin  is  undermined  for 
a  considerable  distance,  and  it  has  an  unhealthy  appearance.    Such  ulcers 


TUBERCULOUS  ADENITIS 


871 


sometimes  continue  for  many  months  in  spite  of  all  treatment,  particu- 
larly if  the  patient's  general  health  is  poor.  The  scars  left  after  them 
are  large  and  unsightly,  and  sometimes  positively  deforming  (Fig.  133). 
Their  appearance  is  quite  characteristic.  They  often  have  many  tabs  of 
skin  attached  to  them;  they  may  form  prominent  ridges  which  undergo 
contraction  like  those  after  burns;  they  are  of  a  purplish-red  color,  and 
adherent  to  the  deeper  tissues.  They  are  often  sensitive  and  painful. 
As  time  passes  they 
atrophy  and  become  less 
conspicuous,  though  they 
remain  throughout  life. 

The  general  health  of 
children  with  tubercu- 
lous glands  of  the  neck 
is  usually  but  little  af- 
fected. Although  the 
local  process  is  often  ex- 
tensive the  absence  of 
general  symptoms  is 
striking,  and  the  secon- 
dary development  of  gen- 
eralized tuberculosis  is 
infrequent.  Both  these 
facts  indicate  that  bovine 
infection  in  the  human 
subject  is  relatively 
mild.  At  any  time  in 
the  course  of  the  disease 
an  examination  of  the 
throat  often  shows  en- 
larged tonsils,  but  even 
when  they  are  not  gross- 
ly altered,  serial  section  proves  them  to  be  tuberculous  in  a  large  propor- 
tion of  the  cases. 

Prognosis. — Tuberculosis  of  the  external  lymph  nodes  is  seldom  if 
ever  the  direct  cause  of  death;  although  the  course  is  often  very  pro- 
tracted, ultimate  recovery  can  usually  be  predicted.  Treves  states  that 
the  percentage  of  those  who  die  from  general  tuberculosis  is  so  small 
that  this  danger  is  not  to  be  considered  an  argument  for  operation. 
Poore  reports  that  of  58  cases  treated  by  operation,  only  2  were  known 
to  have  died  from  tuberculosis.  Dowd  has  collected  reports  of  309  cases, 
chiefly  hospital  patients,  treated  by  removal  more  or  less  complete,  whose 
course  was  followed  for  several  years  after  operation.    Of  these,  203,  or 


Fig.  133. — Cicatbices  Following  a  Neglected  Case 
OF  Tubercttlous  Adenitis,  in  a  Girl  Seven 
Years  Old.  There  is  also  a  tuberculous  patch 
upon  the  skin  of  the  cheek  in  a  not  infrequent 
location. 


872  DISEASES  OF  THE  LYMPH  NODES 

65.4  per  cent,  were  apparently  cured;  57,  or  18.4  per  cent,  were  living, 
though  suffering  from  either  local  or  general  tuberculosisj  50,  or  16.2 
per  cent,  died  of  tuberculosis.  These  statistics  hardly  support  the  hope- 
ful views  of  the  writers  first  quoted^  but  they  are.  we  believe,  more  in 
accord  with  general  experience  in  the  class  which  makes  up  hospital 
patients.     In  private  practice  the  results  are  much  better. 

Diagnosis.- — The  diagnostic  features  of  tuberculous  glands  are  the 
age  of  the  patient — usually  from  two  to  ten  years — the  site  of  the  pri- 
mary swelling,  the  indolent  course,  the  trifling  original  cause,  and  the 
disposition  to  slow  caseation,  softening,  and  abscess.  The  cutaneous  tu- 
berculin reaction  is  of  great  assistance  in  diagnosis;  in  a  young  child  a 
positive  reaction  is  significant,  while  at  any  age  a  negative  reaction  is 
usually  conclusive.  The  cases  of  simple  inflammation  are  usually  in  chil- 
dren under  three  years,  their  progress  is  much  more  rapid.  If  they  do  not 
break  down  they  generally  disappear  in  the  course  of  four  or  five  months. 
They  usually  suppurate,  if  at  all,  during  the  first  month.  Chronic  glan- 
dular enlargements  which  persist  are  usually  tuberculous,  no  matter 
how  good  the  surroundings  or  the  general  health.  Syphilitic  disease  of 
the  cervical  glands  is  relatively  rare  in  children.  It  is  recognized  by 
the  Wassermann  test,  by  the  evidence  of  syphilis  elsewhere,  and  by  the 
effect  of  treatment.  In  Hodgkin's  disease,  glandular  groups  in  other 
parts  of  the  body  are  involved  simultaneously  or  in  rapid  succession. 
There  are  no  signs  of  inflammation  or  caseation;  and  the  swellings  are 
usually  accompanied  by  very  marked  and  definite  general  symptoms  and 
blood  changes.  Malignant  growths  are  very  rare ;  they  increase  rapidly, 
often  attaining  a  great  size  in  a  few  months. 

Treatment. — As  the  tonsils  are  so  frequently  the  seat  of  infection  it 
is  important  to  examine  these  most  carefully  in  every  case.  Unless  it  is 
entirely  clear  that  they  are  free  from  disease  they  should  be  removed. 
Eemoval  of  tuberculous  tonsils  is  sufficient  in  many  cases  to  bring  about 
cessation  of  the  process  in  the  cervical  glands.  Many  begin  to  diminish 
in  size  shortly  after  tonsillectomy.  If  it  is  done  early  in  the  disease 
suppuration  of  the  glands  is  much  less  likely  to  occur.  Adenoid  growths 
of  the  rhinopharynx  and  carious  teeth  should  also  receive  attention. 

A  child  from  the  city  should  be  sent  into  the  country  whenever  this 
is  possible.  The  seaside  has  a  great  reputation  in  such  cases  and  no 
doubt  the  majority  do  very  well  there,  but  some  are  benefited  even  more 
by  a  dry  moimtain  climate.  Climatic  treatment  is  to  be  recommended 
particularly  for  those  children  who  have  pulmonary  lesions  and  there- 
fore infection  with  the  human  type  of  organism.  Those  with  only  tonsil- 
lar and  glandular  tuberculosis  do  well  with  the  removal  of  the  focus. 
This  should  not  be  neglected  in  any  case. 

Drugs  are  of  little  benefit.     Cod-liver  oil,  arsenic  and  iron  are  useful 


TUBERCULOUS  ADENITIS  873 

only  as  general  tonics.  Local  applications  are  of  little  value.  The  parts 
should  not  be  rubbed  or  handled. 

Brilliant  results  have  been  reported  by  Eollier  of  Switzerland  of 
treatment  by  heliotherapy,  or  the  exposure  of  the  diseased  parts  directly 
to  the  sun's  rays.  This  is  especially  to  be  recommended  for  old  cases 
with  extensive  lesions,  when  complete  removal  is  impossible  or  when 
operation  wounds  do  not  heal. 

Operative  Measures. — These  are  indicated,  if  after  the  removal  of  the 
probable  foci  and  a  trial  for  a  few  months  of  climatic  and  general  meas- 
ures, the.glands  do  not  diminish  but  rather  increase  in  size  and  number, 
or  if  there  are  signs  of  softening.  The  advantages  of  operation  are  that 
it  leaves  a  clean  scar  which  when  the  incision  is  properly  made  is  almost 
imperceptible ;  that  it  shortens  the  disease ;  that  if  thoroughly  done  and 
the  deep  as  well  as  the  superficial  glands  are  removed,  it  is  a  radical 
measure.  The  best  results  follow  when  operation  is  done  reasonably 
early  before  the  skin  is  involved  or  the  glands  have  softened  or  have 
formed  extensive  adhesions  to  the  great  vessels  and  neighboring  struc- 
tures; also  when  a  chain  of  glands  is  involved  and  when  the  inflamma- 
tory process  is  slow  or  indolent.  A  thorough  operation  by  a  good  sur- 
geon in  the  great  majority  of  cases  -will  result  in  a  permanent  cure. 
However,  the  operation  is  not  contra-indicated  in  cases  which  have  gone 
on  to  a  later  stage,  although  the  results  may  not  be  quite  so  satisfactory. 

If  more  radical  measures  are  for  any  reason  impossible,  glandular 
abscesses  should  be  opened  as  soon  as  pus  forms,  to  prevent  the  extensive 
undermining  of  the  skin,  which  is  likely  to  occur.  The  opening  should 
be  a  small  one,  and  all  squeezing  of  the  gland  or  surrounding  tissues 
avoided. 

As  an  alternative  to  operative  measures,  or  when  these  are  refused, 
exposure  to  the  X-ray  may  be  tried  and  in  a  certain  proportion  of  cases 
it  is  curative.  The  best  results  are  seen  in  the  early  cases.  The  first 
exposures  should  be  short,  and  they  should  be  repeated  not  oftener  than 
once  a  week. 

Tuherculin  Treatment. — This  has  been  employed  extensively  with 
a  number  of  different  preparations  obtained  from  cultures  of  tubercle 
bacilli.^  It  is  the  general  consensus  of  opinion  that  this  method  of  treat- 
ment is  of  benefit,  and  that  it  diminishes  the  tendency  to  softening  and 
promotes  resolution.  Our  own  .belief  is  that  it  should  not  and  can  not 
take  the  place  of  operative  measures. 

^The  preparations  of  tuberculin  most  widely  used  are  B.F.  (bouillon  filtr6) 
of  Denys;  O.T.  (original  tuberciilin )  ;  T.R.  (tuberculin  residue),  and  B.E. 
(bacillary  emulsion). 

The  doses  are  calculated  in  milligrams,  it  being  considered  that  one  cubic 
centimeter  of  the  fluid  weighs  one  gram,  which  is  nearly  if  not  quite  the  ca.se. 


874  DISEASES  OF  THE  LYMPH  NODES 

The  purpose  is  to  give  enough  tuberculin  to  affect  the  local  process, 
but  never  enough  to  produce  a  general  systemic  reaction — fever,  malaise, 
swelling  of  the  glands,  etc.  It  is  necessary  to  begin  with  a  very  small 
dose  and  to  increase  this  gradually.  If  there  is  any  elevation  of  tempera- 
ture following  an  injection,  the  amount  should  be  diminished  to  a  quarter 
or  less  of  the  dose  given  and  a  return  made  to  the  amoimt  causing  the 
reaction  only  after  several  weeks.  The  best  indication  that  one  has 
I'eached  the  point  where  an  increase  in  dosage  is  to  be  made  with  especial 
care,  is  the  reaction  produced  at  the  site  of  injection.  When  this  is  made 
subcutaneously  there  may  be  around  the  point  of  injection  a  slight  swell- 
ing, induration  and  tenderness  for  some  days.  Injections  should  be  re- 
peated every  four  or  five  days.  An  initial  dose  of  .00002  mgm.  is  proper 
for  an  average  child  of  two  or  three  years.  The  dose  may  be  doubled  at 
each  injection  until  .05  mgm.  is  injected.  After  this  it  is  safer  to  re- 
peat the  same  dose  two  or  three  times  before  increasing  further  and  to 
give  this  dose  at  weekly  intervals.  It  is  not  advisable  to  increase  beyond 
.1  gm.  as  the  maximum  dose.  The  duration  of  treatment  will  depend 
upon  the  effect  upon  the  glands.  It  is  usually  several  months.  Even 
when  the  results  have  been  favorable  it  is  considered  advisable  by  many 
to  repeat  the  course  of  treatment  after  an  interval  of  some  months. 

HODGKIN'S  DISEASE 

{Pseudo-Leukemia) 

Hodgkin's  disease  at  the  present  time  is  to  be  considered  a  distinct 
clinical  and  pathological  entity.  For  many  years  there  was  no  general 
agreement  regarding  its  determining  characteristics  and  in  the  older 
literature  many  cases  were  included  which  were  undoubtedly  not  Hodg- 
kin's disease.  The  condition  is  relatively  rare.  In  infancy  it  is  almost 
unknown,  but  after  the  age  of  three  years  it  is  found  with  increasing 
frequency  throughout  childhood.  It  is  much  more  common  in  males. 
The  essential  cause  of  Hodgkin's  disease  is  unknown.  Numerous  organ- 
isms have  been  described  in  connection  with  it,  especially  modified  forms 
of  the  tubercle  bacillus  and  more  recently  diphtheroid  bacilli.  It  is 
doubtful  if  the  disease  results  from  infection  with  any  of  them. 

Pathology. — The  chief  lesion  is  in  the  lymph  nodes,  which  become 
greatly  enlarged  and  in  addition  new  ones  develop  during  the  course  of 
the  disease.  Those  first  affected  are  usually  in  the  neck,  but  any  of  the 
external  or  internal  groups  of  lymph  nodes  may  be  affected  and  in 
severe  cases  the  disease  may  involve  almost  every  chain  of  glands  in  the 
body.  Of  the  internal  glands  those  of  the  mediastinum  and  retro- 
peritoneal region  are  usually  most  affected.     Large  masses  arc  formed 


HODGKIN'S  DISEASE  875 

by  the  growth  and  multiplication  of  the  lymph  nodes^  but  even  in  the 
largest  masses  the  individual  nodes  are  discrete  and  are  held  together 
only  by  loose  connective  tissue.  The  spleen  is  usually,  the  liver  less  fre- 
quently, involved  and  somewhat  enlarged  by  the  formation  of  lymphoma- 
tous  masses,  which  may  also  infiltrate  almost  any  tissue  of  the  body. 
Microscopically,  the  early  changes  in  the  glands  consist  in  an  increase 
in  the  lymphoid  tissue.  Later  there  is  proliferation  of  the  endothelial 
cells,  the  formation  of  giant  cells  and  an  overgrowth  of  connective  tissue. 
The  eosinophile  cells  are  frequently  present  in  the  tissues  in  great  num- 
bers. The  lymphomatous  masses  in  the  spleen  and  other  organs  have 
the  same  structure  microscopically  as  the  diseased  nodes. 

Symptoms. — The  first  evidence  of  disease  is  usually  the  swelling  of 
one  or  more  cervical  glands.  Thereafter  there  is  a  progressive  involve- 
ment of  other  glands,  though  the  rapidity  with  which  this  occurs  may 
vary  greatly.  At  the  beginning  the  general  health  remains  unaffected 
and  this  usually  continues  until  the  glandular  enlargement  is  wide- 
spread. Then  a  more  or  less  persistent  fever  may  develop  or  anemia 
supervene  or  pressure  symptoms  make  themselves  evident. 

The  fever  may  be  irregular,  with  wide  excursions  and  periods  of  re- 
mission, or,  what  is  more  common,  it  may  be  only  of  a  degree  or  two  but 
persistent.  The  blood  shows  the  characteristics  of  a  secondary  anemia, 
which  increases  in  severity.  The  leucocytes  may  be  slightly  diminished 
or  increased,  but  in  the  late  stages  there  is  usually  a  polymorphonuclear 
leucocytosis  (20,000-30,000  or  more).  There  are  two  constant  features, 
an  increase  in  the  blood  platelets  and  an  increase  in  the  transitional  leu- 
cocytes. Eosinophiles,  while  usually  somewhat  diminished,  may  be 
present  in  great  numbers. 

The  glandular  masses  can  be  felt  to  be  made  up  of  discrete  glands. 
These  are  elastic,  sometimes  distinctly  soft,  at  others,  firm.  They  are 
more  or  less  movable  and  not  adherent  to  the  deeper  structures  nor  to 
the  skin  over  them.  At  any  time  symptoms  may  appear  as  the  result 
of  the  mechanical  pressure  of  the  glands.  This  may  be  on  the  vessels 
of  the  neck  or  extremities,  producing  edema;  upon  the  esophagus,  pro- 
ducing dysphagia;  or  upon  the  trachea  or  bronchi,  producing  dyspnea. 
Intra-abdominal  pressure  may  cause  jaundice  or  chylous  ascites.  In 
most  cases  enlargement  of  the  spleen  can  be  made  out.  In  some  in- 
stances it  is  extreme. 

The  duration  of  the  disease  is  usually  less  than  three  j^ears,  some- 
times only  a  few  weeks.  There  may  be  periods  in  which  the  progress 
seems  arrested,  but  they  are  usually  short.  Death  results  from  asthenia, 
or  from  pressure  usually  upon  the  respiratory  tract,  producing  slow  suffo- 
cation with  most  distressing  symptoms.  The  prognosis  is  bad.  We 
know  of  no  children  with  Hodgkin's  disease  that  have  recovered. 


876  DISEASES  OF  THE  DUCTLESS  GLANDS 

Biagnosis. — The  diagnosis  of  Hodgkin's  disease  may  be  difficult  at 
the  beginning,  when  only  a  few  cervical  glands  are  enlarged.  It  may 
be  confounded  with  glandular  tuberculosis,  with  lymphosarcoma  and 
with  leukemia.  From  tuberculosis  it  is  to  be  differentiated  by  the  wide 
distribution  of  the  progressively  enlarging  glands;  by  their  failure  to 
coalesce,  to  exhibit  inflammatory  reaction  or  to  suppurate ;  by  the  fre- 
quent absence  of  the  von  Pirquet  reaction  and  by  the  more  malignant 
course  and  pressure  symptoms.  Lymphosarcoma  is  more  rapid  in  its 
course,  does  not  usually  cause  fever,  the  glands  do  not  remain  so  discrete 
as  in  Hodgkin's  disease  and  the  spleen  is  seldom  involved.  Leukemia  is 
distinguished  by  less  lymphatic  enlargement,  by  greater  rapidity  of  prog- 
ress, especially  in  the  lymphatic  form,  and  especially  by  the  character  of 
the  blood  findings.  In  doubtful  cases  the  excision  and  examination  of 
a  gland  will  almost  always  give  reliable  information  as  to  the  presence 
or  absence  of  Hodgkin's  disease. 

Treatment. — This  is  very  unsatisfactory,  but  some  remedies  appar- 
ently are  of  temporary  benefit.  Arsenic  in  full  doses  appears  to  benefit 
some  patients.  The  use  of  the  X-ray  has  produced  striking  but  not 
permanent  improvement  in  the  external  glands.  Eecently  vaccines  pre- 
pared from  the  diphtheroid  bacilli  cultivated  from  the  glands  have  been 
employed.  It  is  too  early  to  judge  of  the  influence  of  this  method  of 
treatment.  Tracheotomy  occasionally  is  employed  to  relieve  dyspnea^ 
but  is  seldom  indicated  because  the  obstruction  to  respiration  is  usually 
situated  very  low  in  the  neck  or  in  the  thorax. 


CHAPTEE  III 


DISEASES  OF  THE  DUCTLESS  GLANDS 
THE  SPLEEN 

Weight. — From   l-IU  observations  made  at  the  New  York  Infant 
Asylum  the  following  were  the  weights  recorded  at  the  different  ages : 


Age. 

Ounces. 

Grams. 

Birth                 

13^ 

7  7 

Three  months 

15  5 

Twelve  months 

23  2 

Two  years 

38  5 

Three  years 

46  4 

DISEASES  OF  THE  SPLEEN  877 

Position  and  Methods  of  Examination. — The  normal  position  of  the 
spleen  is  close  against  the  diaphragm,  its  external  surface  being  opposite 
the  ninth,  tenth,  and  eleventh  ribs.  Its  anterior  border  comes  as  far 
forward  as  the  middle  axillary  line,  its  posterior  border  being  usually 
near  the  vertebral  column.  In  infancy  it  is  practically  impossible  to 
outline  the  spleen  by  percussion  unless  it  is  enlarged.  During  full  in- 
spiration the  spleen  is  often  depressed  enough  to  be  felt  at  the  free  border 
of  the  ribs,  but  at  other  times  it  can  not  be  felt  unless  it  is  enlarged  or 
pushed  downward  by  some  pathological  condition  in  the  chest.  Nor- 
mally, the  long  axis  of  the  spleen  is  nearly  parallel  with  the  ribs,  but 
when  the  organ  is  much  enlarged,  its  axis  corresponds  nearly  with  a  line 
drawn  from  the  axillary  line  at  the  border  of  the  ribs  to  the  middle  of 
Poupart's  ligament. 

The  thin  abdominal  walls  of  young  children  render  palpation  of  the 
spleen  much  easier  than  in  adults ;  and  this  is  a  much  more  satisfactory 
method  of  examination  than  is  percussion.  For  satisfactory  palpation 
it  is  necessary  that  the  abdominal  walls  should  not  be  tense.  The  child 
should  lie  upon  his  back  with  the  thighs  flexed  and  the  skin,  of  course, 
bared.  The  physician,  always  having  taken  the  trouble  to  warm  his 
hands,  should  stand  upon  the  left  side  of  the  patient  and  make  pressure 
with  the  tips  of  the  fingers,  which  are  semi-flexed.  The  pressure  should 
be  at  first  light,  and  gradually  increased,  the  fingers  being  then  held 
stationary  during  two  or  three  respiratory  movements.  Under  ordinary 
conditions  the  spleen  can  easily  be  felt  when  it  is  sufficiently  enlarged 
to  be  of  any  diagnostic  importance. 

When  moderately  enlarged,  the  lower  border  of  the  spleen  is  an  inch 
or  so  below  the  free  border  of  the  ribs ;  when  greatly  enlarged,  it  forms 
a  tumor  which  may  nearly  fill  the  left  half  of  the  abdomen.  A  tumor 
in  the  left  hypochondriac  region  is  recognized  to  be  the  spleen,  by  the 
fact  that  it  is  freely  movable  laterally  and  at  its  lower  border  or  ex- 
tremity, while  it  is  attached  above;  also  its  inner  border  can  usually 
be  felt  to  be  thin  and  sharp,  and  marked  about  its  middle  by  quite  a 
deep  notch. 

ENLARGEMENT  OF  THE  SPLEEN 

In  Acute  Disease. — The  spleen  is  most  frequently  and  most  con- 
stantly enlarged  in  malarial  and  typhoid  fevers,  but  it  is  occasionally  so 
in  all  the  acute  infectious  diseases. 

In  most  of  these  cases  the  enlargement  is  chiefly  from  congestion,  but 
there  may  be  acute  hyperplasia  and  an  increase  in  size  of  the  Malpighian 
bodies.  It  may  contain  small  hemorrhages,  and  in  extremely  rare  cases 
the  spleen  may  rupture.     It  is  generally  dark-colored,  soft,  and  some- 


878  DISEASES  OF  THE  DUCTLESS  GLANDS 

what  friable.  In  the  cases  which  recover,  the  splenic  swelling  subsides 
with  the  original  disease. 

In  Chronic  Disease. — Like  the  lymph  nodes,  the  spleen  is  much  more 
often  enlarged  in  children,  particularly  young  children,  than  in  adults. 
Enlargement  is  seen  at  times  in  almost  all  the  chronic  diseases  of  early 
life;  but  it  occurs  most  frequently  in  rickets,  syphilis,  malaria,  tuber- 
culosis, the  blood  diseases,  and  in  amyloid  degeneration.  Besides,  it  may 
be  the  seat  of  a  primary  growth,  either  benign  or  malignant. 

Rickets. — The  splenic  enlargement  which  accompanies  rickets  is  gen- 
erally seen  during  the  first  year;  at  this  period  it  is  very  frequent.  The 
swelling  is  usually  moderate,  but  occasionally  it  is  so  great  that  the 
lower  border  is  three  or  four  inches  below  the  ribs. 

Syphilis. — Enlargement  of  the  spleen  is  one  of  the  most  constant 
lesions  of  hereditary  syphilis.  It  is  present  with  great  uniformity  in 
children  born  with  syphilitic  lesions,  and  very  frequently  during  the 
active  period  of  the  disease  in  early  infancy.  It  is  seen  at  a  later  period 
during  infancy  or  childhood,  associated  with  other  late  symptoms. 

Malaria. — The  swelling  in  cases  of  chronic  malaria  may  be  very  great. 
The  liver  is  not  so  often  enlarged  as  in  syphilis. 

Tuberculosis. — It  is  rare  to  find  anything  more  than  a  moderate 
swelling  of  the  spleen  in  pulmonary  tuberculosis.  In  general  miliary 
tuberculosis,  enlargement  of  the  spleen  is  an  almost  constant  finding. 
The  enlargement  is  usually  progressive,  due  to  an  increase  in  the  number 
and  size  of  the  tuberculous  deposits  which  are  regularly  present. 

Diseases  of  the  Blood. — Marked  enlargement  of  the  spleen  is  found  in 
many  cases  of  secondary  anemia.  The  spleen  is  constantly  swollen,  and 
usually  greatly  so,  in  the  pseudoleukemic  anemia  of  infants,  in  leukemia, 
and  in  Hodgkin's  disease.  In  the  last  two  diseases  the  liver  is  also  en- 
larged, but  to  a  much  less  degree  than  the  spleen ;  in  the  others  it  is  but 
slightly  changed. 

Amyloid  Degeneration. — The  spleen  is  constantly  involved  in  amy- 
loid disease,  and  the  enlargement  of  this  organ,  as  well  as  that  of  the 
liver,  may  be  very  great. 

Cardiac  Disease. — In  all  forms  of  cardiac  disease,  and  in  other  con- 
ditions in  which  there  is  obstruction  to  the  systemic  venous  circulation, 
the  spleen  is  enlarged.  It  is  seen  in  congenital  as  well  as  in  acquired 
cases.  The  liver  is  usually  enlarged,  and  there  may  also  be  edema  of 
the  feet  or  general  anasarca. 

New-groivths,  Tumors,  etc. — It  is  seldom  in  early  life  that  the  spleen 
is  the  seat  of  new-growths;  these  are  usually  varieties  of  sarcoma,  but 
carcinoma  has  also  been  reported. 

Banti's  Disease — Splenic  Anemia. — These  are  rather  unsatisfactory 
terms  which  are  used  to   designate   a   clinical   couditiuii   which   is,    at 


DISEASES  OF  THE  SPLEEN  879 

times,  capable  of  sharp  differentiation,  but  which  pathologically  has  no 
especially  distinguishing  features.  In  the  late  stages,  the  lesions  are 
essentially  those  of  periportal  cirrhosis  of  the  liver.  The  spleen  is 
greatly  enlarged  and  shows  a  marked  increase  in  the  fibrous  tissue  both 
of  the  capsule  and  reticulum.  In  the  early  stages  the  Malpighian 
bodies  may  be  enlarged.  In  the  late  stages  they  are  small  and  in- 
frequent. 

The  onset  is  late  in  childhood,  usually  not  before  the  tenth  year,  and 
the  progress  is  slow.  Attention  is  generally  first  attracted  to  the  anemia 
and  the  symptoms  that  accompany  it,  such  as  dyspnea  on  exertion  and 
cardiac  palpitation.  The  anemia  has  the  characteristics  of  a  secondary 
anemia.  There  is  usually  a  moderate,  relative  increase  of  the  lympho- 
cytes. There  may  be  from  time  to  time  slight  rises  of  temperature  and 
occasionally  epistaxis.  Physical  examination  shows  in  such  instances  a 
moderately  enlarged  and  firm  spleen.  The  splenic  enlargement  is  very 
slow  but  progressive.  It  is  never  extreme.  After  a  time  a  slight  in- 
crease in  size  of  the  liver  occurs.  The  progress  of  the  disease  is  very 
gradual.  A  fair  degree  of  health  may  be  maintained  for  ten  or  twelve 
years.  Then  there  are  superadded  the  evidences  of  hepatic  cirrhosis. 
The  liver  diminishes  in  size  until  it  can  no  longer  be  felt.  There  may 
be  icterus  and  urobilinuria  and  eventually  ascites  vdth  dilatation  of  the 
abdominal  veins,  hematemesis  and  submucous  hemorrhages.  Death 
usually  occurs  from  some  intercurrent  disease  before  the  development 
of  the  evidences  of  hepatic  insufficiency  and  obstruction. 

The  justification  for  considering  Banti's  disease  a  clinical  entity, 
distinct  from  cirrhosis  of  the  liver,  with  which  the  pathological  findings 
are  nearly  identical,  rests  upon  the  duration  of  the  symptoms,  the  dis- 
proportionately large  spleen  and  the  frequent  absence  of.  ascites  and 
icterus.  The  course  of  true  cirrhosis  of  the  liver  in  the  young  is  often 
rapid;  the  duration  is  usually  a  year  or  less.  The  enlargement  of  the 
spleen  is  generally  slight,  while  ascites  often  develops  early  and  is  very 
obstinate.  Syphilis  of  the  liver  and  spleen  may  be  difficult  to  differen- 
tiate from  Banti's  disease  by  physical  examination  alone,  and  several 
cases  diagnosed  as  Banti's  disease  have  been  shown  at  autopsy  to  be  syphi- 
litic in  origin.  The  evidence  afforded  by  the  Wasserniann  reaction  and 
by  careful  examination  for  syphilis  of  other  parts  of  the  body  should  be 
sought.  Hemolytic  jaundice  may  be  excluded  if  there  is  no  increased 
fragility  of  the  red  cells.  In  Gaucher's  disease  the  progress  is  also  slow 
and  a  reasonable  degree  of  health  may  be  maintained  for  many  years. 
There  is  often,  however,  a  history  of  several  cases  in  the  same  family; 
there  may  be  a  brownish  discoloration  of  the  skin;  after  some  years  the 
liver  is  also  enlarged  and  the  spleen  eventually  reaches  proportions  found 
in  no  other  disease. 


880  DISEASES  OF  THE.  DUCTLESS  GLANDS 

It  has  been  maintained  by  Banti  that  the  spleen  is  the  primary  factor 
in  the  disease  and  that  the  liver  is  secondarily  affected.  There  is  little 
to  substantiate  this  view,  except  that  in  the  early  stages  of  the  disease 
striking  benefit  results  from  splenectomy.  Sufficient  time  has  not  yet 
elapsed,  nor  have  sufficient  cases  been  recorded,  to  prove  how  permanent 
the  benefit  will  be.  It  is  clear,  however,  that  splenectomy  is  indicated 
in  the  stages  of  the  disease  before  serious  involvement  of  the  liver. 
When  ascites  has  developed  palliative  treatment  alone  should  be  em- 
ployed. 

Hemolytic  Jaundice — Chronic  Family  Jaundice. — This  disease  is 
usually  hereditary,  but  it  occasionally  exists  in  several  brothers  and  sis- 
ters, the  parents  being  unaffected.  Similar  cases  may  be  seen  without  a 
family  association.  There  are  records  of  many  families  in  which  jaun- 
dice has  existed  through  three  or  four  generations.  It  is  transmitted 
alike  through  the  male  and  female  descendants,  and  not  all  of  the  chil- 
dren in  a  family  are  affected.  The  descendants  of  unaffected  members 
escape.  The  jaundice  may  be  noticed  shortly  after  birth,  or  it  may  de- 
velop at  any  time  during  childhood,  sometimes  not  until  later.  This  is 
the  most  striking  feature  of  the  disease.  The  discoloration  may  be  very 
slight  and  noticeable  only  in  the  sclerotics,  or  the  skin  may  be  icteric. 
The  color  is  never  very  intense.  It  varies  somewhat  in  degree  and  is  in- 
creased after  intercurrent  gastro-intestinal  attacks,  Avhich  are  rather  fre- 
quent.    When  once  developed,  the  icterus  never  entirely  disappears. 

This  jaundice  is  not  obstructive;  the  stools  are  usually  darker  than 
normal  and  the  urine  contains  urobilin  in  excess,  but  no  bile.  There  is 
an  increased  production  of  biliary  pigment.  The  liver  is  normal  or 
slightly  enlarged.  The  spleen  is  regularly,  and  often  excessively,  en- 
larged, and  even  in  youth  there  may  be  attacks  of  biliary  colic  and  of 
perisplenitis.  Anemia  of  a  moderate  grade  is  the  rule.  Both  the  red 
cells  and  hemoglobin  are  reduced,  and  a  few  nucleated  red  cells  may  be 
found.  Eeticulated  red  cells  may  be  demonstrated  by  means  of  vital 
staining.  As  many  as  20  per  cent  of  the  total  red  cells  may  be  reticu- 
lated as  opposed  to  the  normal  of  1  per  cent  or  less.  Very  characteristic 
of  the  disease  is  the  increased  fragility  of  the  red  cells  to  hemolytic 
agents,  especially  to  hypotonic  salt  solutions.  Xormal  red  cells  are  not 
hemolyzed  by  solutions  of  sodium  chlorid  of  a  concentration  of  0.5  per 
cent  or  more.  With  salt  solutions  of  0.45  per  cent  hemolysis  begins  and 
is  complete  with  those  of  0.35  per  cent.  With  hemolytic  jaundice  hemol- 
ysis usually  begins  with  solutions  of  a  concentration  between  0.7  and  0.6 
per  cent  and  is  complete  with  those  between  0.55  and  0.45  per  cent. 

The  growth  and  development  of  children  go  on  uninfluenced  by  the 
condition,  and  many  affected  persons  have  lived  to  an  advanced  age. 
There  are  no  characteristic  post-mortem  findings.    Yarions  driigs.  among 


DISEASES  OF  THE  SPLEEN  881 

them  iron  and  arseuic,  have  been  employed  in  treatment.  The  only 
effective  method  is  surgical.  Splenectomy  has  been  employed  with 
marked  improvement  in  several  instances.  In  some  cases,  symptomatic 
cure  has  been  reported.  Splenectomy  should  be  done  if  there  is  much 
interference  with  the  patient's  general  health. 

Gaucher's  Disease. — This  is  a  rare  disease,  which  frequently  attacks 
two  or  more  members  of  a  family,  but  is  not  hereditary.  It  usually  be- 
gins before  the  age  of  ten  years  and  cases  have  been  reported  in  the  first 
year  of  life.  The  most  striking  feature  is  an  enlargement  of  the  spleen, 
which  is  slowly  progressive  and  may  eventually  nearly  fill  the  abdomen. 
It  is  firm,  smooth  and  not  tender.  While  never  reaching  the  proportions 
of  the  spleen,  the  liver  may  be  considerably  increased  in  size.  It  is  also 
.smooth.  A  secondary  anemia  with  leucopenia  is  constantly  present  but 
is  not  severe.  Associated  with  this  is  a  peculiar  brown  discoloration  of 
1he  skin,  particularly  of  the  face.  In  some  instances,  there  is  a  yellowish 
wedge-shaped  thickening  of  the  conjunctiva  on  either  side  of  the  cornea. 
The  superficial  lymph  glands  may  be  palpable,  but  are  not  materially 
increased  in  size.  The  general  health  may  be  fair  for  many  years.  The 
splenic  and  hepatic  enlargements  may  cause  abdominal  discomfort  and 
even  pain,  but  it  is  rare  for  jaundice  or  ascites  to  develop.  Eventually 
hemorrhages  may  occur  from  slight  traumatism  or  spontaneously  from 
the  mucous  membranes. 

The  disease  may  last  many  years.  Death  usually  results  from  some 
intercurrent  disease.  While  the  origin  of  the  disease  is  obscure,  the 
l)athological  findings  are  entirely  distinctive.  Microscopically  it  is  seen 
that  the  enlargement  of  the  liver  and  spleen  is  due  to  the  accumulation 
of  characteristic  cells  which  widely  invade  these  organs.  The  cells  are 
very  large,  with  small  excentrically  situated  nuclei  and  with  slightly 
granular  cytoplasm.  These  cells  are  found  not  only  in  the  spleen  but 
also  in  the  bone  marrow  and  lymph  glands.  The  accumulation  in  the 
lymph  glands  is  not  sufficient  to  cause  marked  enlargement,  but  is  im- 
portant as  showing  that  the  disease  is  a  systemic  one,  and  not  primarily 
one  confined  to  the  spleen.  The  presence  of  the  distinctive  cells  in  the 
.  glands  may  be  of  assistance  in  diagnosis,  as  in  a  case  reported  by  Knox, 
in  which  the  suspected  diagnosis  was  confirmed  by  the  microscopical 
examination  of  an  excised  lymph  node. 

Medical  treatment  does  not  influence  the  course  of  the  disease.  On 
a  priori  grounds  it  does  not  seem  likely  that  splenectomy  will  produce 
permanent  cure  in  a  disease  whose  lesions  are  so  widely  distributed  in 
other  organs.  A  number  of  cases,  however,  have  been  operated  upon  and 
some  have  shown  a  distinct  improvement.  The  time  that  has  elapsed  in 
the  majority  is,  however,  too  short  to  enable  a  definite  conclusion  as  to 
the  final  result  to  be  reached. 


882  DISEASES  OF  THE  DUCTLESS  GLANDS 

DISEASES  OF  THE   THYROID 
SPORADIC  CRETINISM 

(Athyreosis;   Myxedematous  Idiocy) 

Since  the  early  descriptions  of  this  disease  by  Fagge,  in  1871  and 
1874,  numerous  cases  have  been  published  in  England,  on  the  continent 
of  Europe,  in  America,  and  in  fact,  all  over  the  world,  showing  that 
sporadic  cretinism  is  not  confined  to  any  country.  The  condition  is  a 
relatively  rare  one,  but  in  a  large  dispensary  and  hospital  service  one  or 
more  examples  of  it  are  seen  every  year. 

Etiology. — It  is  now  well  established  that  this  condition  depends 
upon  the  absence  of  the  internal  secretion  of  the  thyroid  gland.  In 
almost  all  the  autopsies  in  cases  of  sporadic  cretinism  that  have  been 
reported  there  has  been  an  entire  absence  of  the  thyroid  gland.  Not  even 
a  trace  of  it  has  been  found.  In  one  or  two  instances  cysts  have  been 
met  with  in  the  region  of  the  lateral  rudiments  of  the  thyroid  gland,  or 
at  the  root  of  the  tongue  in  the  region  of  the  median  rudiment.  These 
cysts  may  contain  a  few  cells  resembling  thyroid  tissue,  but  nothing 
that  is  apparently  capable  of  functionating.  There  are  no  recorded  ob- 
servations upon  cases  of  sporadic  cretinism  that  would  indicate  that  an 
already  developed  thyroid  gland  had  been  affected  by  injury  or  disease. 
The  absence  is  due  to  a  congenital  lack  of  development  such  as  produces 
anencephaly  or  the  absence  of  other  parenchymatous  organs.  As  a  rule 
only  one  case  occurs  in  a  family,  the  other  members  of  which  present 
nothing  abnormal  in  mental  or  physical  development. 

There  are  associated  no  constant  changes  in  the  other  ductless  glands. 
In  the  few  cases  in  which  the  parathyroids  have  been  searched  for  at 
autopsy  they  have  been  found.  Alterations  in  the  pituitary  gland  have 
been  quite  frequently  reported.  It  has  been  found  hypertrojohic  and 
occasionally  cystic,  but  this  is  not  constant. 

Symptoms. — The  symptoms  of  cretinism  in  most  cases  make  their 
appearance  during  the  second  half  of  the  first  year,  but  are  sometimes 
so  slight  as  not  to  be  noticed  until  children  are  two  or  three  years  old. 
Very  rarely  the  condition  is  recognized  as  early  as  the  third  or  fourth 
month.  The  delay  in  the  development  of  the  symptoms  is  to  be  ascribed 
to  the  protection  afforded  the  infant  by  the  thyroid  secretion  of  the 
mother  during  intrauterine  life.  This  view  is  substantiated  by  the  rare 
but  undoubted  instances  where  women  with  either  goiter  or  hyperthyroid- 
ism have  borne  infants  with  cretiiiism  which  was  clinically  recognizable 
at  birth.     Failure  to  grow  and  to  develop  mentally  are  usually  the  first 


SPOEADIC  CRETINISM 


883 


things  to  attract  attention.  The  peculiarity  of  the  facial  expression  is 
soon  noticed.  The  general  appearance  of  the  cretin  is  striking,  and  so 
characteristic  that  when  once  seen  the  disease  can  hardly  fail  to  be  recog- 
nized (Fig.  134).  The  body  is  greatly  dwarfed,  and  children  of  fif- 
teen years  are  often  only  two  and  a  half  or  three  feet  in  height.  All 
the  extremities,  the  fingers  and  the  toes,  are  short  and  thick.  With 
cretins  of  ten  years  of  age,  or  even  more,  the  rclativo  infantile  proportions 


Fig.  134. — A  Typical  Cretin; 
Two  AND  A  Half  Years 
Old.  a  patient  in  the  Babies' 
Hospital. 


Fig.  135. — Same  Patient  at  Six  and  One-third 
Years. 


of  the  body  are  maintained.  There  is  almost  complete  lack  of  growth  at 
the  epiphyseal  junctions  and  there  is  great  delay  in  the  development  of 
the  centers  of  ossification.  X-ray  studies  show  that  the  nuclei  of  the 
tarsal  and  carpal  bones  may  be  absent  until  the  tenth  year  and  that  the 
epiphyses  of  the  long  bones  may  not  be  ossified  until  the  twentieth  or 
thirtieth  year.  The  subcutaneous  tissue  seems  very  thick  and  boggy,  but 
does  not  pit  upon  pressure  like  ordinary  edema.  The  facies  is  extremely 
characteristic.  The  head  seems  large  for  the  body ;  the  fontanel  is  often 
open  until  the  eighth  or  tenth  year,  and  it  may  not  be  closed  even  in 


/  / 


884  DISEASES  OF  THE  DI/C'17.ESS  (ir.ANDS 

adults,  but  the  cranial  bones  are  often  very  thick;  the  forehead  is  low 
and  the  base  of  the  nose  is  broad,  so  that  the  eyes  are  wide  apart ;  the  lips 
are  thick,  the  mouth  half  open,  the  tongue  usually  protrudes  slightly;' 
the  cheeks  are  baggy,  the  eyelids  thick,  the  hair  coarse,  straight,  and 
generally  light-colored.  The  teeth  appear  very  late  and  are  apt  to  decay 
early.    The  second  dentition  may  not  begin  until  adult  life. 

Fatty  tumors  are  quite  constant  in  older  children,  although  they 
are  often  wanting  in  infantile  cases.  They  are  seen  in  the  supraclavicu- 
lar region,  just  behind  the  sternomastoid  muscle,  sometimes  in  the  ax- 
illa, or  between  the  scapulae,  and  sometimes  in  other  parts  of  the  body. 
In  distribution  they  are  apt  to  be  symmetrical,  and  are  usually  about 
half  the  size  of  a  hen's  egg.  The  neck  is  short  and  thick.  No  thyroid 
gland  can  be  made  out  by  palpation,  but  a  small  cyst  may  sometimes  be 
felt  at  the  root  of  the  tongue.  The  chest  is  not  deformed.  The  abdomen 
is  large  and  pendulous.  An  umbilical  hernia  is  almost  always  present. 
The  skin  is  dry,  perspiration  scanty,  and  eczema  is  common.  The  voice 
is  hoarse  and  rough.  Frequently  patients  may  not  walk  until  they  are 
five  or  six  years  old,  and  then  they  waddle  in  a  clumsy  way.  All  the 
movements  of  the  body  are  slow  and  lethargic,  and  everything  indicates 
mental  and  physical  torpor.  The  rectal  temperature  is  usually  subnor- 
mal. We  had  once  an  opportunity  to  observe  an  attack  of  acute  broncho- 
pneumonia in  one  of  these  cretins  two  years  old.  The  symptoms  and 
physical  signs  were  typical,  but  during  the  greater  part  of  the  disease  the 
rectal  temperature  fluctuated  between  95°  and  98.5°  F.  Only  once  was  a 
temperature  above  99°  F.  recorded.  On  account  of  their  low  tempera- 
ture and  torpid  condition  these  patients  are  very  sensitive  to  cold.  They 
live  upon  a  low  plane  of  metabolism  and  the  energy  exchange  is  small. 
The  mental  condition  is  always  greatly  impaired.  Some  are  even  imbe- 
cile. Cretins  are  dull,  placid,  and  good-natured,  rarely  troublesome  or 
excitable;  and  when  fifteen  or  eighteen  years  old  they  appear  like  chil- 
dren of  three  or  four  years.  Speech  may  be  impossible.  The  ability  to 
say  a  few  words  is  acquired  late,  and  in  some  cases  not  at  all.  Almost 
invariably  cretins  suffer  from  constipation.  At  the  age  of  puberty  there 
is  an  absence  of  development  of  the  sexual  organs. 

Diagnosis. — The  diagnosis  of  the  fully  developed  condition  is  very 
easy.  The  facial  expression,  the  protruding  tongue,  the  pendulous  abdo- 
men with  umbilical  hernia,  the  fatty  tumors,  torpor  and  low  tempera- 
ture are  sufficient  to  characterize  cretinism.  The  mistake  is  sometimes 
made  of  confusing  Mongolian  idiocy  with  cretinism.  The  former  may  be 
recognized  by  the  peculiar  formation  of  the  eyes,  the  normal  bone  f orma.- 
tion  and  growth  and  by  the  presence  of  the  symptoms  at  birth.  The 
therapeutic  test  with  thyroid  extract  is  conclusive. 

Prognosis  and  Treatment. — There   is  no   tendency   to   spontaneous 


SPORADIC  CRETINISM  885 

improYemeiit.  If  untreated,  cretins  may  live  to  an  advanced  age,  but 
remain  dwarfs,  seldom  attaining  a  height  of  more  than  three  or  three 
and  a  half  feet.  Their  mental  condition  remains  unimproved.  Treat- 
ment with  preparations  of  the  thyroid  gland  brings  about  an  extraordi- 
nary change.  Transplantation  of  the  gland  has  been  employed  as  well 
as  subcutaneous  injection  of  extracts  and  the  ingestion  of  fresh  glands^ 
and  various  substances  obtained  from  the  gland.     All  these  methods  are 


Fig.  136. — Dr.  J.  P.  West's  Case  of 
Cretinism,  Seventeen  Months 
OLD,  Before  Treatment. 


Fig.  137. — After 
Treatment 
Extract. 


Six 


Months' 
Thyroid 


effective,  but  the  preparation  most  employed  is  the  dried,  powdered 
gland,  usually  called  thyroid  extract,  given  by  mouth.  It  is  nearly  a 
specific  remedy  for  this  disease.  The  improvement  after  its  use  is  truly 
remarkable  (Figs.  136  and  137).  After  a  few  weeks'  treatment  the  en- 
tire appearance  of  the  child  is  changed.  The  idiotic  expression  of  the 
face  is  lost;  the  thickening  of  the  skin  and  subcutaneous  tissues  disap- 
pears ;  there  is  a  marked  increase  in  height  and  in  the  circumference  of 
the  head;  muscular  power  is  rapidly  developed,  so  that  many  soon  be- 
come able  to  walk;  and  progress  is  seen  in  dentition,  and  in  some  older 


886  DISEASES  OF  THE  DUCTLESS  GLANDS 

girls  in  the  establishment  of  menstruation.  Intellectual  progress  is 
much  slower  than  physical  changes;  however,  nearly  all  the  children 
become  much  brighter  and  more  intelligent  and  learn  to  speak. 

If  treatment  is  begun  early,  physical  development  may  be  apparently 
normal,  but  normal  mental  development  we  have  not  seen,  even  in  cases 
in  which  treatment  was  begun  during  the  first  year.  We  have  under 
observation  several  cretins  who  have  been  treated  from  ten  to  fifteen  years. 
Many  of  these  children  seem  quite  intelligent  and  are  able  to  attend 
school,  but  without  exception  they  are  much  below  other  children  of 
their  ages  in  mental  and  usually  in  physical  development.  As  the  thy- 
roid gland  is  absent  in  these  patients  it  is  necessary  for  them  to  con- 
tinue taking  the  thyroid  extract  as  long  as  they  live.  If  it  is  omitted 
relapses  occur  in  a  few  weeks,  even  in  cases  well  advanced  toward  re- 
covery. 

Most  of  the  thyroid  extracts  on  the  market  are  prepared  from  the 
glands  of  the  sheep.  A  reliable  extract  should  be  given  if  results  are 
to  be  expected.  The  thyroid  extract  of  Burroughs  and  Wellcome  we 
have  found  to  be  more  satisfactory  than  many  of  those  on  the  market. 
Of  this  half  a  grain  may  be  given  once  or  twice  a  day  at  first;  after 
the  child  becomes  somewhat  accustomed  to  it  the  daily  dose  may  be 
gradually  increased  to  five  or  six  grains.  Some  disturbances  are  often 
seen  at  the  beginning  of  the  treatment — perspiration,  marked  irritability, 
and  sometimes  a  rise  in  temperature — but  these  soon  pass  off.  For  old 
cases  at  least  five  grains  daily  should  be  given  for  an  indefinite  period. 


HYPOTHYROIDISM 

(Infantile  Myxedema) 

Cases  of  undoubted  thyroid  deficiency  are  met  with  that  differ  from 
sporadic  cretinism  in  the  time  of  their  development  and  in  the  severity 
of  the  symptoms.  Among  them  should  be  classed  those  cases  closely 
resembling  cretinism  but  not  showing  symptoms  until  the  second  or 
third  year  or  even  later  and  then  only  slightly  marked  symptoms.  The 
deficiency  of  the  thyroid  under  such  circumstances  occurs  in  extra- 
uterine life  or  is  incomplete.  There  are  no  pathological  studies  to 
show  the  condition  of  the  gland  and  the  etiological  factors  causing  its 
degeneration  are  unknown.  In  a  certain  number  of  instances  the  condi- 
tion has  followed  some  acute  infectious  disease.  The  symptoms  are 
those  that  have  l)Coii  mentioned  under  sporadic  cretinism,  differing  only 
in  degree.  It  is  \isually  the  failnre  of  mental  oi-  physical  develop- 
ment that  first  attracts  attention;  the  child  is  unable  to  learn,  pays 


HYPOTHYROIDISM 


887 


no  attention  to  commands,  is  not  cleanly  in  his  habits,  or  he  is  much 
smaller  than  his  fellows.  More  rarely  he  is  noticed  to  have  lost  the 
ability  to  do  things  which  he  had  formerly  acquired.  The  height  of 
these  children  is  mnch  below  the  average  but  the  degree  of  dwarfism 
depends  upon  the  time  of  onset  of  the  thyroid  deficiency.  Some  are 
greatly  stunted,  others  less  so;  but  normal  growth  does  not  occur  and 
increase  in  height  is  very  slight  or  absent.  X-ray  pictures  show,  as 
a  rule,  the  presence  of  some  carpal  and  tarsal  centers  of  ossification 
which  indicate  that  for  a  time  at  least  the 
thyroid  has  been  active.  The  facial  expression 
varies  from  the  characteristic  facies  of  cretin- 
ism to  one  that  is  only  slightly  expressionless, 
stupid  or  stolid.  The  lips  are  apt  to  be  some- 
Mdiat  thickened,  the  tongue  also,  but  by  no 
means  always  protruded.  The  hair  is  often 
coarse  and  generally  thick.  The  children  are 
usually  well  nourished,  often  stout.  The  skin 
is  dry  and  thickened  and  the  subcutaneous  tis- 
sue firm.  Fat  pads  are  exceptionally  present. 
The  abdomen  is  usually  large  and  in  the  more 
pronounced  cases  there  is  a  hernia  in  the  umbil- 
ical region.  In  the  less  marked  cases  this  is 
often  lacking.  The  children  readily  complain 
of  cold.  Constipation  is  frequent  but  by  no 
means  the  rule.  Dentition  is  late  and  irregular 
and  the  second  dentition  delayed.  The  voice  is 
usually  deep  and  hoarse. 

These  children  are  quiet  and  placid.  Their 
intelligence  varies  according  to  the  severity  of 
the  disease.  Some  are  imbecile,  some  have  quite 
a  high  degree  of  intelligence,  so  that,  though 
several  years  behind  their  fellows,  they  are  able 
to  attend  school.  In  the  marked  cases  it  is  hardly  possible  to  err  in 
diagnosis.  The  mild  cases  can  only  be  determined  positively  by  the  effect 
of  thyroid  extract  upon  the  symptoms  and  especially  upon  growth.  Thus, 
in  one  of  our  cases  aged  three  and  a  half  (Fig.  138)  the  height  which 
had  been  stationary  for  some  months  increased  nearly  four  inches  in  six 
months  as  the  result  of  thyroid  medication. 

Treatment  with  thyroid  brings  about  prompt  improvement  which 
will  vary  in  extent  according  to  the  severity  of  the  condition.  Striking 
mental  and  physical  improvement  occurs.  It  is  doubtful  if  complete 
intellectual  development  takes  place.  It  is  not  to  be  expected  that 
recovery  of  function  in  the  diseased  thyroid  can  occur.     For  this  reasoji, 


Fig.  138. — Infantile  Myx- 
edema. 


888  DISEASES  OF  TITE  DIT'TLESS  (TLAISDS 

thyroid  extract  should  be  given  continuously  in  the  doses  advised  in 
the  previous  chapter.  Mental  and  physical  deterioration  occur  if  its 
administration  is  interrupted. 

GRAVES'  DISEASE 

{Exophthalmic  Goiter,  Basedoiv's  Disease) 

Typical  Graves'  disease  in  young  children  is  rare.  The  determining 
cause  of  the  perversion  of  the  thyroid  activity  is  unknown.  Hereditary 
influences,  especially  goiter,  Graves'  disease  and  alcoholism  are  believed 
to  play  a  part.  Much  more  important  is  the  effect  of  sex  and  age. 
Girls  are  affected  three  times  as  often  as  boys.  As  the  age  of  puberty 
is  approached  the  cases  become  much  more  frequent.  Under  five  years 
qf  age  Graves'  disease  is  almost  unknown.  The  youngest  case  that  has 
come  under  our  observation  was  in  a  girl  of  five  and  a  half  years. 
Between  five  and  ten  years  a  number  of  cases  have  been  reported,  but 
after  ten  years  it  is  not  very  infrequent. 

The  disease  as  it  occurs  in  childhood  differs  chiefly  in  two  respects 
from  the  type  seen  in  adult  life.  The  symptoms  develop  and  disappear 
with  much  greater  rapidity,  perhaps  even  in  the  course  of  a  few  days, 
and  it  is  generally  believed  the  outlook  with  the  child  is  much  more 
favorable. 

Symptoms. — Attention  is  usually  first  called  to  the  disease  by  rest- 
lessness and  excitability  or  by  the  rapidity  of  the  heart's  action.  En- 
largement of  the  thyroid  may  not  be  evident  at  first  but  is  regularly 
present  at  some  time  during  the  disease.  The  gland  is  generally  uni- 
formly enlarged,  sometimes  to  a  marked  degree;  it  is  firm,  often  hard, 
and  can  be  felt  to  pulsate.  With  improvement  in  the  symptoms  there 
is  a  marked  diminution  in  size,  but  a  slight  degree  of  permanent 
enlargement  usually  remains. 

Exophthalmus  is  present  in  about  four-fifths  of  the  cases.  It  may 
be  extreme.  The  ocular  signs  of  von  Stelwag  and  von  Graefe  are  both 
present  in  the  majority  of  cases.  The  fine  tremor  so  commonly  present 
with  adult  patients  is  usually  lacking.  Involuntary  movements,  if 
present,  are  generally  coarse  incoordinate  movements.  The  skin  is 
often  fine  and  moist.  Perspiration  is  readily  excited,  and  flushing  is 
frequent.  Pigmentation  is  unusual.  The  heart's  action  is  usually  rapid 
and  its  violence  is  often  complained  of.  A  slight  amount  of  cardiac 
dilatation  may  frequently  be  determined  by  physical  examination.  Ner- 
vousness is  pronounced  and  is  in  most  cases  an  early  symptom.  The 
children  are  constantly  in  motion  and  can  be  kept  quiet  with  difficulty. 
The  first  improvement  is  often  noticed  in  a  diminution  of  the  restless- 


HYPERTHYROIDISM  889 

ness.  The  appetite  is  usually  fair  and  the  digestion  good,  but,  as  with 
adults,  the  increased  metabolism  which  accompanies  excessive  thyroid 
activity  causes  loss  of  weight.     Marked  emaciation  occasionally  results. 

The  diarrhea,  so  troublesome  a  symptom  with  the  adult  form  of  the 
disease,  is  seldom  marked.  In  general  it  may  be  said  that  the  disease  is 
milder  than  Avith  adults  and  that  its  course  is  shorter.  It  may  last 
only  a  few  weeks  but  at  times  remains  for  several  years. 

The  prognosis  is  relatively  good.  The  mortality  from  recorded  cases 
has  not  been  more  than  10  per  cent,  while  recovery  is  the  rule.  There 
may  remain  indefinitely  a  slight  degree  of  exophthalmus  and  enlarge- 
ment of  the  thyroid  and  a  tendency  to  cardiac  palpitation  with  tachy- 
cardia. 

The  treatment  should  be  directed  toward  securing,  for  a  time  at 
least,  complete  mental  and  physical  rest.  Everything  tending  to  excite 
or  irritate  should  be  avoided.  It  is  best  to  remove  tlLC  child  from 
contact  with  other  children.  Prolonged  warm  packs  may  assist  in 
producing  rest  and  in  inducing  sleep  which  should  be  encouraged  in 
e\ery  way.  As  the  nervousness  diminishes  mild  exercise  may  be  indulged 
in  and  according  to  the  improvement  of  symptoms  the  normal  regime 
gradually  may  be  resumed.  Studies;  school  attendance  and  contact 
with  other  children  should  only  be  allowed  after  many  weeks  or  months 
and  when  a  nearly  normal  condition  has  again  been  reached.  The  use 
of  drugs,  except  occasionally,  and  for  the  relief  of  special  symptoms, 
has  no  place  in  the  treatment.  Surgical  measures  are  only  to  be  con- 
sidered when  prolonged  medical  treatment  has  failed  and  when  the 
progress  of  the  disease  is  such  as  to  threaten  the  life  of  the  child.  The 
indications  for  the  various  forms  of  operation  are  the  same  as  with 
adults. 

HYPERTHYROIDISM 

Much  more  common  than  fully  developed  Graves'  disease  is  the 
condition  which  is  to  be  referred  to  a  moderate  increase  of  or  perverted 
function  of  the  thyroid  gland.  To  this  the  term  hyperthyroidism  is 
applicable.  The  condition  is  found  mostly  in  girls  and  usually  between 
the  eighth  and  fifteenth  years.  Several  children  in  the  same  family 
may  sufl'er  from  the  condition  and  it  usually  occurs  in  distinctly  neuro- 
pathic children.  The  chief  symptoms  are  restlessness,  irritability  and 
nervousness.  The  children  are  constantly  active.  They  are  apt  to  be 
irritable  and  cry  and  laugh  readily.  They  sleep  badly  and  complain 
frequently  of  headache  and  of  cardiac  palpitation,  especially  upon  exer- 
tion. Their  appetite  and  digestion  are  usually  good  but  there  may  be 
for  some  weeks  or  months  moderate  loss  of  weight  and  strength.    A  mild 


890  DISEASES  OF  THE  DUCTLESS  GLANDS 

degree  of  anemia  is  often  present.  Physical  examination  reveals  in 
the  majority  of  instances  a  slight  enlargement  of  the  thyroid  gland 
which  does  not  pulsate.  Exophthalmus,  beyond  a  slight  staring  ex- 
pression of  the  eyes,  is  not  found,  and  von  Stelwag's  and  von  Graefe's 
signs  are  absent.  The  heart's  action  is  slightly  exaggerated  and  rapid. 
Cardiac  palpitation  may  be  a  cause  of  complaint.  The  hands  of  these 
children  are  apt  to  be  constantly  moist.  The  symptoms  may  last  for 
some  weeks  or  months.  They  usually  disappear  entirely,  especially  if 
proper  measures  are  instituted,  and  in  girls  when  menstruation  becomes 
established.  A  marked  increase  in  the  severity  of  the  symptoms  is  un- 
usual, and  the  development  of  severe  hyperthyroidism  or  Graves'  disease 
from  a  mild  form  is  rare.  The  treatment  is  the  same  as  for  Graves'  dis- 
ease— rest,  quiet  and  removal  from  an  exciting  or  irritating  environment 
should  be  provided  for.  Tea,  coffee  and  alcohol  are  to  be  entirely 
interdicted.     The  treatment  is  hygienic  and  not  medicinal. 


DISEASES  OF  OTHER  DUCTLESS  GLANDS 

A  large  number  of  conditions  which  cannot  be  classified  among  any 
of  the  generally  recognized  diseases  have  been  ascribed  to  disturbances 
of  function  of  the  various  endocrine  or  ductless  glands.  It  is  necessary 
in  most  of  these  instances  to  assume  that  the  disturbance  is  only  func- 
tional since  pathological  changes  are  either  entirely  wanting  or  are 
recorded  in  an  insufficient  number  of  cases  to  establish  a  connection 
between  the  symptoms  and  the  condition  to  which  the  symptoms  are 
attributed. 

Lesions  of  the  pituitary  gland  seldom  if  ever  produce  acromegaly  in 
children.,  Tumors  of  this  gland  or  in  its  neighborhood  may  give  rise  to 
a  group  of  symptoms  known  as  "Frohlich's  syndrome,"  i.  e.,  adiposity, 
delayed  sexual  development,  increased  sugar  tolerance,  and  sometimes 
associated  mental  dulness. 

Tumors  of  the  pineal  gland  are  in  rare  instances  associated  with 
precocious  sexual  development;  tumors  of  the  adrenals,  more  frequently. 
The  exact  association  of  the  interference  with  the  function  of  the  glands 
and  the  precocious  development  is  difficult  to  determine  since  the  over- 
Avhelming  majority  of  pineal  tumors  cause  no  such  symptoms  and 
because  experimental  removal  of  part  or  all  of  these  glands  in  animals 
does  not  produce  comparable  effects. 

Polyglandular  disturbances  affecting  two  or  more  of  the  ductless 
glands  are  held  accountable  for  many  conditions,  particularly  the  various 
types  of  infantilism.  This  is  an  attempt,  in  the  absence  of  any  other 
explanation,  to  ascribe  a  train  of  symi^toms  to  a  number  of  organs  whose 


STATUS  LYMPHATICUS  891 

individual  functions  are  largely  unknown.  At  the  present  time  our 
knowledge  regarding  the  normal  function  of  these  glands  and  the  results 
of  their  disturbed  function  is  so  very  indefinite  that  it  seems  unsafe 
to  ascribe  to  them,  individually  or  collectively,  an  exact  clinical  impor- 
tance.    As  yet  this  has  not  been  established. 

The  use  in  practice  of  the  various  glandular  extracts,  though  prev- 
alent and  increasing,  has  been  in  our  experience  with  most  unsatis- 
factory results.  It  can,  however,  be  definitely  stated  that  their  adminis- 
tration by  mouth  is  free  from  danger. 


DISEASE  OF  THE  THYMUS 
STATUS  LYMPHATICUS 

The  term  status  lymphaticus  is  applied  to  a  very  definite  pathological 
condition  which  is  associated  with  clinical  manifestations,  less  constant 
and  not  characteristic.  The  relation  between  the  lesions  and  the  symp- 
toms is  little  understood,  and  almost  nothing  is  known  of  the  etiology 
or  pathogenesis.  The  most  striking'  part  of  the  lesion  is  the  great 
enlargement  of  the  thymus  gland,  with  which  is  found  a  hyperplasia 
of  the  lymphoid  tissues  throughout  the  body,  more  marked  than  is  seen 
in  any  other  condition  in  childhood.  The  two  most  frequent  symptoms 
are  convulsions  and  attacks  of  asphyxia. 

The  status  lymphaticus  is  most  often  seen  between  the  sixth  and 
twelfth  months,  but  may  be  met  with  in  children  of  any  age.  Enlarge- 
ment of  the  thymus  to  a  degree  sufficient  to  be  regarded  as  pathological, 
is  not  an  infrequent  condition.  An  association  with  rickets  is  often 
observed,  but  it  is  doubtful  whether  this  is  anything  more  than  a  coin- 
cidence. 

Since  the  large  thymus  is  so  important  a  lesion,  it  is  desirable  to 
know  what  may  be  regarded  as  normal.  The  most  extensive  observations 
upon  this  point  have  been  made  by  Bovaird  and  Nicoll,  who  weighed 
the  thymus  in  495  consecutive  autopsies  in  children  under  five  years. 
They  found  that  the  weight  was  greatest  at  birth,  the  average  being 
7.7  grams.  After  this  time  the  change  in  weight  was  very  slight  for 
the  period  of  five  years,  the  average  for  the  entire  495  observations  being 
5.9  grams,  which  was  about  the  same  as  the  average  for  each  of  the  years 
taken  separately.  Excluding  cases  in  which  the  organ  was  so  large  as  to 
be  considered  abnormal  (10  grams  or  over),  the  average  weight  at  birth 
was  G.5  grams;  during  infancy  and  early  childhood,  4  grams.  The 
results  of  these  observations  do  not  differ  essentially  from  those  of  Fried- 
leben,  which  have  been  so  extensively  misquoted.     It  may  therefore  be 


892 


DISEASES  OF  THE  DUCTLESS  GLANDS 


assumed  that  the  average  weight  of  the  normal  thymus  at  birth  is  from 
6  to  7  grams;  from  birth  to  five  years,  from  3  to  4  grams.  Anything 
over  10  grams  may  be  considered  abnormal. 

In  the  status  lymphaticus  the  thymus  is  often  from  five  to  ten  times 
larger  than  normal.  In  the  marked  cases  its  weight  is  from  30  to  40 
grams;  in  the  less  marked  cases  from  15  to  20  grams.  The  appearance 
of  the  enlarged  thymus  is  well   shown    in   t]ie   accompanying  illustra- 


FiG.  139.— Enlarged  Thymus.  The  lungs,  heart,  and  thymus  are  shown  in  the  picture. 
The  lungs  have  been  turned  back,  showing  the  two  lateral  lobes  of  the  thymus  over- 
lapping the  heart;  the  central  lobe,  above,  covers  the  trachea.  History. — Breast  fed, 
male  child,  nine  months  old,  well  developed;  ill  less  than  twenty-four  hours;  dyspnea, 
slight  cyanosis,  with  death  from  asphyxia.  T.  103°  F.  Autopsy. — Besides  the 
large  thymus  there  were  present  the  general  lesions  of  the  status  lymphaticus  to  a 
marked  degree;    lungs  deeply  congested. 


tion  (Fig.  139).  A  thymus  of  the  size  shown  weighs  about  45  grams, 
or  1|  ounces.  In  this  instance  it  was  nearly  as  large  as  one  of  the  lobes 
of  the  lung.  In  general  appearance,  the  enlarged  thymus  is  rather  more 
vascular  than  normal,  but  other  than  hyperplasia,  shoM^s  no  constant  or 
essential  changes,  either  by  gross  or  microscopical  examination. 

The  lymph  nodes  of  the  tracheobronchial  region  are  greatly  enlarged, 
often  to  the  size  of  small  cherries,  and  are  found  in  great  clusters.   Those 


STATUS  LYMPHATICUS  893 

of  the  mesenteric  region  may  be  still  larger.  Peyer's  patches  are  very 
prominent,  and  the  solitary  follicles  of  the  small  intestine  appear  like 
mnstard  seeds  upon  the  folds  of  the  mucous  membrane.  Those  of  the 
colon  are  also  very  prominent.  The  lymphoid  tissues  about  the  pharynx 
and  all  the  lymph  nodes  of  the  body  are  greatly  hypertrophied.  The 
spleen  is  usually  enlarged,  with  prominent  follicles.  There  are  no  other 
constant  changes.  Those  present  are  usually  accidental,  depending  upon 
the  cause  of  death. 

Symptoms. — In  very  early  infancy  this  is  one  of  the  explanations  of 
sudden  death  occurring  after  slight  causes,  and  in  some  cases  without 
any  apparent  cause.  Death  is  often  attributed  to  overlying,  to  asphyxia 
from  aspiration  of  food,  or  to  some  other  condition  affecting  respira- 
tion, or  infants  are  simply  found  dead  in  their  cribs  without  evidence 
of  anything  abnormal  in  history  or  symptoms. 

Even  in  children  who  live  until  they  are  several  months,  sometimes 
several  years,  old,  there  may  be  nothing  in  their  condition  to  indicate 
the  presence  of  the  status  lymphaticus  until  something  acute  occurs. 
This  may  be  in  the  nature  of  a  slight  accident,  a  surgical  operation 
of  a  trivial  character,  the  administration  of  an  anesthetic,  or  some  acute 
disease,  frequently  one  affecting  the  respiratory  tract.  The  symptoms 
associated  with  this  condition  are  frequently  of  a  nervous  character, 
usually  attacks  of  convulsions,  or  they  affect  the  respiration,  causing 
paroxysms  of  dyspnea,  cyanosis,  and  even  asphyxia.  A  frequent  history 
is  somewhat  as  follows :  A  child  previously  regarded  as  healthy,  often 
well  nourished  and  perhaps  entirely  breast  fed,  is  taken  with  convulsions 
followed  by  high  fever,  preceding  which  there  may  have  been  some 
pulmonary  symptoms  suggesting  a  commencing  bronchopneumonia.  The 
convulsions  recur  at  short  intervals;  the  temperature  remains  steadily 
high;  the  signs  in  the  lung  are  few  and  not  proportionate  to  the  other 
symptoms;  and  death  occurs  in  from  twelve  to  thirty-six  hours  often 
in  convulsions. 

In  other  cases  convulsions  are  absent  and  the  prominent  sj^mptom 
is  asphyxia,  which  comes  in  paroxysms  and  may  be  so  complete  as  to 
lead  to  the  suspicion  of  laryngeal  obstruction.  If  intubation  or  trache- 
otomy is  performed,  no  relief  follows.  The  child  may  die  in  the  first 
severe  attack,  which  may  be  preceded  for  a  few  hours  by  moderate 
dyspnea,  or  may  come  on  almost  without  warning.  It  is  more  frequent, 
however,  for  the  first  attack  to  be  less  severe,  the  child  perhaps  being- 
resuscitated  with  some  effort,  after  which  he  may  breathe  almost  as  well 
as  usual.  In  a  few  hours  the  attack  of  asphyxia  is  repeated;  after  sev- 
eral of  these,  each  one  growing  more  severe,  death  occurs.  In  these 
cases  the  elevation  of  temperature  is  usually  slight  and  may  be  wanting. 
Symptoms  similar  to  the  above  but  of  less  severity  and  resulting  in 
30 


Sn4  DISEASES  OF  THE  DUCTLESS  GLANDS 

recovery  would  suggest  status  lymphaticus,  although  the  diagnosis  can 
not  be  established. 

The  cause  of  the  symptoms  is  not  definitely  known.  The  asphyxia 
has  been  ascribed  to  pressure  of  the  large  thymus  upon  the  lungs,  the 
trachea,  the  pneumogastric  nerves,  or  the  auricles  of  the  heart.  Pres- 
sure would  seem  at  times  to  be  a  factor  in  the  production  of  the  dyspnea, 
but  apparently  not  the  chief  one.  Constant  dyspnea,  even  with  a  very 
large  thymus,  has  never  in  our  experience  been  present.  It  does  not 
seem  that  the  large  thymus  produces  its  symptoms  mechanically. 

There  is  another  group  of  cases,  perhaps  the  largest  of  all,  in  which 
there  are  no  symptoms  distinctly  referable  to  the  status  lymphaticus, 
and  yet  this  condition  appears  to  be  the  factor  which  determines  the  fatal 
outcome  of  what  was  apparently  an  infection  or  an  inflammation  of  only 
moderate  severity.  What  is  seen  here  is  simply  a  greatly  diminished 
resistance  to  disease.  In  these  cases  it  is  only  the  autopsy  which  reveals 
the  explanation. 

Diagnosis. — The  diagnosis  of  enlarged  thymus  is  possible  only  by 
physical  examination,  the  symptoms  being  too  indefinite  to  be  relied 
upon.  In  percussing  the  thymus  the  child  should  be  placed  upon  the 
back  and  the  neck  completely  extended.  In  some  cases  of  marked  en- 
largement a  definite  area  of  dulness  can  be  made  out  over  the  base  of 
the  sternum.  The  X-ray  is  also  of  distinct  value,  the  shadow  being 
sometimes  so  marked  especially  to  the  right  as  to  be  conclusive.  Unfor- 
tunately in  many,  perhaps  most  of  the  cases,  both  these  means  of  diag- 
nosis give  probable  results  only,  so  that  while  we  may  suspect  the  condi- 
tion we  can  not  do  more.  Marked  enlargement  of  the  tonsils  and  the 
adenoids  exists  so  frequently  without  thymus  enlargement,  that  this  can 
hardly  be  regarded  as  suggesting  the  condition.  The  hyperplasia  of  the 
tracheobronchial  or  mesenteric  lymph  nodes  or  of  the  follicles  of  the 
intestine  produces  no  especial  symptoms. 

Prognosis. — While  this  condition  apparently  may  exist  for  an  in- 
definite time  without  producing  any  symptoms,  it  undoubtedly  often 
determines  a  fatal  outcome  of  what  might  otherwise  have  been  a  mild 
illness  or  a  trivial  accident.  It  is  especially  important  in  connection 
with  acute  bronchitis  and  bronchopneumonia,  with  attacks  of  convul- 
sions, with  the  shock  of  slight  operations,  and  with  the  administration  of 
anesthetics,  particularly  chloroform.  It  is  one  of  the  most  frequent 
explanations  of  unexpected  death  from  such  slight  causes  as  an  explora- 
tory puncture  or  even  a  hypodermic  injection. 

At  present  no  known  treatment  has  any  influence  upon  the  condi- 
tion. There  is  experimental  evidence  that  the  X-ray  produces  involu- 
tion of  the  thymus  gland;  but  that  it  cures  the  condition  of  status 
lymphaticus  in  the  human  subject  has  not  yet  been  established. 


OSTEOGENESIS  IMPERFECTA  895 

CHAPTER  ly 

DISEASES  OF   THE  BONES  AND   JOINTS 
OSTEOGENESIS  IMPERFECTA 

{Osteopsathyrosis-Fragilitas   Ossiuvi) 

Of  the  etiology  of  this  rare  affection,  little  is  known.  No  especial 
disease  can  be  held  responsible  for  it  and  the  condition  is  not  usually 
hereditary.  It  is  at  times,  however,  found  in  certain  families  associated 
with  a  peculiar  blue  coloring  of  the  sclerotics,  and  in  such  circum- 
stances is  distinctly  hereditary.  In  affected  families  those  children 
Avith  a  tendency  to  fractures  have  blue  sclerotics,  but  not  all  the  chil- 
dren have  this  weakness  of  the  bones.  The  explanation  of  the  associa- 
tion is  not  clear. 

Despite  the  etiological  uncertainty  the  pathological  changes  are 
characteristic.  They  are  found  only  in  the  bones  but  are  present  in 
all  the  bones,  those  formed  in  membrane  as  well  as  those  formed  from 
cartilage.  The  cartilage  itself  is  in  no  way  affected  so  that  the  growth 
of  the  bones  in  length  is  normal.  The  formation  of  bone,  however, 
both  from  the  periosteum  and  in  the  shaft,  is  greatly  interfered  with 
on  account  of  deficient  numbers  and  activity  of  the  osteoblasts.  The 
result  is  that  the  bony  trabeculae  are  infrequent  and  small.  Thus  the 
bones  are  thin  and  very  fragile.  No  changes  have  been  demonstrated 
in  any  of  the  ductless  glands. 

The  most  striking  feature  of  the  disease  is  the  fragility  of  the 
bones — the  ease  with  which  they  undergo  fracture.  This  takes  place 
even  in  intrauterine  life,  so  that  infants  are  at  times  born  with  forty  or 
fifty  fractures  and  with  greatly  distorted  extremities  (Fig.  140).  The 
majority  of  children  with  osteogenesis  imperfecta  are  born  dead  or  die 
shortly  after  birth.  The  bones  of  the  skull  are  frequently  so  slightly 
formed  that  the  whole  cranium  is  soft  and  of  a  parchment-like  consist- 
ency with  widely  separated  sutures.  As  the  result  of  the  numerous 
intrauterine  fractures,  distinct  shortening  of  the  extremities  may  have 
taken  place.  Thus  there  may  be  at  birth  a  certain  similarity  to  the 
configuration  of  chondrodystrophy.  This  shortening  can  also  be  made 
out  by  the  X-ray ;  but  confusion  of  the  two  is  impossible  for  the  density 
of  the  bones  is  always  greatly  diminished  and  multiple  fractures  are  al- 
most always  in  evidence.  Any  of  the  bones,  including  the  ribs,  may  be 
fractured. 

Those  infants  who  survive  show  a  greater  or  less  marked  fragility 
of  the  bones.    Fracture  sometimes  occurs  from  ordinary  handling  which 


CHONDROBYSTl^OPHY  897 

it  is  quite  impossible  to  prevent,  or  in  other  instances  only  when  a 
moderate  degree  of  force  is  applied.  Callous  formation  is  slight  and 
the  process  of  repair  of  longer  duration  than  with  the  normal  child. 
In  exceptional  insta,nces  the  fragility  of  the  bones  is  only  manifested 
after  several  years  so  that  there  may  be  no  suspicion  of  any  trouble  imtil 
a  number  of  fractures  occur  as  the  result  of  very  little  traumatism. 
Following  the  numerous  fractures  and  the  difficulty  of  healing,  there 
is  usually  greater  or  less  shortening  and  deformity  of  the  bones.  It 
may  be  extreme. 

The  progress  of  the  disease  varies  much  in  the  different  cases;  in 
some  children  there  is  no  tendency  to  improvement;  in  others,  usually 
in  those  in  which  the  fragility  is  considerably  less,  there  seems  to  be 
improvement  in  the  condition  of  the  bones  so  that  about  the  time  of 
puberty,  or  shortly  after,  fractures  do  not  occur  except  when  there  is 
the  application  of  unusual  force.  There  is  no  known  treatment  that 
influences  either  the  severity  or  the  course  of  the  disease. 


CHONDRODYSTROPHY 

(Achondroplasia) 

This  rather  rare  condition,  often  improperly  called  congenital  or 
fetal  rickets,  is  the  cause  of  some  of  the  most  marked  examples  of 
dwarfism  known.  It  was  recognized  as  an  abnormality  by  the  early 
Egyptians  and  has  figured  in  art  in  various  ways  since  that  date. 
Paintings  show  that  many  of  the  old  court  jesters  were  of  this  type. 
Because  of  their  striking  appearance,  these  dwarfs  have  always  excited 
much  curiosity   and  interest. 

The  causes  of  chondrodystrophy  are  unknown ; .  only  in  rare  cases 
has  any  hereditary  connection  been  traced.  The  pathological  process 
begins  in  fetal  life  and  consists  in  a  disturbance  of  the  normal  ossifica- 
tion of  primary  cartilage.  It  affects  endochondral  ossification  only, 
never  intramembranous  ossification.  The  fiat  bones,  therefore,  escape 
entirely.  The  vertebrae  are  only  slightly  affected  while  the  long  bones 
of  the  extremities  suffer  most  but  not  equally,  though  the  disturbance 
is  symmetrical.  The  humeri  and  femora  are  almost  always  the  seat 
of  the  greatest  interference  with  growth.  One  of  the  most  striking 
changes  in  the  skull  is  the  synostosis  or  early  ossification  of  the  tribasilar 
bone;  this  is  formed  of  two  parts  of  the  sphenoid  and  the  sphenoidal 
process  of  the  occipital  bone.  Normally  this  ossification  does  not  take 
place  until  adult  life ;  in  children  with  chondrodystrophy  it  often  begins 
in  utero.    This  prevents  a  normal  expansion  at  the  base  of  the  skull,  and 


898 


DISEASES  OF  THE  BONES  AND  JOINTS 


Fig.  141. — Skull  in  Chondbodtstrophy,  Showing  Frontal  Prominence  and  Prog- 
nathism.    Girl  six  years  old. 

the  brain,  as  it  grows,  is  thus  crowded  upward  and  forward,  causing  the 

great  prominence  of  the  forehead  (Fig. 
141).  The  upper  jaw  appears  very  prom- 
inent on  account  of  the  depression  at  the 
root  of  the  nose. 

In  the  long  hones  there  is  a  marked  in- 
terference with  the  normal  proliferation  of 
cartilage  cells.  This  interference  may  be 
seen  in  all  degrees.  In  some  cases  a  peri- 
osteal lamella  pushes  its  way  between  the 
epiphysis  and  diaphysis,  still  further  re- 
stricting the  growth  of  the  long  bones.  As 
bone  formation  beneath  the  periosteum  goes 
on  normally,  the  bones  in  chondrodys- 
trophy are  thick  as  well  as  sliort. 

Symptoms. — The  majority  of  children 
suffering  from  this  condition  are  either 
born  dead  or  die  shortly  after  birth.  Those 
who  survive  are  delicate  during  infancy,  but 
afterward  may  become  strong  and  healthy. 
The  most  striking  thing  about  their  appear- 
ance is  the  very  short  legs  and  arms  as  compared  with  the  length  of  the 
body.     At  birtli  the  arms  in  many  cases  do  not  reach  to  the  waist  line, 


Fig.  142.  —  Normally  De- 
veloped Long  Bones  of  a 
Fetus  Compared  with 
those  of  Chondrodys- 
trophy.    (Spillmann.) 


CHONDRODYSTROPHY 


899 


and  the  length  of  the  body  may  be  less  than  the  circumference  of  the 
head.  The  epiphyses  appear  somewhat  enlarged,  the  abdomen  is  prom- 
inent, the  skin  of  the  extremities  is  in  deep 
folds,  the  soft  parts  seeming  to  be  much  too 
abundant  for  the  shortened  bones  (Fig.  I-IS). 
In  infancy  these  children  are  often  quite  fat. 
The  facial  expression  is  characteristic.  There 
is  usually  a  deep  depression  and  flattening  at 
the  base  of  the  nose,  with  a  very  marked  prom- 
inence of  the  forehead.  The  head  may  not 
only  seem  large,  but  by  measurement  may  be 
one  or  even  two  inches  above  the  normal  aver- 
age. An  erroneous  diagnosis  of  hydrocephalus 
is  often  made  in  the  early  stage.  Dentition  is 
slightly  later  than  normal,  but  not  more  so 
than  is  seen  in  moderate  rickets.  Marked  re- 
laxation of  the  ligaments  and  rather  feeble 
muscular  power  often  delay  walking  until  the  third  or  fourth  year. 
If  the  head  is  large,  the  fontanel  may  not  close  till  the  fourth  or  fifth 
year.  The  so-called  "trident  hand" 
is  characteristic.  The  fingers  are  very 
short  and  of  nearly  equal  length,  and 
an  angular  separation  is  seen  at  the 
second  joint  (Fig.  14J:). 


Fig.  143. — Chondrodystbo- 
PHY.  Infantile  Figure. 
(Marie.) 


Fig.  144. — Characteristic  Hand  of 
Chondrodystrophy,       (Marie.) 


Fig.  145. — A,  Normally  Developed  Boy, 
Age  Eight  Years.  B,  Typical  Chon- 
drodystrophy. Age  Eighteen  Years 
(Marie.) 


These  dwarfs  are  usually  somewhat  subnormal  in  their  mental  de- 
velopment but  cannot  be  classed  as  defectives.     They  are  good-natured, 


900  DISEASES  OF  THE  BOXES  AND  JOIXTS 

often  amusing,  easily  controlled,  and  frequently  live  to  a  great  age. 
AVitb  advancing  years  the  figure  assumes  a  very  peculiar  and  charai- 
teristic  appearance.  The  prominent  hips^  with  the  marked  lordosis, 
shortened  extremities,  and  late  bowing  of  the  legs,  present  a  striking 
picture  (Fig.  145).  The  maximum  height  attained  is  often  not  more 
than  three  and  a  half  or  four  feet.  Although  while  young  of  feeble 
muscular  power,  later  in  life  they  often  become  very  muscular.  ^Mien 
adult  life  is  reached  the  sexual  powers  are  normal;  if  the  women 
become  pregnant,  Cesarian  section  is  almost  always  required  on  account 
of  deformity  of  the  pelvis. 

In  infancy,  chondrodystrophy  is  often  confounded  with  rickets,  hy- 
drocephalus, cretinism  and  osteogenesis  imperfecta;  but  its  features  are 
so  characteristic  that  the  mistake  can  hardly  be  made  if  the  child  is 
carefully  examined.  In  severe  osteogenesis  imperfecta  the  femora  may 
be  very  short  but  the  association  with  multiple  fractures  determines 
the  diagnosis.  Xo  known  treatment  has  any  influence  upon  the  condi- 
tion.    The  use  of  the  thyroid  extract  is  entirely  without  efEect. 


ACUTE  ARTHRITIS  OF  INFANTS 

The  terms  acuie  purulent  synovitis,  acute  epiphi/sitis,  pyemia  of 
bone,  and  acute  osteomyelitis,  have  all  been  applied  to  this  condition. 
The  disease  is  really  a  form  of  pyemia.  The  causes  and  lesions  may 
differ  considerably  in  the  different  cases,  but  clinically  they  all  have 
certain  features  in  common,  viz.,  an  acute  joint  inflammation  with  sup- 
puration. 

The  acute  arthritis  of  infants  is  essentially  a  disease  of  the  first  year, 
and  is  much  more  frequently  seen  in  the  first  six  months.  The  inflam- 
mation may  begin  in  the  joint,  at  the  epiphyseal  junction,  or  in  the 
medullary  canal;  but,  however  it  may  start,  the  joint  is  soon  invaded. 
The  nature  of  the  arthritis  varies  somewhat  with  the  exciting  cause. 
When  it  is  due  to  the  gonococcus,  it  is  usually  confined  to  the  joint; 
there  is  in  most  such  cases  a  superficial  inflammation  involving  the 
synovial  membrane,  but  rarely  leading  to  destructive  changes  in  the 
cartilage,  ligaments,  or  bone.  "When  it  is  due  to  the  streptococcus  or 
staphylococcus,  it  may  begin  elsewhere  than  in  the  joint,  which,  how- 
ever, is  usually  soon  involved,  and  complete  disorganization  may  follo\\". 
It  may  also  result  in  a  diffuse  osteomyelitis,  in  a  subperiosteal  ab- 
scess, or  a  separation  of  the  epiphysis.  As  a  late  result  there  may  be  a 
pathological  dislocation  or  a  "flail  joint*';  less  frequently  there  is 
ankylosis. 

Etiology. — The  cause  of  acute  arthritis  in  infants  is  the  entrance 


AGUTE  APvTHEITIS  OF  INFANTS  901 

of  pyogenic  organisms  into  the  circulation.  In  cases  occurring  in  the 
newly  born  the  most  frequent  organism  is  the  streptococcus^  at  other 
times  the  gonococcus.  Less  frequently  are  found  the  staphylococcus  or 
the  pneumococcus  and  very  rarely  the  influenza  bacillus.  In  most  cases 
occurring  during  the  first  two  months  of  life,  the  portal  of  entry  is 
the  umbilical  cord,  though  infection  may  take  place  through  the 
skin,  conjunctiva,  genital  tract,  or  the  mouth.  In  the  cases  developing 
later  it  is  often  difficult  to  determine  the  point  of  entry,  especially 
when  the  cause  is,  the  gonococcus.  Of  26  cases  of  acute  gonococcus 
arthritis  observed  in  the  Babies'  Hospital,  only  2  occurring  during  the 
first  month  could  be  classed  as  infections  of  the  newly  born.  The  cases 
were  observed  during  a  hospital  epidemic  of  gonococcus  vaginitis,  and 
yet  19  were  in  male  children,  in  no  one  of  whom  was  there  any  genital 
lesion,  and  in  only  one  was  there  conjunctivitis.  Of  the  7  cases  occur- 
ring in  girls,  only  2  had  vaginitis.  The  portal  of  entry  in  these  cases 
could  not  be  definitely  determined.  We  have  also  observed  isolated  cases 
of  gonococcus  arthritis  in  the  course  of  a  gonococcus  pyemia  when  it 
was  impossible  to  determine  the  mode  of  entrance  of  the  organism  into 
the  circulation. 

Symptoms. — General  symptoms  often  precede  the  local  ones.  In  the 
most  acute  cases  the  temperature  is  high  and  widely  fluctuating,  accom- 
panied by  other  symptoms  of  a  severe  infection.  The  earliest  local 
symptoms  are  pain  and  tenderness,  soon  followed  by  swelling,  which  may 
develop  quite  rapidly  in  a  single  joint,  or  in  several  joints  simultane- 
ously. In  those  superficially  situated  there  is  redness  of  the  skin,  and 
fluctuation  may  be  evident  in  three  or  four  days.  In  cases  coming  on 
more  gradually  the  temperature  may  be  only  from  100°  to  102°  F.,  and 
suppuration  may  not  occur  for  two  or  three  weeks.  In  the  most  severe 
cases  the  progress  is  rapid,  one  joint  after  another  being  involved,  with 
general  symptoms  of  pyemia,  and  death  may  occur  in  a  week  or  ten  days, 
usually  from  some  visceral  inflammation,  pneumonia,  pericarditis,  or 
meningitis.  In  such  cases  blood  cultures  usually  show  the  presence  of 
the  organism  to  which  the  infection  is  due.  In  the  less  severe  type, 
which  is  more  often  seen,  the  symptoms  may  last  for  five  or  six  weeks. 
When  pus  is  not  evacuated  extensive  burrowing  often  takes  place. 

In  Townsend's  collection  of  73  cases,  the  joints  were  involved  in  the 
following  order:  hip,  in  38;  knee,  in  27;  shoulder,  in  12;  wrist,  in  5; 
ankle,  in  -i;  elbow,  in  4;  small  joints,  in  4.  In  three-fourths  of  these 
cases  only  a  single  joint  was  affected.  In  the  26  gonococcus  cases 
referred  to  the  localization  was  as  follows:  finger  or  metacarpus,  in 
20;  ankle,  in  18;  knee,  in  17;  wrist,  in  12;  toe  or  metatarsus,  in  10; 
shoulder,  in  9 ;  elbow,  in  5 ;  temporo-maxillary,  in  1 ;  hip,  in  1.  The 
average  number  of  joints  involved  was  4  or  5,  the  largest  number  being 


902  DISEASES  OF  THE  BOXES  AND  JOINTS 

8.  The  tendency  of  the  gonocoecus  infections  to  involve  the  small  joints 
is  striking. 

Diagnosis. — When  several  joints  are  involved,  the  disease  is  often 
mistaken  for  acute  articular  rheumatism,  which,  however,  at  this  age  is 
so  rare  that  it  may  be  ignored.  Blood  cultures  are  of  diagnostic  value. 
Syphilitic  epiphysitis  resembles  it  in  the  localized  tenderness  and  dis- 
ability; but  the  rapid  swelling  and  the  severe  constitutional  symptoms 
are  lacking. 

Treatment. — Cold  applications  or  wet  dressings  may  be  useful  in 
relieving  the  symptoms.  In  some  cases,  most  frequently  when  the  cause 
is  the  gonocoecus,  the  inflammation  subsides  without  suppuration.  In 
infections  due  to  other  organisms,  suppuration  almost  invariably  occurs 
and  early  free  incision  should  be  made,  followed  by  fixation  of  the 
joint.  The  results  depend  in  no  small  degree  upon  the  promptness  with 
which  the  pus  is  evacuated.  In  the  gonocoecus  cases  there  may  be  com- 
plete recovery.     In  most  of  the  others  the  functions  are  impaired. 

The  use  of  vaccines  is  to  be  advised  in  all  these  cases.  The  best 
results  are  seen  in  infections  due  to  the  staphylococcus  and  next,  those 
due  to  the  gonocoecus.  In  such  cases,  autogenous  appear  to  have  little 
if  any  advantage  over  stock  vaccines.  Injections  should  be  repeated  every 
five  or  six  days  in  increasing  doses. 


CHRONIC   ARTHRITIS 

{Atrophic  Arthritis,   Still's  Disease) 

Under  the  heading  of  chronic  arthritis  are  probably  included  a 
number  of  chronic  joint  affections  which  as  yet  we  are  unable  to  separate. 
They  all  have  as  a  common  characteristic  a  crippling  of  the  joints,  not 
on  account  of  primary  changes  of  the  bones  or  cartilages  but  as  the 
result  of  lesions  of  the  synovial  membrane,  capsule,  ligaments  and  peri- 
articular structures  which  may  later  cause  secondary  changes  in  the 
bone  and  cartilage.  As  there  is  no  sharp  line  of  demarcation  between 
these  conditions  it  is  convenient  to  discuss  them  all  under  one  heading. 

Etiology. — The  frequency  with  which  these  forms  of  arthritis  begin 
in  the  young  is  very  striking.  They  are  often  seen  in  children  under 
three  years  of  age,  and  the  histories  of  those  seen  later  often  date  back 
to  this  period  of  life.  Boys  are  rather  oftener  affected  than  girls. 
While  no  history  of  infection  may  be  obtained,  in  quite  a  number  of 
instances  the  disease  immediately  follows  or  occurs  shortly  after  some 
infectious  disease  or  suppurative  process.  Scarlet  fever  and  measles, 
particularly  the  former,  are  the  exanthemata  after  Mdiieh  chronic  arth- 


CHRONIC  ARTHRITIS  903 

ritis  is  most  often  seeu.  Demnie  has  described,  and  we  also  have 
observed,  very  severe  progressive  arthritis  following  scarlet  fever.  The 
suppurative  process  which  precedes  the  arthritis  may  be  anywhere  in 
the  body — in  the  pleural  cavity,  the  bones,  the  accessory  nasal  sinuses, 
the  teeth  or  the  tonsils.  A  history  of  rheumatism  is  not  infrequently 
obtained.  It  is  doubtful  if  at  this  age  it  is  really  true  rheumatism,  but 
rather  an  unusually  acute  onset  of  the  arthritis  with  fever.  Hemophilia 
with  hemorrhages  into  the  joint  may  be  followed  by  severe  joint  lesions, 
but  these  are  quite  distinct  from  the  condition  now  under  considera- 
tion. Nor  has  this  form  of  arthritis  a  close  connection  with  syphilis  or 
tuberculosis. 

Pathology. — Early  in  the  disease  and  for  a  considerable  time  the 
joint  surfaces  and  the  bones  are  not  involved.  The  lesion  is  chiefly  in 
the  synovial  membrane,  joint  capsule,  ligaments  and  surrounding  struc- 
tures. The  synovial  membrane  is  thickened;  its  villous  processes  are 
hypertrophied  and  the  meml^rane  is  hyperemic  and  edematous.  After  a 
time  it  becomes  thickened  by  the  growth  of  new  tissue.  The  same  condi- 
tion occurs  in  the  capsule.  The  joint  itself  may  contain  fluid;  this  is 
usually  quite  clear.  Later,  the  cartilages  may  be  somewhat  eroded  at 
their  edges  by  the  hypertrophied  villi  of  the  synovial  membrane.  Very 
rarely,  and  only  after  many  years,  there  may  be  fibrous  or  even  bony 
ankylosis.  Except  for  this,  the  only  changes  in  the  bones  themselves  are 
atrophic.     They  show  all  grades  of  osteoporosis. 

In  a  certain  number  of  instances,  changes  in  other  viscera  are 
found.  The  spleen  and  lymphatic  glands  may  be  increased  to  several 
times  their  normal  size,  but  they  show  nothing  characteristic.  The 
lesion  is  merely  hyperplasia.  Very  rarely,  without  apparent  cause, 
general  amyloid  degeneration  of  the  viscera  is  found. 

Symptoms. — The  onset  may  be  acute  with  fever  and  with  involve- 
ment of  the  joints  almost  coincident  with  the  fever,  or  there  may  be 
SAvelling  and  articular  pain  and  tenderness  with  no  fever  whatever.  At 
other  times  there  may  be  general  symptoms  for  many  weeks  before  the 
joints  are  found  to  be  involved.  We  have  seen  one  boy  who  had  fever 
for  nearly  three  months  before  the  involvement  of  his  wrists,  which 
was  followed  rapidly  by  that  of  his  ankles  and  knees.  No  matter  what 
the  mode  of  onset  the  joints  usually  involved  are,  in  order  of  frequency, 
those  of  the  carpus  and  phalanges,  the  wrists,  elbows,  ankles,  knees,  hips 
and  the  cervical  spine.  Karely  other  joints  such  as  the  sternoclavicular 
and  the  maxillary  are  implicated  in  the  process.  The  articular  lesions 
are  usually  symmetrical,  but  may  differ  in  severity  upon  the  two  sides. 
The  joints  are  swollen  and  are  moderately  tender  to  the  touch;  on  palpa- 
tion they  give  a  somewhat  doughy  sensation.  They  frequently  contain 
fluid  but  usually  not  a  large  amount.     The  fluid  may  disappear  and 


904  DISEASES  OF  THE  BOXES  AND  JOINTS 

re-accumulate  rapidly.  The  appearance  of  the  fingers  is  very  characteris- 
tic, the  first  interphalangeal  joint  heing  the  one  earliest  and  most  severely 
affected.  The  articular  involvement  causes  flexion  of  the  joints  to  a 
greater  or  less  extent  and  this  deformity  increases  with  the  progress  of 
the  disease.  The  pain  is  not  great,  nor  is  there  tenderness  upon  pressure, 
but  attempts  to  bring  the  joints  into  their  normal  position  by  active  or 
passive  motion  are  impossible  both  on  account  of  pain  and  the  changes 
in  the  peri-articular  structures.  The  joints  are  often  covered  by  fine, 
shiny  skin.  There  may  be  no  fever  whatever,  and  only  the  articular  swel- 
lings. In  other  circumstances,  fever  may  be  a  prominent  symptom. 
There  may  be  a  persistent  elevation  of  temperature,  a  degree  or  two  above 
normal  or  for  weeks  there  may  be  daily  exacerbations  and  remissions  of 
several  degrees.  At  times  the  fever  disappears  and  may  be  absent  for 
months,  but  when  it  has  once  been  a  feature  of  the  disease  it  is  likely 
to  return.  With  the  febrile  form  of  arthritis  there  is  usually  enlarge- 
ment of  the  superficial  lymphatic  glands,  chiefly  the  inguinal  and 
axillary.  The  cervical  glands  may  also  be  involved  and  not  infrequently 
the  epitrochlears.  The  sjaleen  is  often  enlarged  and  rarely  the  liver 
also.  There  may  be  albuminuria  and  casts  in  the  urine.  With  all 
forms  of  chronic  arthritis  the  general  condition  of  the  child  suffers. 
There  is  usually  a  moderate  degree  of  secondary  anemia  which  is  most 
marked  in  the  febrile  form.  To  the  form  of  arthritis  with  fever  and 
enlargement  of  the  spleen  and  lymphatic  glands,  the  name  "Still's  dis- 
ease" is  frequently  applied. 

An  examination  with  the  X-ray  shows  a  thickening  of  the  peri- 
articular structures,  often  distention  of  the  joint,  and  a  greater  or 
less  degree  of  osteoporosis.     JSTo  osteophytes  can  be  demonstrated. 

There  is  a  great  difference  in  the  rapidity  with  which  crippling  of 
the  joints  occurs.  In  one  case  as  much  damage  may  be  done  in  a  few 
weeks  as  occurs  in  years  in  another.  Eventually  motion  in  the  extremi- 
ties may  be  nearly  impossible  with  the  joints  fixed  in  positions  of 
extreme  deformity. 

The  course  is  usually  progressive  from  bad  to  worse.  The  crippling 
becomes  greater  and  greater  though  the  general  health  may  remain 
fair.  Death,  in  such  circumstances,  is  due  to  some  intercurrent 
disease,  very  rarely  to  amyloid  degeneration  of  the  viscera.  If  the 
cause  of  the  disease  can  be  removed,  the  prognosis  is  good  so  far  as 
further  deformity  is  concerned.  Even  when  no  cause  can  be  discovered, 
arrest  of  the  disease  may  occur,  and  at  times  recovery  is  almost  complete, 
but  this  result  is  so  rare  as  hardly  to  be  expected. 

Treatment. — This  should  always  include  a  careful  search  for  any- 
thing tliat  might  act  as  an  etiological  factor.  Especially  should  septic 
processes  in  tlie  tonsils,   in  the  accessory  sinuses  and  in  the  teeth  be 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS  905 

sought.  Unless  the  cause  can  be  removed,  treatment  is  merely  pallia- 
tive. The  patient  should  be  placed  under  the  best  hygienic  conrlitions 
with  as  much  life  out  of  doors  as  possible.  Apparatus  should  not  lie 
worn  excej^t  to  prevent  deformity  and  to  assist  in  walking. 


TUBERCULOUS  DISEASE   OF  THE  BONES  AND  JOINTS 

The  chronic  forms  of  tuberculous  bone  disease,  on  account  of  their 
insidious  onset  and  the  frequency  with  which  they  simulate  other  dis- 
easeS;,  more  frequently  fall,  in  the  early  stage  at  least,  into  the  hands  of 
the  physician  than  into  those  of  the  general  or  orthopedic  surgeon.  All 
that  will  be  attempted  in  this  chapter  will  be  to  outline  in  a  general 
way  the  most  important  forms — viz.,  disease  of  the  vertebrae,  hip,  and 
knee — dwelling  particularly  upon  the  early  symptoms  and  diagnosis. 
For  their  fuller  discussion,  particularly  as  to  the  details  of  treatment, 
the  reader  is  referred  to  text-books  on  general  or  orthopedic  surgery. 
The  causes  are  the  same,  and  the  lesions  are  very  similar  in  all  forms, 
and  will  therefore  be  considered  together. 

Etjolo^. — The  age  at  which  tukereulosis  of  the  bones  most  fre- 
quently begins,  is  from  the  third  to  the  eighth  year,  it  being  compara- 
tively rare  before  the  end  of  the  second  year.  The  sexes  are  affected 
with  about  equal  frequency.  Tuberculous  bone  disease  may  occur  in  a 
child  who  has  previously  been  in  apparent  health,  but  more  often  in  one 
who  has  been  reduced  by  some  previous  illness,  especially  one  of  the  infec- 
tious diseases ;  of  these,  it  most  frequently  follows  measles  and  whooping- 
cough.  Of  seventy-one  cases  in  children  investigated  by  Park  and 
Krumwiede,  or  collected  by  them,  the  bacillus  was  of  the  human  type 
in  sixty-eight  and  bovine  in  but  three  instances. 

A  family  history  of  tuberculosis  is  present  in  a  large  number,  but 
by  no  means  in  a  majority,  of  the  cases.  Like  tuberculosis  of  the  cer- 
vical glands,  it  is  rarely  preceded  by  other  tuberculous  processes,  al- 
though it  may  be  followed  by  them.  It  usually  appears  as  an  example 
of  primary  infection ;  but  it  is  quite  impossible  that  such  should  actually 
be  the  case.  There  has  previously  been  a  latent  focus  of  tuberculosis 
elsewhere  in  the  body.  In  many  cases  disease  of  the  bronchial  glands 
has  been  demonstrated  by  autopsy.  Infection  from  these  or  from  other 
tuberculous  lymph  glands  is  the  most  frequent  point  of  origin  of  infec- 
tion in  cases  of  bone  disease. 

Traumatism  is  often  an  exciting  cause,  and  it  may  determine  the 
site  of  the  disease. 

Lesions. — The  tuberculous  joint  diseases  of  childhood  are,  as  a  rule, 
secondary  to  disease  of  the  bones.     Hip-joint  disease  usually  begins  in 


906  DISEASES  OF  THE  BONES  AND  JOINTS 

the  head  of  the  femur^  and  knee-joint  disease  in  one  of  the  condyles; 
ankle-joint  disease  in  the  lower  epiphysis  of  the  tibia,  etc. 

The  frequency  with  which  disease  is  seen  in  the  different  locations  is 
shown  by  the  following  table,  which  gives  the  number  of  cases  of  each 
form  applying  for  treatment  at  the  Hospital  for  Euptured  and  Crippled, 
New  York,  during  ten  years :  . 

Spine 2,145  cases,  or  37 . 5  per  cent. 

Hip 1,937  "  "34.0  "  " 

Knee 1,222  "  "  21.5  " 

Ankle  or  tarsus. 255  "  "     4.5  "  " 

Elbow 71  "  "     1.2  "  " 

Wrist 50  "  "     0.9  "  " 

Shoulder 24  "  "     0.4  "  « 

Total 5,704  100.0 

The  character  of  the  bone  disease  upon  which  chronic  joint  disease 
depends  is  generally  a  primary  ostitis,  which-  affects  the  articular  ex- 
tremities of  the  long  bones,  usually  beginning  near  the  epiphyseal  line ; 
in  the  short  bones  it  is  a  central  ostitis.  The  stages  in  the  process  are, 
congestion,  swelling,  and  cell  infiltration,  followed  by  caseation,  and 
frequently  by  softening  and  suppuration.  In  the  early  stage,  tlie 
bone  is  slightly  enlarged,  and  on  section  one  or  more  yellowish  foci  of! 
disease  are  seen.  The  disease  may  be  arrested  in  this  stage,  encapsula- 
tion of  the  inflammatory  products  taking  place ;  or  it  may  continue  until 
there  is  a  more  or  less  extensive  breaking  down  or  disintegration  of  the 
affected  bone.  As  the  disease  extends  there  are  involved  the  periosteum, 
the  articular  cartilage,  and  finally  the  joint  itself.  Abscess  may  form  in 
the  joint  or  in  the  soft  parts  surrounding  the  bone.  The  process  is  quite 
analogous  to  tuberculous  disease  of  the  lung.  As  the  disease  advances 
ligamentous  attachments  are  loosened,  and  displacement  of  the  parts 
occurs  with  the  production  of  deformity,  due  partly  to  muscular  con- 
traction and  partly  to  the  weight  of  the  body.  The  inflammatory  proc- 
ess, with  its  resulting  disintegration,  generally  goes  on  to  a  certain 
point,  where  it  is  arrested.  Gradually  the  broken-down  bone  substance 
is  separated  and  thrown  ofE  in  small  particles  in  the  discharge,  and  a 
reparative  process  begins,  with  the  formation  of  healthy  bone.  Where 
joint  structures  have  been  destroyed,  cure  takes  place  by  bony  ankylosis. 
Sometimes  the  disease  finds  its  way  to  the  surface  without  involving  the 
joint;  at  other  times  the  disease  may  be  arrested,  and  its  products  be- 
come encapsulated  within  the  bone.  Inflammation  of  the  joint  may 
occur  by  a  gradual  extension  of  the  inflammatory  process,  or  by  a  sud- 
den perforation  of  the  articular  lamella.  As  a  result  of  extensive  dis- 
ease, all  the  joint  structures  may  be  affected — the  synovial  membrane. 


CARIES  OF  THE  SPINE  907 

ligaments,  articular  cartilages,  and  the  cellular  tissue  surrounding  the 
Joint.  The  process  of  disintegration  and  that  of  repair  are  both  very 
chronic  and  measured  by  months  or  years.  The  entire  course  of  the 
disease  is  from  one  to  ten  years,  three  years  being  about  the  average  dura- 
tion. In  the  great  proportion  of  cases  but  one  Joint  is  involved,  although 
it  is  not  infrequent  in  hospitals  to  see  two,  three,  and  sometimes  four  of 
the  large  Joints  affected  in  the  same  patient. 

Secondary  Lesions. — Abscesses  form  in  a  considerable  proportion  of 
the  cases,  and  often  burrow  a  long  distance  before  they  reach  the  surface. 
Amyloid  degeneration  of  the  liver,  spleen,  and  kidney,  and  sometimes  of 
the  intestines,  occurs  as  the  result  of  the  prolonged  suppuration,  chiefly 
in  connection  with  disease  of  the  hip  or  spine,  occasionally  with  that  of 
the  knee.  General  or  localized  tuberculosis,  particularly  tuberculous 
meningitis,  may  develop  at  any  time  and  prove  fatal. 

Caries  of  the  Spine — Pott's  Disease 

This  consists  in  a  tuberculous  inflammation  of  the  bodies  of  the  ver- 
tebrae, usually  beginning  in  the  central  portion  and  extending  to  the 
periosteum,  ligaments,  cartilages,  and,  in  fact,  to  all  the  contiguous 
structures.  Secondarily  it  involves  the  membranes  of  the  cord,  the 
roots  of  the  spinal  nerves,  and  even  the  cord  itself.  The  number  of  ver- 
tebrae usually  affected  is  from  two  to  five.  The  gross  appearance  of  the 
lesion  in  a  well-marked  case  is  shown  in  the  accompanying  cut  (Fig. 
146).  After  the  bodies  of  the  vertebrae  have  become  softened  and  par- 
tially broken  down  by  disease,  the  pressure  from  the  superincumbent 
weight  of  the  body  causes  them  to  fall  together  and  produces  a  back- 
ward displacement  of  the  spinous  processes,  giving  rise  to  the  deformity 
known  as  kyphosis,  which  in  its  extreme  form  is  popularly  known  as 
"hunchback." 

Any  part  of  the  vertebral  column  may  be  affected;  but  the  disease 
is  most  frequent  in  the  dorsal  region,  as  shown  by  the  following  statistics 
from  the  Hospital  for  Ruptured  and  Crippled:  Of  2,143  eases,  73.5 
I)er  cent  affected  the  dorsal  region,  15.3  per  cent  the  lumbar  region, 
and  12.2  per  cent  the  cervical  region. 

Symptoms. — The  onset  is  gradual,  often  insidious,  and  the  early 
symptoms  are  frequently  overlooked  or  misinterpreted.  The  case  may 
go  on  for  weeks  or  even  months  before  the  true  nature  of  the  disease 
is  recognized,  which  is  often  not  until  deformity  has  occurred.  In 
nearly  all  cases,  however,  the  early  symptoms  are  sufficiently  character- 
istic to  enable  a  careful  observer  to  make  a  diagnosis  before  the  stage 
of  deformity. 

The  most  constant  early  symptoms  are:     (1)    pains  caused  by  the 


908 


DISEASES  OF  THE  BONES  AND  JOINTS 


irritation  of  the  nerve  roots  and  referred  to  various  parts  of  the  body, 
following  the  distribution  of  the  spinal  nerves;  (2)  rigidity  of  the 
spine  from  muscular  spasm,  this  being  an  attempt  to  prevent  motion 
at  the  seat  of  disease;  and  (3)  the  assvmiption  of  various  postures  cal- 
culated to  relieve  pressure  upon  the  diseased  vertebral  bodies.  Some- 
times the  first  symptoms  are  those  of  pressure-paralysis;  at  others  they 
are  the  local  signs  of  abscess.  In  addition  to  the  local  symptoms  men- 
tioned, there  is  usually  disturbed  sleep,  often  accompanied  by  moaning. 

Cervical  Disease. — The  pains  are  often 
felt  above  the  point  of  disease,  frequently  in 
the  form  of  occipital  neuralgia;  sometimes 
they  are  referred  to  the  front  or  the  side  of 
the  neck.  They  may  be  so  frequent  and  so 
severe  that  the  face  assumes  a  constant  ex- 
pression of  anxiety  or  distress.  In  other 
cases  pain  is  excited  only  by  an  attempt  at 
movement.  The  muscular  spasm  most  fre- 
quently takes  the  form  of  slight  torticollis, 
sometimes  of  slight  opisthotonus;  sometimes 
there  is  simply  a  fixation  of  the  head  by  a 
tonic  spasm  of  all  the  muscles  of  the  neck; 
both  active  and  passive  motion  is  resisted, 
and  any  movement  may  be  so  painful  that 
the  child  involuntarily  steadies  his  head  with 
his  hands.  These  symptoms  come  on  grad- 
ually and  are  persistent.  Sometimes  they  are 
overlooked,  and  the  first  thing  to  attract  at- 
tention is  a  progressive  weakness  in  the  lower 
extremities,  which  proves  to  be  the  beginning 
of  paraplegia.  Occasionally  the  first  marked 
symptoms  are  those  due  to  the  formation  of  a 
retropharyngeal  or  a  retro-esophageal  abscess. 
The  deformity  from  cervical  disease  de- 
velops much  later  than  when  the  disease  is 
located  elsewhere.  Usually  the  neck  appears  broadened  or  thickened  in 
a  nearly  uniform  way,  and  often  the  head  seems  to  have  settled  down- 
ward upon  the  shoulders.  In  the  lower  cervical  region  a  kyphosis  is  not 
infrequent;  but  in  the  middle  and  upper  regions  there  is  more  often  an 
anterior  prominence,  which  may  be  felt  in  the  posterior  wall  of  the 
pharynx. 

Dorsal  Disease. — The  referred  pains  are  now  below  the  seat  of  dis- 
ease, and  take  the  form  of  intercostal  neuralgia  or  pain  in  the  epigas- 
trium or  the  abdomen.     They  are  often  ascribed  to  cold,  malaria,  indi- 


FiG.  146. — Pott's  Disease  of 
THE  Upper  Dorsal  Re- 
gion. A  vertical  section 
of  the  spine,  showing  dis- 
integration of  the  bodies 
of  the  vertebrae  and  en- 
croachment upon  the  spi- 
■  nal  canal.  (From  a  patient 
dying  in  the  Hospital  for 
Ruptured   and    Crippled.) 


CARIES  OF  THE  SPINE  9a9 

gestion,  or  worms.  There  is  a  disposition  to  assume  the  prone  position 
while  sleeping,  and  also  to  lean  across  a  chair  or  the  lap  of  the  nurse. 
The  child  walks  carefully,  holding  the  spine  erect  and  very  stiff,  and 
exhibits  great  caution  in  getting  into  or  out  of  bed,  or  in  rising  from  a 
recumbent  position.  In  the  beginning  there  may  be  a  slight  lordosis,  or 
forward  curve  at  the  seat  of  disease,  instead  of  the  usual  kyphosis  or 
backward  projection,  but  the  latter  soon  takes  its  place,  and  with  it  is 
seen  the  compensatory  lordosis  in  the  lumbar  region. 

Lumbar  Disease. — The  first  symptoms  here  are  often  pain  and  lame- 
ness, referred  to  one  of  the  lower  extremities.  This  frequently  leads  to 
the  suspicion  that  the  hip  is  the  seat  of  disease.  In  addition  to  the 
lameness  there  may  be  a  tilting  of  the  pelvis  to  one  side,  and  sometimes 
quite  a  distinct  lateral  curvature  of  the  spine.  Eeferred  pains  are  not 
so  frequent  nor  so  severe  as  when  the  upper  part  of  the  spine  is  affected ; 
they  may  be  felt  in  the  groin,  in  the  loin,  in  the  thigh,  in  the  buttock,  or 
in  the  hypogastrium.  The  gait  and  attitude  are  very  characteristic: 
Throwing  the  shoulders  well  back,  the  patient  walks  stifffy,  with  short 
steps,  holding  the  spine  with  the  greatest  care.  He  rises  from  the  floor 
awkwardly  and  with  difficulty.  Deformity  is  not  usually  so  early  nor  so 
marked  as  when  the  disease  is  dorsal,  and  often  before  it  is.  visible  there 
are  symptoms  due  to  the  formation  of  psoas  abscess — lameness,  flexion 
of  one  thigh,  and  a  tumor  deep  in  the  iliac  fossa  or  at  the  upper  and 
inner  aspect  of  the  thigh;  in  both  locations  it  has  often  been  mistaken 
for  hernia. 

Physical  Examination. — Whenever  any  of  the  above  symptoms  are 
present,  the  child  should  be  stripped  and  submitted  to  a  thorough  ex- 
amination, the  purpose  of  which  should  be  to  determine,  first,  the 
existence  of  any  deformity;  secondly,  the  mobility  of  the  spine;  thirdly, 
the  presence  of  any  secondary  lesions,  such  as  abscesses  or  paralysis. 
The  mobility  of  the  spine  is  best  determined  by  studying  the  attitude, 
gait,  and  posture  of  the  child,  and  the  manner  of  stooping  or  rising 
from  the  floor.  The  gait  has  already  been  described  with  the  symptoms 
of  lumbar  disease.  As  it  has  been  aptly  put,  "the  child  walks  with  his 
legs,  but  not  with  his  back."  In  stooping,  the  same  disinclination  to 
bend  or  move  the  spine  is  seen.  It  is  often  impossible  to  induce  the  child 
to  stoop  at  all,  and  when  he  does  so,  to  pick  up  some  object,  there  is 
acute  flexion  at  the  knee  and  hip,  but  as  little  bending  of  the  spine  as 
possible.  In  rising  from  the  recumbent  position  the  same  thing  is  seen. 
The  posture  and  attitude  of  the  child  will  be  modified  by  the  position 
of  the  disease,  and  somewhat  by  the  activity  of  the  process  at  the  time; 
however,  by  comparing  the  movements  referred  to  with  those  of  a 
healthy  child,  the  great  difference  will  at  once  be  apparent.  If  the 
symptoms  point  to  cervical  disease,  a  digital  exploration  of  the  pharynx 


910  DISEASES  OF  THE  BOXES  AND  JOINTS 

for  deformity  or  abscess  should  be  made,  aud  the  extremities  should 
be  examined  for  paralysis.  If  the  disease  is  in  the  lumbar  region, 
deep  palpation  of  the  iliac  fossa  should  be  made  to  discover  a  psoas 
abscess,  and  the  passive  movements  of  the  thigh  should  be  carefully 
tested  to  determine  whether  there  is  any  resistance  to  extreme  extension, 
this  often  being  present  before  the  psoas  tumor.  Xo  matter  how 
clearly  the  lameness  may  be  at  the  hip,  it  should  be  remembered  that 
this  often  results  from  disease  of  the  lumbar  spine.  If  the  thigh  is  flexed 
and  freely  movable  except  in  extension,  tlie  symptoms  are  probably  the 
result  of  psoas  irritation,  for  in  hip- joint  disease  the  other  movements 
of  the  joint  are  also  resisted. 

The  deformity  of  Pott's  disease  is  often  spoken  of  as  "'angular"  cur- 
vature of  the  spine.  AAliile  this  is  a  true  description  of  the  disease  at 
an  advanced  stage,  there  is  often  in  the  early  stage  only  a  general  curve. 
Later  a  slight  knuckle  is  seen  from  the  unnatural  projection  of  a  single 
spinous  process.  This  deformity  may  increase  and  finally  involve  five  or 
six  vertebrae.  It  is  usually  greatest  in  the  upper  dorsal  region.  A  slight 
prominence,  which  does  not  disappear  on  suspending  the  patient,  is 
always  suspicious. 

Tenderness  upon  pressure  over  the  spinous  processes  and  increased 
sensitiveness  to  heat  and  cold  are  rarely  present.  Pain  may  sometimes 
be  produced  by  downward  pressure  upon  the  head  or  shoulders  in  the 
axis  of  the  spine.  This  symptom  is  not  necessary  for  diagnosis,  aud  the 
attempt  to  elicit  it  is  strongly  condemned  by  Gibney,  who  has  seen 
serious  harm  follow^  such  a  test. 

Course  of  tlie  Disease. — Caries  of  the  spine  is  a  very  chronic  disease, 
its  course  being  measured  by  months  or  years,  but  marked,  as  in  all 
chronic  diseases,  by  periods  of  remission  and  exacerbation.  An  exacer- 
bation may  follow  traumatism,  and  is  often  accompanied  by  the  forma- 
tion of  an  abscess.  After  the  disease  has  lasted  from  one  to  three  years, 
the  destructive  inflammation  usually  ceases  and  repair  begins,  a  cure 
l)eing  final!}'  effected  by  a  process  of  consolidation  of  the  fragments 
of  the  diseased  vertebrae,  and  the  production  of  ankylosis.  Eelapses  are 
easily  excited  by  traumatism,  by  improper  treatment,  or  by  discon- 
tinuing the  use  of  mechanical  supports  before  the  disease  is  quite 
arrested. 

Abscesses. — The  frequency  with  which  abscesses  occur  depends  some- 
what upon  the  treatment.  Townsend  states  that  of  380  cases,  abscess 
was  present  in  twenty  per  cent.  They  are  rarely  seen  earlier  than 
three  or  four  months  from  the  beginning  of  symptoms,  and  usually 
belong  to  the  second  year  of  the  disease.  They  sometimes  form  with 
acute  symptoms,  but  more  frequently  they  appear  as  typical  cold 
abscesses.     Those  connected  with  cervical  disease  are  retropharyngeal  or 


CARIES  OF  THE  SPIXE  Oil 

retro-esophageal,  or  they  may  open  externally,  usually  just  above  the 
clavicle,  in  front  of  the  sternomastoid  muscle.  Those  with  disease  of 
the  lower  cervical  and  upper  dorsal  vertebrae  are  apt  to  l)urr()W  along 
the  spine,  appearing  in  the  lumbar  region;  rarely  they  may  rupture 
into  the  esophagus  or  the  pleural  cavity.  Those  with  disease  of  the 
lower  dorsal  or  lumbar  vertebrae  may  open  just  aljove  tlu'  iliac  crest 
posteriorly,  or  burrow  anteriorly  between  the  abdominal  muscles,  but 
the  usual  course  is  for  them  to  follow  the  psoas  muscle,  appearing  in 
the  groin  just  above  Poupart's  ligament  or  at  the  upper  and  inner 
aspect  of  the  thigh. 

Paralysis  occurs  in  about  one-half  the  cases  in  which  the  disease 
affects  the  lower  cervical  and  upper  dorsal  vertebrae,  but  it  is  rare  when 
the  disease  is  below  the  middle  dorsal  region  (see  Compression  Myelitis). 

Prognosis. — The  actual  mortality  of  Pott's  disease  is  difficult  to  state, 
so  many  of  the  consequences  of  the  disease  being  remote  and  not  fully 
appreciated  until  adult  life  is  reached.  The  general  mortality  from  all 
causes  is  from  ten  to  twenty  per  cent.  The  causes  of  death  are  exhaus- 
tion from  prolonged  suppuration,  amyloid  degeneration,  myelitis,  gen- 
eral tuberculosis,  and  tuberculous  meningitis.  Sudden  death  occasion- 
ally occurs  from  pressure  upon  the  cord  in  the  upper  cervical  region. 
or  from  the  pressure  effects  of  abscesses  in  the  posterior  pharynx  or  in 
the  posterior  mediastinum. 

The  i^rognosis  as  to  the  amount  of  permanent  deformity  will  depend 
upon  the  seat  of  the  disease,  the  time  at  which  treatment  is  begun,  and 
upon  the  thoroughness  with  which  it  is  carried  out.  The  best  results  as 
to  deformity  are  obtained  when  the  disease  is  below  the  middle  dorsal 
region.  With  improved  methods  of  treatment  begun  early,  a  large 
number  of  these  patients  recover  with  an  insignificant  amount  of  de- 
formity, and  some  with  none  whatever. 

Diagnosis. — The  spinal  deformity  resulting  from  Pott's  disease  may 
be  confounded  with  rachitic  kyphosis  or  with  rotary  lateral  curvature. 
Eachitic  curvatures  are  usually  seen  in  children  under  eighteen  months 
of  age,  a  time  when  Pott's  disease  is  rare;  there  are  other  signs  of  rickets 
present,  and  instead  of  rigidity  there  is  usually  undue  mobility  of  the 
spine.  ^\niat  is  true  of  rickets  may  be  said  of  all  curvatures  depending 
upon  malnutrition.  In  young  children,  especially,  the  tuberculin  test  is 
of  considerable  assistance  in  diagnosis. 

Eotary  lateral  curvature  is  seen  about  pul^erty,  rarely  in  yo\ing  chil- 
dren except  in  connection  with  rickets,  A  slight  lateral  deviation  of  the 
spine,  sometimes  seen  in  the  early  stages  of  caries,  may  resemble  a  case 
of  incipient  rotary  curvature.  The  latter  is  not  attended  by  pain  or 
rigidity,  and  is  most  frequent  in  yoimg  girls  from  eleven  to  fourteen 
years  of  age. 


912  DISEASES  OF  THE  BONES  AND  JOINTS 

Other  abscesses  may  be  mistaken  for  those  dependent  upon  vertebral 
caries.  This  difficulty  is  likely  to  exist  in  the  cases  attended  by  very 
little  spinal  deformity.  These  abscesses  are  most  frequently  in  the  iliac 
fossa  or  in  the  lumbar  region,  and  may  be  due  to  perinephritis  or  ap- 
pendicitis. The  latter  are  more  acute  than  those  depending  upon  bone 
disease  and  usually  accompanied  by  fever.  Tumors  of  the  vertebrae  or 
of  the  spinal  cord  may  give  rise  to  symptoms  almost  identical  with  those 
resulting  from  compression  myelitis  due  to  Pott's  disease.  Both  of 
these  are  rare  (vide  Tumors  of  the  Cord). 

Treatment. — The  treatment  of  Pott's  disease  is  both  general  and 
local,  and  neither  should  be  neglected.  The  constitutional  treatment 
should  be  similar  to  that  employed  in  other  forms  of  tuberculosis.  The 
local  treatment  belongs  to  the  domain  of  orthopedic  surgery. 

Articular  Ostitis  of  the  Hip — Hip- Joint  Disease 

In  early  childhood  this  generally  begins  as  a  chronic  ostitis  in  the 
head  of  the  femur,  starting  near  the  epiphyseal  line.  Exceptionally, 
and  oftener  in  older  children,  it  begins  in  the  acetabulum.  The  path- 
ological process,  as  well  as  the  clinical  history,  is  generally  described  as 
consisting  of  three  stages.  In  the  first  stage — that  of  ostitis — the  lesions 
are  limited  to  the  bone;  in  the  second  stage — that  of  arthritis^ — all  the 
joint  structures  are  involved,  and  in  this  stage  suppuration  usually 
occurs;  in  the  third  stage  there  is  breaking  down  and  absorption  of 
the  head  and  sometimes  of  the  neck  of  the  femur,  which,  with  destruc- 
tion of  the  ligaments,  leads  to  marked  displacement  of  the  parts  from 
muscular  contraction.  The  disease  may  be  arrested  in  the  first  or  in 
the  second  stage,  or  it  may  continue  through  all  three  stages. 

Symptoms. — Clinically,  the  usual  duration  of  the  first  stage  is  three 
or  four  months ;  it  may  last  only  for  a  few  weeks,  it  may  extend  over  two 
or  three  years,,  and  the  disease  may  be  arrested  in  this  stage.  The  onset 
is  usually  very  gradual,  and  the  symptoms  are  often  considered  of  trivial 
importance  until  they  have  continued  for  some  weeks.  Generally  the 
first  thing  noticed  is  slight  lameness,  due  to  stiffness  of  the  joint.  In 
the  beginning  this  may  be  seen  only  in  the  morning,  wearing  off  during 
the  day.  It  may  be  accompanied  by  some  tenderness  about  the  hip  and 
a  disinclination  to  walk.  A  little  later  the  child  complains  of  pain, 
which  is  most  frequently  referred  to  the  front  of  the  knee  or  the  inner 
aspect  of  the  thigh,  but  only  in  rare  cases  to  the  hip  itself.  This  is  slight 
at  first,  but  gradually  increases  in  frequency  and  severity,  and  soon  there 
are  added  the  "starting  pains"  at  night,  which  are  one  of  the  most 
characteristic  features  of  early  hip  disease.  These  pains  are  produced  by 
a  sudden  spasm  of  the  muscles  during  sleep.     The  child  often  cries  out 


HIP-JOINT  DISEASE 


»13 


sharply  without  waking,  sometimes  wakes  with  a  cry;  this  is  often  re- 
peated several  times  during  the  night.  Soon  restlessness  and  fretfulness 
during  the  day  are  present.  The  lameness,  which  at  first  was  slight  and 
occasional,  or  noticed  only  in  the  morning,  comes  to  be  a  constant  symp- 
tom, and  week  by  week  increases  in  severity.  The  evolution  of  these 
symptoms  may  take  only  a  few  weeks,  but  sometimes  they  come  and 
go  in  the  most  inexplicable  manner  during  a 
period  of  several  months,  or  even  one  to  two 
years,  before  they  are  fully  developed. 

Every  child  with  a  suspicious  lameness,  or 
with  pains  like  those  mentioned,  should  be 
stripped  and  submitted  to  a  thorough  exam- 
ination. The  first  points  to  be  observed  on 
inspection  relate  to  the  general  contour  of  the 
hip ;  every  prominence  and  depression  should 
be  carefully  noted.  Then  the  attitude  and 
gait  should  be  studied;  and  finally  all  the 
functions  of  the  joint  should  be  carefully 
tested,  and  the  limbs  measured,  to  determine 
the  existence  of  shortening  or  atrophy.  At 
every  step  a  comparison  should  be  made  with 
the  sound  limb.  The  contour  of  the  hip  is 
changed  quite  uniformly ;  there  is  broadening 
and  flattening  of  the  whole  gluteal  region; 
the  trochanter  is  unnaturally  prominent ;  the 
gluteal  fold  is  shortened,  and  often  single  in- 
stead of  double.  There  is  no  characteristic 
position  of  the  limb  in  this  stage.  There  is 
atrophy  of  the  thigh  and  often  of  the  calf 
In  Fig.  147  is  shown  the  appearance  of  a  typ- 
ical case  in  the  full  development  of  the  first 
stage.  In  walking,  the  child  favors  the  dis- 
eased side,  throwing  the  weight  as  much  as 
possible  upon  the  sound  limb;  but  all  these 
symptoms  are  of  much  less  importance  for 
diagnosis  than  is  an  examination  of  the  func- 
tions of  the  joint. 

For  this  purpose  the  child  should  be  placed  upon  a  table  upon  his 
back,  and  the  various  movements  of  the  hip — abduction,  adduction, 
flexion,  extension,  and  rotation — should  be  executed,  first  with  the  sound 
limb  and  then  with  the  suspected  one.  the  two  being  carefully  compared 
at  every  point  to  determine  the  degree  of  motion  allowed.  It  is  not 
necessary   that  force    should   be   employed   or   pain   inflicted.      If   the 


Fig.  147. — ^Hip-Joint  Disease, 
AT  THE  End  of  the  Fibst 
Stage.  Showing  muscu- 
lar atrophy,  prominence 
of  the  trochanter,  flatten- 
ing of  the  gluteal  region, 
and  a  single  gluteal  fold. 


914  DISEASES  OF  THE  BONES  AND  JOINTS 

symptoms  have  existed  for  some  weeks,  there  is  geuerally  a  limitation 
of  motion  at  the  hip  in  all  directions,  but  first  usually  in  abduction, 
rotation,  or  extension.  In  more  advanced  cases,  no  motion  whatever 
may  be  permitted  at  the  joint,  the  pelvis  tilting  with  the  slightest 
movement  of  the  femur.  This  fixation  of  the  hip  is  due  to  tonic  mus- 
cular spasm.  Crowding  the  articular  surfaces  together,  by  pressure 
upon  the  heel  or  trochanter,  produces  pain,  which  is  usually  referred 
to  the  joint.  This  test  should  be  carefully  m-ade,  lest  injury  be  inflicted. 
Examinations  should  not  be  made  under  ether,  since  in  this  way  serious 
injury  may  be  done  unconsciously. 

Second  Stage. — This  has  been  called  the  stage  of  arthritis.  Its 
existence  may  be  assumed  when  the  limb  takes  the  position  of  marked 
jjermanent  deformity,  which  is  due  at  this  period  to  muscular  action, 
not  to  destructive  bone  changes.  The  transition  from  the  first  to  the 
second  stage  is  in  most  cases  a  gradual  one,  and  the  line  between  the 
two  can  not  be  sharply  drawn;  sometimes,  however,  it  is  rapid,  and 
marked  by  a  sharp  exacerbation  of  all  the  symptoms.  This  may  indicate 
a  sudden  perforation  of  the  joint  and  the  rapid  develo|)ment  of  sup- 
purative arthritis.  Such  is  the  usual  result  when  an  abscess  which  has 
been  slowly  forming  in  the  bone  opens  into  the  joint;  or  acute  joint 
inflammation  may  be  lighted  up  without  so  evident  a  cause.  Sometimes 
the  pus  reaches  the  surface  below  the  capsular  ligament,  and  the  joint 
remains  intact.  An  acute  exacerbation  is  indicated  by  increased  pain, 
excessive  tenderness  about  the  hip,  often  by  inability  to  walk,  or  even 
to  bear  any  weight  upon  the  limb,  and  frequently  by  fever.  The  posi- 
tion assumed  by  the  limb  is  now  fairly  characteristic.  The  foot  is 
generally  everted,  the  thigh  slightly  flexed  and  rotated  outward,  and 
the  limb  apparently  lengthened.  There  may  be  infiltration  anywhere 
about  the  hip,  due  to  the  formation  of  an  abscess.  The  muscular 
spasm  is  so  great  that  the  joint  is  locked — no  motion  whatever  being 
allowed.  Abscesses  may  form  at  any  point  about  the  hip;  they  are 
especially  frequent  at  the  upper  and  outer  aspect  of  the  thigh,  and  may 
burrow  long  distances  before  reaching  the  surface.  The  duration  of  the 
second  stage  also  is  indefinite,  but  it  usually  lasts  from  a  few  months 
to  a  year,  or  the  disease  may  be  arrested  in  this  stage. 

Third  Stage. — -There  is  now  marked  deformity,  which  is  the  result 
of  muscular  contraction  after  absorption  of  the  head  and  sometimes  the 
neck  of  the  femur,  and  destruction  of  the  ligaments.  The  position  of 
the  limb  is  a  very  constant  one,  and  resembles  that  present  in  dislocation 
upon  the  dorsum  of  the  ilium.  There  is  shortening  of  from  one  to  four 
inches;  the  thigh  is  strongly  flexed,  adducted,  and  rotated  inward,  and 
the  foot  is  inverted;  the  trochanter  lies  against  the  outer  surface  of  the 
ilium,  and  is  above  Nelaton's  line.     In  this  position  the  joint  may  be- 


HIP-JOINT  DISEASE  915 

come  ankylosed.  The  displacement  usually  comes  on  gradually,  but  it  is 
sometimes  so  sudden  as  to  be  mistaken  for  a  true  dislocation,  although 
the  latter   is   exceedingly   rare  in  the  course  of  hip  disease. 

There  is  now  marked  atrophy  of  all  the  muscles  of  the  limb,  and  the 
thigh  may  be  two  or  three  inches  smaller  than  its  fellow.  No  motion  at 
all  is  usually  allowed  at  the  hip,  but  this  is  compensated  for  to  some 
degree  by  the  exaggerated  mobility  of  the  lumbar  spine.  The  spinal 
curvature — lordosis — is  very  marked  both  upon  standing  and  walking. 
The  duration  of  this  stage  may  be  several  years.  From  time  to  time 
exacerbations  occur,  often  excited  by  falls,  and  accompanied  by  the 
formation  of  new  abscesses.  In  protracted  cases,  all  the  soft  parts  about 
the  hip  may  be  seamed  with  cicatrices  from  old  sinuses.  After  the  dis- 
ease has  gone  on  to  the  third  stage,  cure  can  take  place  only  by  anky- 
losis. 

Diagnosis. — The  important  point  in  the  early  diagnosis  of  ostitis  of 
the  hip,  is  the  gradual  evolution  of  the  symptoms,  the  most  characteristic 
of  which  are  lameness,  "starting  pains"  at  night,  and  impairment  of 
all  the  functions  of  the  joint.  Mistakes  in  diagnosis  most  frequently 
arise  from  a  failure  to  obtain  a  careful  history,  and  from  relying  too 
much  upon  the  symptoms  of  lameness  and  deformity.  The  essentially 
chronic  character  of  the  disease  should  constantly  be  borne  in  mind. 
In  the  vast  majority  of  cases,  with  a  careful  history  and  a  thorough 
examination,  there  can  be  but  little  doubt  as  to  the  diagnosis  except 
at  the  very  outset.  The  proportion  of  obscure  and  irregular  cases  to 
those  following  the  regular  course  is  small. 

In  the  early  stage,  hip-joint  disease  may  be  confounded  with  a  strain 
of  the  joint,  with  muscular  rheumatism,  poliomyelitis,  periostitis  of  the 
shaft  of  the  femur,  phlegmonous  inflammation  in  the  neighborhood  of 
the  joint,  or  with  caries  of  the  lumbar  spine.  In  the  second  stage  there 
is  even  less  difficulty  in  diagnosis,  although  abscesses  resulting  from 
perinephritis  or  appendicitis  have  been  mistaken  for  those  arising  from 
hip  disease.     In  the  third  stage,  a  mistake  is  almost  impossible. 

Prognosis. — This  is  to  be  considered  "both  with  reference  to  life  and 
limb.  The  records  of  the  Hospital  for  Euptured  and  Crippled  show  the 
mortality  of  hospital  patients  with  hip  disease  to  be  nearly  twenty-five 
per  cent.  This  includes  deaths  directly  or  indirectly  traceable  to  the 
disease.  The  causes  are  nearly  the  same  as  in  caries  of  the  spine — 
exhaustion  from  prolonged  suppuration,  amyloid  degeneration,  and  gen- 
eral tuberculosis  or  tuberculous  meningitis. 

Under  the  most  favorable  conditions,  the  disease  may  be  arrested  in 
the  first  stage,  and  recovery  occur  without  lameness  or  any  noticeable 
impairment  of  the  joint  functions.  This  result,  however,  is  not  often 
obtained,  because  the  disease  is  usually  well  advanced  before  it  is  recog- 


916  DISEASES  OF  THE  BONES  AND  JOINTS 

iiized,  or  because  of  the  difficu%  in  the  way  of  earryiiig  out  all  the 
details  of  treatment  in  the  best  possible  manner.  If  the  disease  has 
advanced  to  the  second  stage  and  suppuration  has  occurred,  there  always 
results  some  impairment  of  the  joint  functions;  usually  there  are  decided 
lameness  and  marked  muscular  atrophy,  but  very  little  shortening  or 
deformity,  provided  the  limb  has  been  kept  in  the  proper  position.  If 
the  disease  has  advanced  to  the  third  stage,  there  are  always  marked 
shortening,  deformity,  and  lameness. 

Treatment. — The  indications  for  constitutional  treatment  are  the 
same  as  in  caries  of  the  spine.  The  purpose  of  local  treatment  is  to 
secure  constant  and  complete  rest  for  the  diseased  parts,  and  to  prevent 
deformity.     It  should  be  in  the  hands  of  an  orthopedic  surgeon. 

Articular  Ostitis  of  the  Knee — Knee-Joint  Disease — }y]iiie  Swelling 

Ostitis  of  the  knee  usually  begins  in  one  of  the  condyles  of  the  femur^ 
the  inner  much  oftener  than  the  outer  one;  less  frequently  it  begins  in 
the  head  of  the  tibia.  The  pathological  process  is  very  much  like  that 
at  the  hip.  There  is  in  the  first  stage  a  central  ostitis  accompanied  by 
infiltration  and  expansion  of  the  part  of  the  bone  affected.  The  disease 
may  remain  limited  to  the  bone,  the  inflammatory  products  becoming 
encapsulated,  or  softening  and  breaking  down  may  occur,  with  the  for- 
mation of  an  abscess.  Gradually  the  process  extends  outward,  and  the 
periosteum  and  the  soft  parts  are  involved.  The  disease  may  invade  the 
joint  itself  in  a  destructive  inflammation,  or  pus  may  escape  externally 
without  seriously  involving  the  joint  structures.  The  degree  to  which 
the  joint  is  involved  varies  much  in  different  cases;  there  may  be  only 
a  simple  synovitis,  a  suppurative  arthritis,  or  a  destruction  of  the  car- 
tilages and  articular  ends  of  the  bones,  synovial  membrane,  and  liga- 
ments, so  that  in  the  advanced  stage  all  traces  of  a  joint  structure 
are  lost. 

If  the  process  remains  limited  to  the  bone,  recovery  may  take  place 
with  very  little  impairment  of  the  joint  functions.  If  suppuration 
in  the  joint  has  taken  place,  there  will  be  more  or  less  stiffness  and 
fibrous  or  bony  ankylosis.  When  there  is  destruction  of  the  ligaments 
and  articular  ends  of  the  bones,  the  limb  assumes  a  characteristic  posi- 
tion— the  joint  is  flexed,  the  tibia  is  displaced  backward  and  rotated 
outward,  and  there  is  marked  over-riding  of  the  femur.  Bony  ankylosis 
in  this  position  is  often  seen. 

Symptoms. — The  earliest  symptoms  of  disease  at  the  knee  are  usually 
a  slight  stiffness  of  the  joint,  with  a  disposition  to  flexion  and  slight 
lameness.  At  first  these  symptoms  are  noticed  only  occasionally;  finally 
they  become  constant  and  there  is  pain,  which  is  usually  referred  to  the 


KNEE-JOINT  DISEASE  917 

knee;  In  some  cases  there  are  "starting  pains"  at  night,  although  these 
are  less  constant  and  less  severe  than  in  hip  disease.  Swelling  is  noticed 
early,  as  the  diseased  parts  are  superficial.  At  first  this  is  chieflj'  of  the 
bone  itself;  the  condyle,  usually  the  inner  one,  is  enlarged  aiid  elon- 
gated, often  to  a  marked  degree,  before  there  is  any  infiltration  of  the 
soft  parts.  Later  there  is  a  general  fusiform  swelling,  involving  the 
entire  joint  and  effacing  all  the  normal  outlines.  Some  tenderness  upon 
pressure  over  the  bone  afl^ected  is  present  quite  early,  and  there  may  be 
atrophy  of  the  muscles  of  the  thigh  and  calf.  The  knee  is  flexed  and 
slightly  rotated  outward,  the  position  which  secures  the  most  complete 
relaxation  of  the  joint  structures.  In  some  cases  there  is  seen  the  char- 
acteristic swelling  due  to  distention  of  the  synovial  membrane.  Ab- 
scesses may  form  anywhere  about  the  joint ;  very  frequently  they  burrow 
beneath  the  tendon  of  the  quadriceps  extensor  as  far  as  the  middle  of  the 
thigh.  Gradually  the  deformity  increases  until  the  leg  may  be  flexed  at 
a  right  angle,  and  rotated  outward  over  an  arc  of  twenty  or  thirty 
degrees. 

The  course  of  the  disease  resembles  that  of  ostitis  of  the  hip  and  the 
spine.  During  periods  of  remission  pain  and  tenderness  often  subside 
for  several  months  so  completely  as  to  lead  to  the  supposition  that  the 
disease  has  been  arrested.  An  exacerbation  is  often  excited  by  a  fall  or 
a  strain  of  the  joint,  or  it  may  follow  an  attack  of  acute  illness.  The 
disease  may  then  progress  rapidly  and  abscess  after  abscess  form,  with 
extensive  destruction  of  all  the  joint  structures  and  the  production  of 
permanent  deformity. 

Prog^iosis. — The  danger  to  life  is  considerably  less  than  in  disease  of 
tlie  hip  or  spine.  Death,  however,  results  from  the  same  causes — exhaus- 
tion, amyloid  degeneration,  and  general  tuberculosis  or  tuberculous 
meningitis. 

With  an  early  diagnosis  and  proper  treatment  the  disease  may,  in  a 
considerable  proportion  of  cases,  remain  limited  to  the  bone,  and  the 
resulting  lameness  and  deformity  be  very  slight ;  but  otherwise  a  certain 
amount  of  lameness  results  from  the  stiffness  of  the  joint.  This  may  be 
due  either  to  fibrous  thickening  or  to  bony  ankylosis.  IST early  all  patients 
are  able  to  walk  without  crutches,  and  if  proper  treatment  has  Ijeeu 
carried  out  there  is  neither  marked  shortening  nor  deformity,  although 
there  is  always  great  muscular  atrophy. 

Dia^osis. — The  important  symptoms  for  diagnosis  are  the  gradual 
onset,  the  early  swelling  which  is  due  to  enlargement  of  the  bone,  and 
the  constant  lameness  and  deformity.  The  disease  may  be  confounded 
Avith  rheumatism,  with  synovitis,  and  even  with  scurvy.  In  all  these 
cases  the  resemblance  exists  only  during  the  period  of  exacerbation.  A" 
careful  history,  however,  will  usually  make  the  diagnosis  clear. 


018  DISEASES  OF  THE  BONES  AND  JOINTS 

Treatment.— The  general  treatment  is  the  same  as  in  other  forms  of 
joint  disease.  The  indications  for  local  treatment  are  the  same  as  in 
hip  disease. 

Tuberculous  Osteomyelitis 

This  disease  is  rarely  seen  except  in  the  short  tubular  bones,  most 
frequently  those  of  the  hand  and  fingers.  From  this  fact  it  is  often 
called  scrofulous  or  tuberculous  dactylitis.  It  is  described  by  many 
writers  under  the  name  of  spina  ventosa.  linger  gives  the  following 
figures  showing  the  frequency  with  which  the  different  bones  were  af- 
fected: fingers  in  43,  toes  in  3,  metacarpus  in  41,  metatarsus  in  14, 
radius  in  2,  ulna  in  2,  tibia  in  3,  jaw  in  3.  The  first  phalanx  of  the  index 
finger  is  the  bone  which  is  most  frequently  the  seat  of  disease.  In  the 
majority  of  cases  the  process  is  confined  to  a  single  bone,  although  it  is 
not  rare  to  see  five  or  six  afEected.  In  such  cases  the  disease  is  seldom 
symmetrical.  The  process  is  a  chronic  inflammation,  beginning  in  the 
center  of  the  bone  with  the  deposit  of  tuberculous  material.  The  swell- 
ing which  follows  causes  an  expansion  of  the  bone  and  thinning  of  the 
shaft,  until  a  mere  shell  may  remain.  The  later  changes  are  inflamma- 
tion of  the  periosteum  and  the  soft  parts,  the  formation  of  abscesses  and 
sinuses,  necrosis,  the  exfoliation  of  sequestra,  etc.  The  entire  disease 
lasts  from  one  to  three  years,  and  causes  in  most  cases  marked  deformity. 

Tuberculous  dactylitis  is  essentially  a  disease  of  early  childhood,  be- 
ing seen  most  frequently  during  the  second  and  third  years.  The 
disease  frequently  appears  to  be  the  only  tuberculous  lesion  in  the  body, 
but  tuberculosis  of  other  parts,  especially  other  bones,  may  be  associated. 

Symptoms. — The  disease  usually  begins  as  a  painless  enlargement  of 
one  of  the  phalanges,  most  frequently  the  first  one  of  the  index  finger. 
It  may  be  two  or  three  months  before  it  is  of  sufficient  size  to  attract 
much  attention.  Exceptionally  the  inflammation  is  a  more  active  one, 
and  is  accompanied  by  both  pain  and  tenderness.  The  swelling  is  quite 
characteristic;  it  is  smooth,  hard,  uniform,  and  generally  spindle- 
shaped,  involving  the  entire  phalanx  of  the  affected  finger.  The  appear- 
ance of  a  severe  typical  case  is  shown  in  Fig.  148.  Later  there  is 
discoloration  of  the  skin,  and  usually  there  is  suppuration.  The  abscess 
generally  opens  at  the  side  of  the  finger,  and  a  curdy  pus  is  evacuated. 
If  the  opening  is  enlarged  by  an  incision  there  is  found  a  cavity  partly 
filled  with  caseous  matter,  and  dead  bone  is  felt,  and  perhaps  a  loose 
sequestrum.  The  cavity  is  surrounded  by  a  thin  shell  of  new  bone, 
which  is  formed  from  the  periosteum.  If  no  operation  is  done  the  dis- 
charge continues  for  weeks  or  months,  other  abscesses  often  form,  and 
finally  several  small  sequestra  are  exfoliated — sometimes  a  single  large 
one — which  is  the  shell  of  the  diseased  phalanx  almost  entire. 


TUBERCULOUS  OSTEOMYELITIS  919 

In  some  eases  tlie  disease  is  arrested  before  neerosis  oeeurs,  but  in  the 
majority  this  is  not  so.  After  the  wounds  have  all  healed  the  finger 
remains  shortened,  deformed,  arid  often  useless.  In  some  cases  the  dis- 
organization is  so  extensive  that  amputation  is  necessary. 

Diagnosis. — The  recognition  of  dactylitis  is  usually  easy,  but  as 
symptoms  almost  identical  may  be  seen  in  a  syphilitic  inflammation,  it 
is  often  difficult  to  tell  with  which  of  the  two  forms  one  has  to  deal. 
The  tuberculous  form  is  much  more  frequent  and  is  usually  seen  in 
children  over  two  years  of  age;  it  may  occur  in  a  patient  with  tuber- 
culous  antecedents,   or   it   may   be  associated   with   other   tuberculous 


Fiu.  148. — TuBEKCULous  Dactylitis. 

lesions.  Syphilitic  dactylitis  is  distinguished  by  the  fact  that  it  is  more 
often  seen  in  young  infants,  that  the  lesion  is  more  frequently  multiple, 
that  it  is  often  symmetrical,  and  that  other  manifestations  of  syphilis 
are  generally  present.  The  Wassermann  and  the  tuberculin  tests  give 
definite  information  in  nearly  all  cases. 

Treatment. — Painting  with  iodin  and  like  measures  are  useless.  The 
diseased  part  should  be  kept  at  rest — if  a  finger,  by  the  application 
of  a  splint.  Every  means  should  be  taken  to  build  up  the  patient's  gen- 
eral health,  as  this  is  the  most  effective  way  to  influence  the  local  process. 
The  general  verdict  of  surgeons  is  against  early  excision  as  a  means  of 
arresting  the  disease.  Abscesses  should  be  opened  early  and  freely,  all 
diseased  bone  removed,  the  finger  kept  in  proper  position,  and  the  wound 
treated  according  to  general  surgical  principles.  Under  almost  any 
treatment  the  disease  is  a  protracted  one,  and  rarely  lasts  less  than  a 
year. 


920  DISEASES   OF  THE  SKIN 

CHAPTER  V 
DISEASES  OF  THE  SKIN 

The  skin  at  birth  is  covered  with  a  whitish  sebaceous  secretion,  the 
vernix  caseosa.  The  skin  itself  is  of  a  deep-purplish  color,  which 
changes  to  a  bright  red  over  the  face  and  trunk  in  a  few  minutes,  with 
the  establishment  of  normal  respiration,  and  in  a  few  hours  the  whole 
body  has  the  same  tint.  This  excessive  redness  slowly  fades  during  the 
first  month,  at  the  end  of  which  time  the  skin  has  assumed  the  pale  pink 
of  infancy.  On  the  third  or  fourth  day  there  may  be  seen  the  first  signs 
of  physiological  icterus ;  this  generally  disappears  by  the  end  of  the  second 
week. 

The  epidermis  which  is  present  at  birth  soon  loosens  and  is  thrown 
off.  This  normal  desquamation  usually  begins  upon  the  fourth  or  fifth 
day,  and  is  completed  in  ten  days  or  two  weeks.  If  the  skin  is  fre- 
quently oiled  and  properly  bathed,  desquamation  is  scarcely  noticeable 
unless  a  close  examination  is  made.  In  soine  infants,  especially  those 
who  are  delicate  and  cachectic,  it  is  very  much  more  marked. 

Perspiration  is  rarely  present  before  the  end  of  the  fourth  month, 
and  is  then  seen  only  upon  the  forehead.  In  healthy  infants  it  is 
scarcely  noticeable  during  the  first  year.  Copious  perspiration  is  most 
frequently  a  symptom  of  rickets;  less  marked  perspiration  may  occur 
with  any  general  weakness  or  during  acute  illness. 

CONGENITAL  ICHTHYOSIS 

Congenital,  or  more  properly  fetal,  ichthyosis  in  its  severe  form  is 
a  rare  disease,  characterized  by  the  formation,  usually  all  over  the  body, 
of  a  thick,  horny  epidermis  resembling  parchment.  This  is  divided  by 
fissures  or  shallow  furrows  into  irregular  patches;  sometimes  these  arc 
two  or  three  inches  wide,  at  others  as  small  as  a  pin's  head.  In  its 
milder  form  it  is  not  uncommon.  The  disease  begins  in  the  early 
months  of  fetal  life,  and  is  an  abnormality  in  the  development  of  the 
skin,  there  being  an  excessive  proliferation  of  the  layers  of  the  epi- 
dermis. 

Symptoms. — In  the  gravest  form  of  the  disease  the  child  often  lives 
but  a  few  hours,  and  rarely  more  than  a  week.  The  openings  of  the 
nostrils  and  the  ears  may  be  occluded  by  the  excessive  production  of 
epithelial  cells.  The  eyes  are  in  a  condition  of  ectropion,  and  there  are 
often  deformities  of  the  mouth  and  other  orifices  due  to  the  contractions 


MILIARIA 


921 


of  the  skin.  The  nails  and  hair  are  usually  imperfectly  developed.  The 
body  seems  encased  in  a  hard,  horny  covering,  and  looks  as  if  it  had  been 
varnished  or  covered  with  collodion.  The  skin  cracks  or  splits  and  the 
edges  curl  up,  an  appearance  which  has  been  aptly  compared  to  the  skin 
of  a  boiled  potato. 

In  the  milder  form,  the  duration  of  life  is  indefinite,  depending  upon 
the  degree  of  development  of  the  disease;  but  even  in  such  cases  there 
may  be  seen  the  deformities  at 
the  orifices  of  the  body,  and 
there  may  also  be  a  continued 
exfoliation  of  the  epidermis  in 
large  irregidar  patches.  After 
this  has  separated,  the  skin  be- 
neath appears  red  and  moist, 
but  gradually  becomes  dry, 
hard,  and  shining,  slowly  con- 
tracting until  it  splits  in  vari- 
ous directions. 

The  outlook  is  unfavorable 
in  all  cases ;  in  most  of  the  se- 
vere forms  death  occurs  in  in- 
fancy, but  in  some  of  the  mild- 
er ones,  life  may  be  prolonged 
indefinitely.  The  "alligator 
boy"  of  the  "Dime  Museum"  is 
an  example  of  this  class. 

Treatment. — The  indica- 
tions are  to  keep  the  skin  moist 
and  soft  by  the  use  of  oils,  con- 
tinuous baths,  etc.,  and  to  pre- 
vent infection  by  perfect  clean- 
liness.      Although    a     certain 

amount  of  im^provement  usually  follows  these  measures,  a  cure  is  not  to 
be  expected. 


Fig. 


149. — Congenital  Icthyosis,  Six  Weeks 
Old. 


MILIARIA 


The  term  miliaria  is  applied  to  an  obstruction  of  the  sweat  glands, 
which  may  occur  either  with  or  without  inflammation.  The  non-inflam- 
matory form  is  known  as  sudamina  the  inflammatory  forms  as  miliaric, 
rubra,  miliaria  vesiculosa   and  miliaria  jjapulosa. 

Sudamina. — In  this  form  there  is  no  inflammation.  The  sweat  ducts, 
according  to  Crocker,  are  blocked  bv  an  accumulation  of  epithelial  cells 


922  DISEASES  OF  THE  SKIN 

while  no  perspiration  is  going  on ;  and  when  the  process  is  restored  the 
fluid,  being  unable  to  escape,  accumulates  in  the  form  of  tiny  vesicles. 
These  appear  like  small  pearly  bodies  very  closely  set,  and  disappear  in 
the  course  of  a  few  days  by  absorption.  Fresh  crops  may  appear  from 
time  to  time.  Sudamina  may  be  seen  in  any  of  the  continued  fevers  or 
exhausting  diseases.     It  requires  no  treatment. 

Miliaria  Rubra.. — This  condition,  also  known  as  red  gum,  strophulus, 
etc.,  is  a  sweat  rash,  usually  seen  in  young  infants  as  the  result  of  ex- 
cessive clothing.  It  is  most  frequently  observed  upon  the  cheeks  and 
neck,  often  upon  the  side  of  the  face  upon  which  the  infant  sleeps,  or  the 
side  held  against  the  mother's  body  while  nursing,  if  this  is  done  upon 
only  one  breast.  The  eruption  consists  of  scattered  red  papules,  some- 
times with  tiny  vesicles.  Miliaria  rubra  is  an  iuflannnation  about  the 
sweat  glands,  the  result  of  which  is  a  retention  of  their  secretion.  There 
is  generally  little  or  no  itching.  The  treatment  consists  in  the  removal 
of  the  cause,  and  the  ai)plication  of  some  absorbent  powder,  such  as 
boric  acid  and  starch. 

Miliaria  Papulosa  {Liclien  Tropicus,  FricJcIy  Heat,  etc.). — This  is 
the  most  common  and  most  important  variety  of  miliaria.  There  is  in 
this  disease  an  obstruction  of  the  sweat  glands  by  inflammatory  products. 
The  lesion  consists  in  the  formation  of  bright-red  papules,  which  are 
very  closely  set,  the  summits  of  some  of  them  being  surmounted  by  tiny 
vesicles,  and  here  and  there  in  severe  cases  even  small  pustules  may  be 
seen.  If  not  interfered  with  by  scratching,  the  vesicles  dry  up  without 
rupture,  and  are  followed  by  a  slight  desquamation.  Where  there  is  much 
scratching,  an  eczematous  condition  may  result.  Miliaria  papulosa  comes 
out  with  great  rapidity,  especially  upon  the  neck,  forehead,  back,  and 
chest.  It  is  accompanied  by  an  almost  intolerable  itching  and  stinging 
sensation.  Over  other  parts  of  the  body  profuse  perspiration  occurs. 
The  disease  is  produced  by  very  hot  weather  and  excessive  clothing. 
Although  the  duration  of  a  single  attack  is  but  two  or  three  days,  in 
susceptible  patients  it  may  keep  recurring  for  weeks,  being  exceedingly 
intractable.  Where  there  is  much  scratching,  the  resulting  eczema  is 
very  troublesome.     It  is  not  infrequently  followed  by  furunculosis. 

The  diagnosis  of  miliaria  rubra  and  miliaria  papulosa  is  usually  easy. 
They  are  distinguished  from  eczema  by  the  suddenness  with  which  they 
appear,  by  the  associated  sweating  of  other  parts  of  the  body,  by  the 
transitory  character  of  the  eruption,  and  by  the  fact  that  Ibe  rash  ne\er 
occurs  in  circumscribed  patches. 

Prickly  heat  is  to  be  prevented  by  light  clothing,  frequent  bathing, 
and  the  plentiful  use  of  a  good  toilet  powder,  such  as  boric  acid  and 
starch.  Tlie  skin  should  be  jjrotected  against  the  irritation  of  flannel 
undergarments  by  the  interposition  of  silk  or  linen.     When  the  inflam- 


ECZEMA  923 


mation  is  at  its  height,  relief  is  obtained  by  the  application  of  a  calamin 
and  zinc  lotion,  or  by  a  dilute  solution  of  the  acetate  of  lead;  carbolic 
acid  riiay  be  added  to  either,  when  the  itching  is  intense.  In  some  cases 
bland  powders  are  preferable  to  lotions. 


SEBORRHEA 

Seborrhea  is  considered  by  dermatologists  generally,  as  a  functional 
disease  of  the  sebaceous  glands ;  although  Unna  regards  all  such  cases  as 
parasitic  in  origin  and  inflammatory,  and  classes  them  as  seborrheic 
eczema.  The  disease  may  aifect  almost  any  part  of  the  body,  and  chil- 
dren of  any  age,  but  the  most  frequent  form  is  that  which  is  seen  upon 
the  scalp  in  young  infants.  This  is  the  most  important  variety,  and 
the  only  one  which  will  be  here  considered. 

Seborrhea  of  the  scalp  is  characterized  by  the  formation  upon  the 
vertex,  of  dirty-yellow  crusts,  which  are  soft,  greasy,  and  friable.  They 
are  composed  of  epithelial  cells,  fat-globules,  and  granular  masses,  to 
which  is  always  added  dirt.  In  neglected  cases  the  hairy  scalp  is  nearly 
covered  by  a  dense  crust,  which  may,  be  as  thick  as  heavy  pasteboard. 
If  the  crusts  are  removed  the  underlying  scalp  may  be  found  perfectly 
healthy,  but  more  frequently,  in  cases  of  long  standing,  it  is  eczematous. 
The  eczema  is  set  up  by  the  decomposition  of  the  exudation,  or  by  the 
efforts  to  remove  the  crusts  by  such  means  as  the  fine-toothed  comb,  com- 
monly employed' in  domestic  practice.  There  is  little  tendency  to  spon- 
taneous improvement  or  recovery,  and  the  condition  often  lasts  for 
months.  Every  seborrhea  should  be  treated,  for  when  neglected  it  fur- 
nishes a  favorable  soil  for  the  development  of  eczema. 

Only  local  treatment  is  required.  The  crusts  are  first  to  be  softened 
with  oil,  and  then  removed  by  washing  thoroughly  with  warm  water 
and  soap,  after  which  an  ointment  of  resorcin,  2-per-cent  strength,  or  of 
sulphur,  10-per-cent  strength,  should  be  applied.  The  oil  and  soap  and 
water  are  repeated  every  few  days,  or  as  often  as  the  crusts  form.  In 
the  meantime  the  scalp  is  kept  covered  with  the  ointment. 


ECZEMA 

Eczema  is  the  most  frequent  and  altogether  the  most  important  dis- 
ease of  the  skin  in  early  life.  The  scope  of  the  present  work  permits 
only  a  discussion  of  such  features  and  varieties  as  are  peculiar  to  in- 
fants and  young  children.  The  eczema  of  older  children  does  not  differ 
in  any  essential  jooints  from  that  of  adults. 


924  DISEASES  OF  THE  SKIN 

Etiology.— The  conditions  in  infancy  which  predispose  to  eczema 
are,  first,  that  the  skin  is  extremely  delicate,  and  hence  more  easily 
affected  hy  external  irritants  and  microorganisms;  secondly,  its__more 
intense  glancliilar  activity.  While  all  children  are  susceptible,  there  are 
certain  ones  in  whom  the  susceptibility  is  very  marked,  and  in  them  the 
slightest  amount  of  external  irritation,  or  the  most  trivial  disturbance 
of  digestion  may  produce  a  severe  eruption.  Eczema  is  one  of  the  chief 
manifestations  of  the  exudative  diathesis  (Czerny).  It  is  _  especially 
prevalent  in  some  families  and  is  not  infrequently  inherited  with  the 
other  evidences  of  the  diathesis.  Eczema  is  common  in  fat,  healthy-look- 
ing infants,  both  in  those  who  are  nursing  and  in  those  who  are  arti- 
ficially fed.  It  rarely  occurs  in  poorly  nourished  children.  Children 
with  eczema  are  not  infrequently  subjects  of  asthma  in  later  life.  Ec- 
zema may  apparently  be  initiated  and  is  certainly  aggravated  by  over- 
feeding, whether  it  be  with  breast  milk  or  artificial  food.  The  food  ele- 
ment which  seems  to  be  particularly  to  blame  is  the  fat,  but  farinaceous 
food  in  excess  has  also  a  bad  effect.  Schloss  and  Blackfan  have  shown 
that  there  is  a  susceptibility  to  animal  protein  on  the  part  of  most  pa- 
tients with  eczema,  as  shown  by  cutaneous  tests  with  various  proteins. 
Most  of  the  patients  are  susceptible  to  egg  white  and  many  to  cow's 
milk.  A  few  are  susceptible  to  woman's  milk.  Some  children  even  with 
severe  eczema  are  insusceptible.  The  exact  meaning  of  this  susceptibility 
is  not  clear. 

The  exciting  causes  of  eczema  may  be  external  or  internal.  Of  the 
former  the  most  important  are  heat,  cold  dry  air,  and  winds — as  in  the 
familiar  chapping  of  the  face — the  use  of  "hard"  water  or  of  strong  soaps 
in  bathing.  The  disease  may  be  due  to  the  irritation  of  clothing,  to 
want  of  cleanliness,  or  to  irritating  discharges  from  mucous  surfaces,  as 
in  the  eczema  of  the  upper  lip,  thighs,  or  buttocks.  It  accompanies  most 
of  the  parasitic  skin  diseases,  particularly  pediculosis,  scabies  and  ring- 
worm. 

What  part  is  played  by  microorganisms  in  the  etiology  of  eczema 
has  not  yet  been  fully  determined.  As  a  primary  factor  they  do  not 
seem  to  be  of  the  first  importance.  Secondary  infection,  however,  occurs 
in  most  cases,  and  this  is  important  in  keeping  up  the  disease. 

Simple  Chronic  Eczema — Eczema  Rubrum. — This  is  the  most  fre- 
quent form  of  eczema  occurring  in  infants  and  young  children,  and  is 
usually  seen  upon  the  face.  It  affects  by  preference  the  cheeks,  forehead, 
and  scalp,  not  infrequently  the  ears  and  neck,  and  may  occur  upon  any 
■part  of  the  body.  Upon  the  trunk  and  extremities  the  eruption  is  usually 
in  patches,  but  in  rare  cases  may  cover  nearly  the  entire  body.  The  dis- 
ease generally  begins  upon  the  cheeks  with  the  formation  of  small  red 
papules;  later  these  coalesce,  and  there  is  a  moist,  red  surface  exuding 


ECZEMA  925 

serum.  The  secretion  dries  and  forms  thick,  gummy  crusts,  which 
may  be  so  hard  as  to  form  a  mask  for  the  face.  From  the  scratching 
caused  by  the  almost  intolerable  itching,  the  surface  bleeds  freely,  and 
the  dried  blood  gives  to  the  crusts  a  dirty-brown  color  and  adds  to  the 
distressing  appearance.  The  skin  is  often  much  swollen.  After  the 
removal  of  the  crusts  there  is  seen,  in  acute  cases,  a  red,  inflamed,  gran- 
ular surface,  moist  and  bleeding  readily.  When  the  process  is  less 
active,  there  is  redness,  thickening,  induration,  and  scaliness  of  the 
skin,  and  marked  itching.  In  the  same  case  these  stages  may  alter- 
nate, exacerbations  occurring  whenever  the  exciting  cause  is  partic- 
ularly active.  From  the  cheeks  the  disease  spreads  to  the  forehead, 
ears,  and  scalp,  and  here  similar  lesions  are  seen.  Upon  the  trunk  and 
extremities  thick  crusts  rarely  form,  but  the  skin  is  red,  thickened,  and 
scaly.  The  parts  most  often  affected  are  the  forearms,  legs,  abdomen, 
and  back ;  occasionally  the  eruption  is  general.  Eczema  of  the  occipital 
region  of  the  scalp  is  usually  due  to  pediculosis. 

Swelling  of  the  lymph  nodes  in  the  neighborhood  of  the  eruption 
is  a  constant  feature  of  eczema  of  the  face  and  scalp;  these  may  reach 
the  size  of  a  chestnut  or  walnut,  and  occasionally  they  may  suppurate. 
Intense  itching  is  a  characteristic  feature  of  all  cases  of  eczema  of  the 
face  or  scalp. 

While  most  children  with  eczema  are  well  nourished  in  the  begin- 
ning, and  some  remain  so  during  a  prolonged  attack,  the  general  health 
of  many  is  undermined.  The  itching  and  discomfort  cause  constant 
irritability,  loss  of  sleep,  and  other  nervous  symptoms  which  sometimes 
seriously  impair  the  child's  nutrition. 

The  effects  of  very  extensive  eczema  resemble  in  some  particulars 
those  of  burns  of  the  second  degree.  There  may  be  fever,  delirium, 
other  nervous  symptoms  and  even  a  fatal  termination.  We  have  seen 
several  cases  with  a  generalized  eczema  in  which  there  developed,  with- 
out evident  cause,  exceedingly  high  temperature,  in  two  eases  reaching 
109°  F.,  accompanied  by  symptoms  of  a.  most  profound  intoxication. 
Most  of  the  infants  with  such  symptoms  die,  but  one  child  recovered  in 
whom  the  temperature  mentioned  was  reached.  No  satisfactory  explan- 
ation of  these  severe  intoxications  has  yet  been  offered. 

There  are  some  patients  in  whom  an  alternation  of  eczema  and  at- 
tacks of  bronchitis  with  asthma  may  occur.  During  the  eczema,  the 
pulmonary  symptoms  are  entirely  wanting;  but  when  the  eczema  is  re- 
lieved the  pulmonary  symptoms  rapidly  develop.  In  a  few  patients  an 
alternation  of  eczema  and  diarrhea  is  observed. 

Patients  with  eczema  are  exceedingly  prone  to  develop  attacks  of 
diarrhea  and  this  condition  nearly  always  brings  about  a  marked  im- 
provement in  the  skin,  though  the  diarrhea  is  often  difficult  to  control. 
31 


926  DISEASES  OF  THE  SKIN 

Eczema  of  the  face  is  very  clirojiic,  easily  improved,  but  cured  only 
with  great  difficulty.  There  is  a  strong  tendency  to  relapse,  brought  on 
by  neglect  of  local  treatment,  by  any  digestive  disturbances,  or  by  over- 
feeding. 

The  predisposition  to  eczema  often  ceases  with  the  second  year;  those 
who  have  suffered  from  it  almost  constantly  during  infancy  may  be  free 
from  it  during  the  remainder  of  childhood.  This  is  in  part  to  be  ex- 
plained by  the  loss  of  fat  in  consequence  of  more  active  exercise  and  a 
diet  which  is  more  largely  nitrogenous.  When  the  disease  continues 
through  the  third  and  fourth  years,  the  associated  infantile  condition, 
obesity,  is  not  infrequently  present. 

Pustular  Eczema  of  the  Scalp. — This  condition,  often  called  "simple 
impetigo,"  is  less  frequently  seen  in  infants  than  in  children  from  two 
to  five  years  old.  There  are  usually  present  from  half  a  dozen  to  fifty 
greenish-yellow  crusts  matting  the  hair,  usually  discrete,  but  sometimes 
coalescing  to  form  a  mask  over  half  the  scalp.  There  is  very  little  itch- 
ing, in  some  cases  none  at  all.  The  lymph  glands  are  invariably  en- 
larged. This  form  of  eczema  is  due  to  infection  with  pyogenic  organ- 
isms. The  children  constantly  re-infect  themselves,  and  in  this  way  the 
disease  may  be  prolonged  indefinitely.  It  is  possible,  too,  that  infection 
may  spread  to  other  children. 

Intertrigo. — This  term  is  rather  indiscriminately  applied  to  any 
eruption  which  develops  upon  two  moist  surfaces,  which  are  in  contact. 
It  is  often  regarded  as  a  form  of  eczema.  There  may  be  a  simple 
erythema  or  an  eczema  resulting  from  traumatism  or  the  decomposition 
of  secretions.  Intertrigo  is  seen  in  the  folds  of  the  groin,  between  the 
scrotum  and  the  thighs,  between  the  buttocks,  about  the  anus,  in  the 
axillae,  in  the  neck,  or  behind  the  ears.  Its  essential  causes  are  moisture, 
friction,  want  of  cleanliness,  and  sometimes  infection.  The  disease  is 
generally  seen  in  its  worst  form  abo^^t  the  thighs,  genitals,  and  buttocks ; 
it  sometimes  covers  the  sacrum  and  extends  down  to  the  middle  of  the 
thighs.  There  is  an  intense  uniform  redness,  and  in  some  cases  the  epi- 
dermis is  denuded  over  large  areas,  and  the  surface  is  moist.  There  is 
no  thick  crusting  and  little  or  no  itching.  Intertrigo  is  usually  easy  to 
control  except  in  very  poorly  nourished  or  marantic  children,  among 
whom  it  is  especially  frequent. 

Diagnosis  of  Eczema. — This  is  usually  quite  an  easy  matter.  In  the 
majority  of  cases,  the  disease  afi^ects  the  face  or  the  scalp,  and  its  appear- 
ances are  typical.  Eczema  of  the  body  or  extremities  may  be  confounded 
with  scabies  or  syphilis,  and  occasionally  with  other  forms  of  skin  dis- 
ease. Scahies  resembles  eczema  in  its  intense  itching  and  multiform 
lesions;  but  in  the  former,  one  may  often  find  evidences  of  its  presence 
in  other  members  of  the  family ;  tlie  parts  most  frequently  affected  are 


ECZEMA  I         927 

the  flexures  of  the  wrists,  the  elbows,  the  skin  between  the  fingers,  the 
margins  of  the  axillae,  the  lower  part  of  the  abdomen  and  back,  and,  in 
boys,  the  penis;  and  by  careful  examination  with  a  lens  some  of  the 
characteristic  burrows  are  certain  to  be  discovered. 

Syphilis  is  likely  to  be  confounded  with  papular  eczema  of  the  but- 
tocks. The  latter  affects  the  parts  near  the  anus,  and  the  irritation  may 
lead  to  the  development  of  spots  closely  resembling  mucous  patches.  The 
local  appearances  may  at  times  be  indistinguishable  from  syphilis,  and 
the  diagnosis  is  to  be  made  only  by  the  other  symptoms  present.  In 
syphilis  the  characteristic  eruption  is  seen  usually  upon  the  face,  hands, 
legs,  aiul  sometimes  the  palms  and  soles;  there  is  no  itching  and  very 
little  evidence  of  inflammation;  the  eruption  is  copper-colored,  and  oc- 
curs as  small  circumscribed  spots;  there  are  usually  present  other  symp- 
toms, such  as  the  coryza,  the  syphilitic  cachexia,  and  enlargement  of  the 
spleen. 

The  diagnosis  from  pediculosis  and  ring-worm  of  the  scalp,  rarely 
presents  any  difficulties. 

Prognosis. — All  cases  of  chronic  eczema  are  tedious.  There  is  only  a 
slight  tendency  to  spontaneous  improvement,  and  very  little  to  spontane- 
ous recovery  during  early  infancy.  About  the  end  of  the  first  year  the 
disease  disappears  in  many  children;  some  relapse  after  this  time,  but 
others  are  never  again  troubled  with  eczema.  In  a  severe  case  of  gen- 
eral eczema  the  possibility  of  the  development  of  severe  toxic  symptoms 
should  not  be  forgotten.  In  any  given  case  of  eczema,  the  prognosis- 
depends  upon  the  duration  of  the  disease,  its  severity,  and  very  much 
upon  the  cooperation  of  the  mother  or  nurse.  The  results  obtained  de- 
pend not  only  upon  the  particular  line  of  treatment  adopted,  but  upon 
how  well  it  is  carried  out.  Usually  it  must  be  continued  for  several 
months.  Intertrigo  is  in  most  cases  easily  cured,  unless  the  patient  is 
suffering  from  extreme  malnutrition. 

Treatment. — ^A  judicious  combination  of  general  and  local  measures 
is  necessary  for  the  best  results.  Unless  disturbances  of  nutrition  can 
be  removed,  local  treatment  will  give  only  temporary  relief.  External 
causes  also  must  be  investigated. 

A  thorough  investigation  into  the  food  is  necessary,  not  only  as  to 
its  character,  but  as  to  quantity  and  preparation,  the  manner  and  fre- 
quency of  feeding,  etc.  If  the  patient  is  a  nursing  infant,  very  fat  and 
well  nourished,  the  amount  of  food  should  be  reduced  by  lengthening 
the  interval  between  feedings  and  shortening  the  time  which  the  child 
is  allowed  to  remain  at  the  breast  at  one  nursing.*  Plain  water,  or 
better,  some  alkaline  water,  should  be  given  freely  between  the  nursings. 
In  children  fed  upon  cow's  milk  the  quantity  may  be  too  great,  or  the 
trouble  may  be  with  the  sugar,  but  more  frequently  with  the  fat.     This 


928  DISEASES  OF  THE  SKIN 

should  first  be  reduced  and  if  no  improvement  occurs  the  sugar  should 
also  be  diminished. 

During  the  latter  part  of  the  first  and  the  entire  second  year,  the 
usual  error  is  that  of  overfeeding,  with  in  some  cases  an  excessive  use 
of  solid  food,  very  often  with  too  much  milk.  The  diet  should  then  be 
much  reduced,  and  the  amount  of  solid  food  restricted.  The  diet 
which  suits  most  children  best  is  one  composed  of  a  moderate  amount  of 
milk,  beef  juice,  broth,  cooked  fruit  and  green  vegetables;  eggs  and  meat 
must  be  used  with  caution.  The  cereals — rice,  wheat  or  barley^ — may  be 
added,  in  small  amounts  at  first.  Any  form  of  indigestion  which  exists 
is  to  be  managed  according  to  the  special  indications  in  each  case.  When 
there  is  a  susceptibility  to  proteins,  as  shown  by  cutaneous  tests,  a  reduc- 
tion or  for  the  time  a  complete  removal  from  the  diet  of  the  protein 
causing  the  reaction  should  be  made  with  children  over  one  year  old. 
In  older  patients  the  results  are  sometimes  very  striking. 

The  diet  of  older  children  needs  to  be  watched  no  less  closely  than 
that  of  infants.  The  general  rules  laid  down  elsewhere  for  feeding  after 
the  second  year  should  be  observed. 

Elimination  by  the  kidneys  should  be  stimulated  by  the  very  free  use 
of  water,  to  which  may  be  added  an  alkaline  diuretic — the  citrate  or  ace- 
tate of  potassium,  from  ten  to  twenty  grains  daily. 

Attention  to  the  condition  of  the  bowels  is  of  the  greatest  importance. 
To  overcome  the  tendency  to  constipation  is  in  many  cases  to  cure  the 
eczema.  Suggestions  under  this  head  will  be  found  in  the  chapter  on 
Chronic  Constipation.  The  bowels  must  not  only  be  opened,  they  must 
be  kept  open  by  the  daily  use,  if  necessary,  of  some  of  the  milder  laxa- 
tives, such  as  magnesia,  phosphate  of  sodium,  rhubarb,  or  cascara. 

When  the  disease  occurs  in  flabby,  anemic,  or  poorly-nourished  chil- 
dren, iron,  arsenic  and  bitter  tonics  are  required,  but  rarely  cod-liver 
oil.  In  other  words,  the  child's  general  condition  should  be  treated  just 
as  if  no  eczema  existed. 

The  general  management  of  cases  is  important.  The  skin  must  be 
carefully  protected  by  an  ointment  Avhenever  the  child  is  in  the  open 
air;  if  the  weather  is  very  cold,  or  there  are  high  winds,  children  with 
active  eczema  should  not  go  out,  but  be  aired  indoors.  Never  should  an 
eczematous  surface  be  washed  with  plain  water,  and  miich  less  with 
castile  soap  and  water.  When  washing  is  necessary,  it  may  be  done  with 
bran  water,  milk  and  water,  or  starch  and  water,  to  which  borax  (a  tea- 
spoonful  to  the  quart)  may  be  added.  The  clothing  should  not  be  so 
excessive  as  to  keep  the  child  constantly  in  a  perspiration.  Napkins 
should  not  be  washed  in  strong  soda  solutions,  nor,  in  case  of  eczema  of 
the  buttocks^  should  they  ever  be  used  a  second  time  after  being  simply 
dried. 


ECZEMA  929 

111  eczema  of  the  face  it  is  absolutely  necessary  to  prevent  the  child 
from  scratching  the  parts.  The  use  of  a  mask  is  not  always  sufficient, 
nor  the  wearing  of  mittens;  nor  is  the  local  application  of  anti-pruritic 
lotions  or  ointments  altogether  successful.  In  severe  cases  mechanical 
restraint  is  absolutely  indispensable.  The  most  satisfactory  method  is 
to  surround  the  arms  at  the  elbows  by  pasteboard  splints,  and  hold  them 
in  place  by  banclages.  This  allows  free  use  of  the  hands,  but  makes  it 
imjDossible  for  the  child  to  reach  the  face. 

Local  Treatment. — Local  treatment  is>always  necessary,  for  not  only 
are  the  causes  sometimes  entirely  external,  but  the  condition  may  persist 
after  the  original  internal  cause  has  been  removed.  There  are  several 
indications  to  be  met  by  local  treatment  at  different  stages  in  the  disease : 
( 1 )  To  remove  crusts  and  other  inflammatory  products ;  ( 2 )  to  allay 
congestion  and  acute  inflammation;  (3)  to  relieve  itching;  (4)  to  pro- 
tect the  delicate  new  skin  which  is  forming;  (5)  to  prevent  infection; 
(G)  to  stimulate  the  skin  in  the  chronic  stages  of  the  disease. 

Preparatory  to  the  use  of  any  application,  the  scales,  crusts,  and  other 
products  of  inflammation  must  be  softened  and  removed  in  order  that 
the  diseased  surface  may  be  reached.  In  most  cases  it  is  sufficient  to 
soften  the  crusts  by  the  use  of  olive  oil  for  twelve  or  twenty-four  hours, 
and  then  remove  them  by  soap  and  warm  water.  If  the  crusts  are  very 
hard  and  thick,  they  can  be  softened  by  a  poultice.  During  the  stage  of 
acute  inflammation  only  sedative  applications  should  be  used,  such  as  a 
lotion  of  zinc  and  calamin.^  A  piece  of  muslin  should  be  dipped  in  the 
solution,  and  applied  to  the  affected  part,  being  kept  in  place  by  a  ban- 
dage or  the  skin  may  be  frequently  wetted  with  the  lotion  which  is  al- 
lowed to  dry  on.  If  there  is  much  itching,  one  per  cent  of  carbolic  acid 
may  be  added. 

Another  plan  of  treatment,  where  there  is  much  secretion,  is  to  keep 
the  surface  covered  with  equal  parts  of  boric  acid  and  starch  or  talcum 
powder.  An  application  which  is  often  successful  in  allaying  the  in- 
tense burning  and  itching  is  black  wash.  This  is  applied  several  times 
a  day  in  full  strength  or  diluted  and  allowed  to  dry  on,  after  which  a 
protective  ointment  is  used. 

A  soothing  application  in  general  eczema  is  one  composed  of  equal 
parts  of  lime-water  and  sweet-almond  oil;  sometimes  this  may  be  advan- 
tageously followed  by  smearing  the  body  with  a  thick  starch  paste  and 
allowing  it  to  dry  on. 

^  IJ  Pulv.  calaminae  preparatae 3ij 

Zinci   oxidi 5ss. 

Glycerinae     Si 

Liquor   calcis    Si  j 

Aquae  rosae Sviij 


930  DISEASES  OF  TTTE  SKIN 

As  a  simjDle  protective  ointment,  one  containing  starch,  zinc  oxid,  or 
bismuth,  either  alone  or  in  combination,  may  be  used.  An  excellent 
formula  is  zinc  oxid  ointment  with  two  per  cent  of  salicylic  acid. 

Later,  when  the  inflammation  is  less  acute  and  the  itching  severe, 
tar  in  the  strength  of  ten  to  twenty  per  cent  may  be  substituted  for  the 
salicylic  acid. 

All  ointments  used  should  be  spread  upon  muslin,  and  kept  in  close 
contact  with  the  inflamed  part  by  means  of  a  bandage  or  mask.  Little 
or  nothing  is  accomplished  by  simply  rubbing  the  ointment  upon  the 
affected  part.  An  ointment  containing  five  or  ten  per  cent  of  calomel 
is  often  the  best  application  for  an  eczema  which  is  not  too  extensive. 

The  methods  of  treatment  above  mentioned  are  especially  applicable 
to  eczema  of  the  face  and  scalp.  For  pustular  eczema  of  the  scalp  the 
best  application  is  the  white  precipitate  ointment,  which  should  be  com- 
bined with  three  or  four  parts  of  vaseline.  This  is  excellent  also  for 
small  eczematous  patches  upon  the  body,  but  it  is  not  to  be  used  over  a 
large  surface. 

In  intertrigo,  the  treatment  should  have  reference  to  the  pathologi- 
cal condition  which  is  jjresent.  Cases  of  simple  erythema  usually  yield 
promptly  to  cleanliness  and  the  free  use  of  absorbent  antiseptic  powders, 
such  as  boric  acid  and  starch  in  equal  parts,  or  calomel  two  per  cent  may 
be  used  with  talcum.  If  there  is  an  acute  dermatitis,  the  calamin  and 
zinc  lotion  may  be  used,  and  later  some  protecting  ointment.  When  in- 
fection has  been  added,  lotions  of  resorcin  or  ichthyol,  one-half  of  one 
per  cent  strength,  should  first  be  applied,  and  the  skin  then  covered  with 
one  of  the  powders  mentioned;  both  are  to  be  repeated  as  often  as  the 
parts  are  wet  by  urine  or  soiled  by  feces.  It  is  important  in  all  cases 
that  the  diseased  surfaces  should  be  kept  separated,  which  is  best  done 
by  boric  acid  and  starch.  All  napkins  should  be  immediately  removed 
when  soiled. 

In  cases  of  chronic  eczema,  where  the  skin  remains  thickened,  red, 
scaly,  and  itching,  stimulating  applications  are  to  be  used,  such  as  the 
tincture  of  green  soaj)  or  stronger  preparations  of  tar. 


FURUNCULOSIS 

A  furuncle,  or  boil,  is  a  circumscribed  inflammation  of  the  subcuta- 
neous cellular  tissue,  usually  beginning  in  a  hair  follicle,  and  usually 
ending  in  suppuration.  When  severe,  it  may  result  in  necrosis  of  the 
follicle,  which  forms  the  "core,"  or  the  necrotic  process  may  extend  to 
the  surrounding  tissues  for  a  variable  distance.  The  ordinary  boil  need 
not  be  described,  as  it  presents  nothing  peculiar  in  early  life.     The  con- 


FURUNCULOSIS  931 

dition,  however,  which  is  characteristic  of  young  children  is  the  forma- 
tion of  small  ones  in  great  numbers.  It  is  to  this  more  especially  that 
the  term  furunculosis  is  applied.  The  principal  location  of  these  small 
abscesses  is,  in  nearly  all  cases,  the  scalp,  face,  and  shoulders,  althougli 
they  may  be  found  upon  any  part  of  the  body.  They  are  sometimes 
numbered  by  hundreds,  and  appear  in  crops  for  a  period  of  several 
months.  In  size,  they  usually  vary  from  a  pea  to  an  almond,  and  they 
rarely  contain  a  core.  Infants  are  much  more  often  the  subjects  of  this 
disease  than  are  those  who  have  passed  the  second  year.  In  the  great 
majority  of  cases  furunculosis  is  not  serious,  yet,  occurring,  as  it  often 
does,  in  infants  who  are  already  suffering  from  extreme  malnutrition, 
whose  tissues  possess  but  little  resistance,  the  process  may  develop  into 
a  condition  which  may  prove  fatal. 

Furunculosis  may  be  seen  in  children  who  are  in  other  respects  appar- 
ently healthy,  even  robust ;  but  the  majority  are  in  a  more  or  less  debili- 
tated condition,  and  often  are  the  subjects  of  digestive  disturbances.  The 
disease  is  quite  frequent  in  syphilitic  infants ;  but  these  simple  abscesses 
are  to  be  sharply  distinguished  from  those  which  result  from  the  breaking 
down  of  gummata  of  the  skin.  Want  of  cleanliness  of  the  skin  is  a 
factor  of  some  importance  in  producing  the  disease.  Furunculosis  may 
be  associated  with  eczema.  The  exciting  cause  in  all  cases,  as  shown  by 
recent  investigations,  is  the  entrance  of  the  staphylococcus  pyogenes 
aureus,  sometimes  with  other  organisms,  into  the  follicles  of  the  skin. 

Treatment. — The  general  treatment  is  to  be  directed  toward  any 
disturbance  of  digestion  or  nutrition  which  is  present.  Tonics  are  indi- 
cated in  most  cases,  but  no  reliance  can  be  placed  upon  drugs  such  as 
sulphid  of  calcium  or  the  hypophosphites,  in  arresting  the  disease.  Local 
treatment  should  have  for  its  first  object  thorough  cleanliness  of  the  skin. 
This  is  best  secured  by  frequently  bathing  the  parts  affected  with  a  1  to 
5,000  solution  of  bichlorid.  Single  furuncles  may  often  be  aborted  by 
touching  them  with  pure  carbolic  acid  or  the  application  of  Bier's  cups. 
In  our  experience  the  best  plan  of  treating  the  multiple  small  furuncles, 
is  to  delay  incision  until  they  have  pointed,  then  to  incise  and  empty  thij 
follicle  completely  by  compression.  Where  the  abscesses  are  of  large  size 
and  upon  the  scalp,  it  is  wise  to  make  compression  by  applying  a  snug 
bandage  for  a  day.  For  general  furunculosis  or  the  continual  recurrence 
of  larger  abscesses  the  use  of  staphylococcus  vaccines  is  altogether  the 
most  effective  treatment.  While  autogenous  vaccines  are  perhaps  prefer- 
able, the  use  of  stock  vaccines  seems  in  most  cases  to  be  equally  effec- 
tive. Injections  should  ])e  repeated  every  four  or  five  days;  beginning 
with  fifty  millions,  the  dose  may  be  increased  to  one  hundred  millions, 
or  even  more.  The  beneficial  effects  in  most  cases  are  very  striking  and 
the  cure  permanent. 


932  DISEASES  OF  THE  SKIN 


GANGRENOUS  DERMATITIS 

This  is  not  a  frequent  disease,  and  is  seen  almost  exclusively  in  in- 
fancy. It  may  be  primary  or  it  may  follow  other  diseases,  and  hence  has 
been  described  under  many  different  names,  viz.,  varicella  gangrenosa, 
ecthyma^  pemphigus  gangrenosa,  etc. 

The  lesion  consists  in  small,  discrete  areas  of  inflammation  of  the 
skin,  ending  in  necrosis.  In  the  primary  cases  there  is  usually  first  seen 
a  vesicle,  about  as  large  as  a  pea,  with  a  dusky  areola;  it  increases  in 
size  and  becomes  a  pustule.  Crusts  form  which  are  quite  adherent,  and 
on  removing  them  a  loss  of  tissue  is  seen.  The  ulcers  usually  have 
sharp  but  not  undermined  edges,  often  presenting  a  "punched-out"  ap- 
pearance. By  the  coalescence  of  several  smaller  ones,  ulcers  an  inch  or 
more  in  diameter  are  sometimes  formed. 

The  primary  form  of  gangrenous  dermatitis  occurs  in  wretched, 
j)oorly-nourished  infants,  and  is  most  often  seen  upon  the  buttocks.  In 
this  location  it  may  be  mistaken  for  syphilis.  The  secondary  form  is 
more  common,  and  usually  follows  varicella,  less  frequently  vaccinia,  or 
impetigo.  In  such  cases  the  lesion  is  most  often  seen  upon  the  upper 
half  of  the  body,  especially  upon  the  neck  and  chest.  It  follows  the  ordi- 
nary lesions  of  varicella  and  continues  usually,  in  spite  of  treatment, 
from  one  to  four  weeks,  in  many  cases  ending  fatally.  The  disease. al- 
ways occurs  in  infants  of  poor  vitality,  often  in  those  suffering  from 
marasmus,  and  is  seldom  seen  outside  of  institutions.  It  may  be  accom- 
panied by  fever,  and  other  severe  constitutional  symptoms. 

For  the  production  of  the  disease,  two  factors  are  necessary:  first, 
the  constitutional  condition  referred  to;  and,  secondly,  the  entrance  of 
pyogenic  germs,  usually  the  streptococcus  pyogenes. 

Treatment. — Every  means  possible  should  be  employed  to  build  up 
the  general  health  of  the  infant  by  fresh  air,  careful  feeding,  etc.  Lo- 
cally, strict  cleanliness  and  antiseptic  applications  are  necessary.  The 
best  application  is  a  solution  of  bichlorid  (1  to  5,000),  or  an  ointment 
of  ichthyol  or  white  precipitate. 

IMPETIGO  CONTAGIOSA 

Impetigo  contagiosa  is  a  disease  characterized  by  the  formation  of 
discrete  vesiculopustules,  occurring  most  frequently  upon  the  hands  and 
face.  Cases  are  usually  seen  in  groups  affecting  children  in  one  family 
or  institution.  Impetigo  may  be  communicated  from  one  person  to 
another,  and  spread  by  auto-inoculation  from  one  part  of  the  body  to 
another. 


IMPETIGO  CONTAGIOSA  933 

One  rarely  has  an  opportunity  to  see  the  disease  until  vesicles  have 
formed.  These  are  usually  from  one-fourth  to  one-half  inch  in  diam- 
eter, and  are  flaccid,  never  distended.  Later,  their  contents  become 
slightly  yellowish;  then  they  rupture  and  dry,  forming  thick  yellovi^ 
crusts,  which  have  the  appearance  of  being  "stuck  on,"  the  surrounding- 
skin  being  quite  healthy.  After  the  crusts  fall  off,  a  small  red  patch 
remains,  which  slowly  fades.  The  true  skin  is  not  involved,  except  in 
poorly  nourished,  cachectic  subjects,  as  a  result  of  continued  local  irrita- 
tion, like  scratching.  Under  such  conditions  ulceration  may  occur. 
Instead  of  the  small  vesiculopustules  described,  bullae  from  one  to  two 
inches  in  diameter  may  form,  filled  first  with  serum,  afterward  with 
sero-pus.  Very  little  inflammation  is  seen  about  these  patches,  and  in 
most  cases  the  intervening  skin  is  normal. 

The  favorite  seat  of  the  eruption  is  the  face,  especially  about  the 
chin,  next  the  hands,  the  neck,  the  feet  and  legs,  the  forearms,  and  the 
scalp;  it  is  rarely  seen  upon  the  abdomen,  and  never  upon  the  back. 
There  may  be  only  half  a  dozen  vesiculopustules,  or  from  thirty  to  forty 
may  be  present.  The  smaller  ones  sometimes  coalesce  and  form  others 
of  considerable  size.  Itching  is  never  a  prominent  symptom,  and  in 
most  cases  it  is  absent  altogether. 

The  usual  duration  of  impetigo  contagiosa  is  two  or  three  weeks;  it, 
however,  runs  no  regular  course,  and  by  continued  auto-inoculation  may 
last  much  longer  than  this. 

The  studies  of  Gilchrist  point  to  a  streptococcus  of  low  virulence  as 
the  cause  of  this  disease.  European  investigators,  however,  have  more 
often  found  the  staphylococcus  pyogenes  aureus  in  the  vesicles.  Im- 
petigo contagiosa  may  occur  in  any  child,  but  is  seen  most  frequently  in 
one  who  is  poorly  nourished. 

The  diagnosis  is  not  often  difficult,  and  is  made  by  the  following 
features,  viz.,  the  occurrence  of  several  cases  together,  the  isolated 
vesiculopustules  situated  upon  the  face  and  hands,  the  slight  itching, 
and  the  prompt  cure  by  local  measures  only.  The  bullous  form,  how- 
ever, is  frequently  confounded  with  pemphigus;  many  cases  in  which 
the  diagnosis  of  pemphigus  is  made  are  examples  of  impetigo. 

Treatment. — This  is  simple  and  usually  very  eft'ective.  The  crusts 
are  to  be  softened  and  removed  by  thoroughly  washing  the  part  with 
soap  and  water  or  a  bichlorid  solution,  after  which  the  white  precipitate 
ointment,  combined  with  three  parts  of  vaseline,  should  be  applied. 

URTICARIA 

Urticaria  is  a  frequent  disease  in  early  life,  and  presents  some  fea- 
tures, particularly  in  infants  and  young  children,  wliicb  are  quite  dif- 


934  DISEASES  OF  THE  SKIX 

i'erejit  i'roiii  those  seuii  in  adultn.  This  is  duo  to  the  i'tu-t  iJiat  j^apidcs 
and  vesicles^,  and  occasionally  pustules,  are  associated  with  the  wheals. 
As  the  wheals  quickly  subside,  it  frequently  happens  that  the  other 
lesions  mentioned  are  the  only  ones  present.  This  fact  has  given  rise 
to  considerable  confusion  in  names,  and  the  urticaria  of  infancy  has 
been  called  lichen  urticatus^  urticaria  papulosa,  strophulus,  etc.  It  is 
now  pretty  generally  agreed  that  the  clinical  picture,  which  is  a  familiar 
one,  belongs  to  a  single  disease,  and  that  this  is  urticaria. 

The  initial  lesion  is  the  wheal,  biit  on  account  of  the  extreme  suscep- 
tibility of  the  skin  in  young  children,  the  process  is  more  intense  than 
in  older  patients,  so  that  it  may  result  in  the  formation  of  an  inflam- 
matory papule  or  a  vesicle.  In  a  few  hours  the  wheal  may  subside,  and 
only  the  papules  or  vesicles  remain,  and  without  a  good  history  the  dis- 
ease may  be  a  very  obscure  one.  The  papules  and  vesicles  occur  with 
greatest  frequency  upon  the  hands  and  feet,  particularly  the  palms  and 
soles. 

The  more  severe  form  of  the  disease  in  poorly  nourished  children 
is  sometimes  accompanied  by  a  pustular  eruption,  and  there  may  even 
be  deep  ulceration  (ecthyma).  The  usual  appearance  of  the  eruption  is 
a  number  of  small  inflamed  red  papules  whose  tops  are  covered  with 
crusts,  the  result  of  scratching.  The  eruption  may  be  limited  to  the 
extremities  or  it  may  be  general.  It  is  as  a  rule  more  severe  in  regions 
accessible  to  scratching. 

There  is  usually  severe  itching,  which  leads  to  loss  of  sleep,  and  often 
in  this  way  the  disease  afl'ects  the  general  health  of  the  child.  The  urti- 
caria of  older  children  does  not  difl^er  essentially  from  the  same  disease 
in  adults.  The  alternation  of  urticaria  and  asthma  is  occasionally  met 
with. 

The  character  of  the  eruption  in  urticaria  and  even  its  distribution 
often  suggest  scabies;  and  unless  one  has  had  an  opportunity  to  wit- 
ness the  development  of  the  lesions,  a  difl:erential  diagnosis  may  be  very 
difiicult,  as  almost  every  lesion,  except  the  wheal,  may  be  identical  in 
both  diseases.    Other  cases  may  resemble  varicella. 

Urticaria  in  early  life  is  most  frequently  the  result  of  some  disturb- 
ance in  the  digestive  tract.  Almost  any  sort  of  derangement  may  pro- 
duce it,  the  exciting  cause  varying  with  the  patient. 

Treatment. — The  milder  forms  of  urticaria  usually  respond  quickly 
to  treatment ;  but  when  it  is  severe  and  has  existed  for  several  weeks,  it  is 
one  of  the  most  troublesome  and  intractable  skin  diseases  of  childhood. 
The  treatment  is  to  be  directed  primarily  toward  the  condition  of  the 
digestive  organs.  Children  should  be  put  upon  a  very  simple  diet,  al- 
ways excluding  sweets,  and  usually  fruits,  especially  raw  fruits.  The 
bowels  should  be  kept  open  by  calomel,  a  nightly  dose  of  castor  oil,  or  a 


SCABIES  935 

morning  dose  of  magnesia.  If  the  urine  is  excessively  acid  and  scanty, 
alkaline  diuretics  should  be  given. 

All  local  causes  of  irritation,  such  as  rough  flannel  underclothing, 
sliould  be  removed.  The  sleep  may  be  so  much  disturbed  as  to  require 
the  use  of  trional  or  bromid  and  chloral. 

The  local  irritation  and  itching  may  be  relieved  by  a  very  dilute 
solution  of  the  subacetate  of  lead  or  carbolic  acid,  or  by  diluted  vinegar, 
or  the  fluid  extract  of  hamamelis,  or  bicarbonate  of  soda,  and  vi^ater. 
In  severe  urticaria  almost  immediate  relief  may  be  obtained  by  the  hypo- 
dermic injection  of  three  to  eight  drops  of  a  1-1000  solution  of  epineph- 
rin;  the  relief  often  lasts  twelve  to  twenty-four  hours.  When  pustules 
are  present,  the  white  precii3itate  ointment  may  be  used,  combined  with 
four  parts  of  vaseline;  in  the  papular  and  vesicular  forms,  an  ointment 
of  ichthyol,  one-per-cent  strength.  In  many  cases  the  improvement  in 
the  general  health  by  the  use  of  tonics,  change  of  air,  etc.,  will  accom- 
plish more  than  any  measures  directed  especially  to  the  relief  of  the 
urticaria. 

SCABIES 

Scabies  is  a  contagious  disease  due  to  the  burrowing  into  the  skin  of 
the  female  acarus,  with  secondary  lesions  which  result  from  scratching. 

The  burrowing  of  the  acarus  is  usually  where  the  skin  is  thinnest — 
viz.,  between  the  fingers,  on  the  flexor  surfaces  of  the  wrist,  the  axillae, 
and,  in  males,  the  genitals.  It  is  not  seen  upon  the  face,  except  in  in- 
fancy, when  infection  may  occur  from  contact  with  the  breasts  of  the 
mother.  The  lesion  excited  by  the  acarus  is  usually  a  papule  or  a  vesicle, 
sometimes  a  pustule.  In  some  cases  no  evidences  of  inflammation  are 
present,  but  in  infants  and  young  children  they  may  be  marked — pustu- 
lar eruptions  being  frequent  and  often  extensive,  especially  upon  the 
hands  and  feet.  The  characteristic  burrow  is  from  one-fourth  to  one-half 
inch  in  length,  and  appears  as  a  fine  brown  or  black  line,  at  the  end  of 
which  the  acarus  may  be  discovered  as  a  small  white  speck.  The  burrows 
are  often  difficult  to  find  in  infants.  They  are  generally  to  be  seen  along 
the  ulnar  border  of  the  hand  and  between  the  fingers.  The  intensity  of 
the  inflammatory  lesions  varies  greatly  in  different  cases;  in  some  they 
are  very  few,  while  in  others,  particularly  in  delicate,  cachectic,  and 
neglected  children,  they  are  sometimes  very  severe,  so  that  the  skin  of 
the  affected  part  is  nearly  covered  with  pustules.  These  secondary  lesions 
are  due  to  infection  by  the  streptococcus  or  staphylococcus.  A  pustular 
eruption  upon  the  hands  should  always  suggest  scabies.  The  lesions 
which  result  from  scratching  may  be  found  on  any  accessible  portion 
of  the  body.     They  are  usually  at  first  linear,  bloody  marks,  but  after 


936  DISEASES  OF  THE  SKIN 

a  time  these  may  not  be  visible.  In  little  children  "urticaria  is  often 
associated. 

The  diagnosis  of  scabies  is  usually  quite  easy,  as  several  children  in 
a  family  are  likely  to  be  affected,  particularly  if  they  occupy  the  same 
bed.  The  diagnostic  features  of  the  eruption  are  the  presence  of  papules, 
vesicles,  or  pustules,  especially  upon  the  hands,  wrists,  and  genitals.  A 
careful  examination  with  a  lens  will  usually  disclose  some  of  the  char- 
acteristic burrows,  or  even  the  acarus.  In  infancy,  scabies  may  be  easily 
confounded  with  the  vesicular  form  of  urticaria,  unless  the  development 
of  the  lesions  has  been  observed. 

Scabies  may  always  be  cured,  provided  sufficient  precautions  are  taken 
to  prevent  re-infection.  This  necessitates  boiling  or  baking,  not  only  the 
patient's  clothes,  but  all  the  bedding  as  well. 

Treatment. — This  should  always  be  begun  by  a  hot  bath,  in  order  to 
soften  the  epithelial  scales  about  the  burrows.  The  body  should  be  thor- 
oughly scrubbed  with  soap  and  water,  preferably  with  a  nail-brush,  the 
bath  being  continued  for  at  least  half  an  hour.  It  is  well  to  do  this  at 
night.  After  the  bath,  the  body  is  anointed  with  the  parasiticide,  which 
should  be  thoroughly  rubbed  into  the  skin,  clean  clothing  applied,  and 
the  child  put  into  a  perfectly  clean  bed.  In  the  morning  the  ointment 
may  be  washed  off,  but  none  of  the  clothing  previously  worn  should  be 
put  on.  This  treatment  is  to  be  repeated  on  two  or  three  successive 
nights,  and  if  thoroughly  done  it  will  effect  a  cure.  The  ordinary  sul- 
phur ointment  is  too  irritating  for  use  in  little  children,  and  one  of  the 
following  may  be  substituted:  j8-naphthol,  15  parts;  creta  preparata,  10 
parts;  vaseline,  100  parts  (Kaposi);  or,  precipitated  sulphur,  1  part; 
balsam  of  Peru,  1  part ;  vaseline,  8  parts ;  or  the  simple  balsam  of  Peru 
may  be  applied  without  dilution.  After  the  use  of  the  parasiticide  there 
is  generally  required,  for  a  few  days,  some  soothing  application  like  those 
mentioned  in  the  chapter  upon  Eczema. 


TINEA  TONSURANS— RING-WORM  OF  THE  SCALP 

Ring-worm  of  the  scalp  is  a  very  frequent  disease  in  institutions  for 
children,  often  occurring  as  an  epidemic.  According  to  Crocker,  the 
primary  lesion  consists  in  a  red  papule  surrounding  a  hair,  which  soon 
increases  to  a  small  circular  patch;  this  spreads  at  its  outer  margin, 
gradually  increasing  in  size  until  it  is  from  one  to  two  inches  in  diameter, 
but  rarely  larger  than  this.  Sometimes  several  of  the  patches  coalesce. 
These  affected  areas  always  have  rounded  borders,  and  are  sharply  out- 
lined. Here  the  hairs  arc  very  brittle,  and  often  broken  off  close  to  the 
scalp,  so  that  the  area  may  appear  to  be  bald.     Where  they  have  not 


TINEA  TONStJRANS— RING-WORM  OF  THE  SCALP  937 

fallen  off,  the  hairs  have  lost  their  luster.  The  stumps  of  the  broken 
hairs  point  in  all  directions. 

The  fungi  which  produce  the  disease  belong  chiefly  to  the  group  of 
small  spored  fungi  or  microsporons.  Of  the  several  microsporons  that 
have  been  shown  to  have  etiological  significance,  the  niicrosporon  Au- 
douini  is  the  one  of  importance  in  this  country.  The  large-spored  fungi 
(tricophyton  crateriforme  or  tricopbyton  acuminatum)  are  responsible 
for  a  small  proportion  of  cases.  The  fungi  penetrate  the  shaft  of  the 
hair,  both  the  spores  and  the  mycelium  being  seen  under  the  microscope. 
The  spores  are  present  in  great  numbers  in  the  hair,  but  the  mycelium  is 
most  abundant  in  the  scales.  The  amount  of  inflammation  found  in  the 
diseased  areas  varies  much  in  the  different  cases.  There  may  be  only  a 
scaliness  of  the  scalp,  or  a  formation  of  pustules  in  the  hair  follicles,  the 
hairs  loosening  and  falling  out  in  consequence.  In  young  infants,  where 
the  hair  is  scanty  and  thin,  the  disease  resembles  tinea  circinata — i.  e., 
it  is  superficial,  and  the  hair  follicles  are  often  not  involved.  Children 
of  all  ages  are  liable  to  tinea  tonsurans.  It  flourishes  particularly  in 
institutions  and  among  those  children  who  are  dirty  and  generally  neg- 
lected. 

The  diagnostic  feature  of  the  disease  is  the  presence  of  scaly  patches, 
with  loss  of  hair.  The  patches  are  usually  circular,  and  by  examination 
with  a  lens  the  stimips  of  broken  hairs  are  seen  all  over  the  diseased 
areas.  By  a  microscopical  examination  the  fungus  is  discovered.  In 
typical  cases  the  diagnosis  is  easy  if  the  process  is  at  all  advanced,  but 
there  are  many  atypical  forms  and  many  mild  cases  where  the  recogni- 
tion of  the  disease  is  difficult.  The  symptoms  are  often  masked  by  the 
inflammatory  conditions  present.  The  disease  may  be  confounded  with 
seborrhea;  but  in  the  latter  the  lesion  is  diffuse,  never  sharply  defined; 
there  is  general  thinning  of  the  hair  over  the  scalp,  and  never  the 
stumpy,  broken  hairs.  Psoriasis  has  points  of  resemblance;  but  it  is 
usually  found  on  other  parts  of  the  body,  especially  the  knees  and  el- 
bows, and  upon  the  scalp  the  patches  are  more  numerous  and  smaller. 
In  eczema  the  loss  of  hair  in  circumscribed  patches  is  never  seen,  nor 
are  the  broken  stumps. 

Tinea  tonsurans  is  always  curable,  provided  the  patient  can  be  kept 
under  close  surveillance,  and  treatment  thoroughly  carried  out,  but  it  is 
particularly  obstinate.  There  is  no  tendency  to  spontaneous  recovery 
except  toward  puberty,  when  many  of  the  cases  recover  even  without 
treatment.  In  a  recent  case,  treatment  must  usually  be  continued  for 
several  weeks  or  months,  and  in  chronic  cases  from  six  months  to  one 
year,  with  the  closest  watchfulness. 

Treatment. — The  great  difficulty  in  treatment  is  to  get  the  parasiti- 
cide deeply  enough  into  the  scalp  to  reach  the  fungus,  since  this  is  often 


9.3S  DISEASES  OF  THE  EAR 

at  the  very  bottom  of  the  hair  follicles.  As  a  first  step,  the  hair  should 
be  cut  short  all  over  the  patch  and  for  at  least  an  inch  beyond  it;  this  is 
necessary  in  order  to  get  at  the  diseased  part  and  to  detect  new  foci  of 
infection  early — if  possible  before  the  fungus  has  extended  deeply  into 
the  follicles.  The  parasiticide  should  be  applied  not  only  upon  but 
around  the  patch,  and  the  entire  scalp  should  be  washed  thoroughly  two 
or  three  times  a  week.  -To  prevent  the  disease  spreading,  all  the  scales 
are  to  be  kept  softened  by  the  use  of  carbolic  soap.  The  hair  should 
not  be  brushed,  as  this  tends  to  scatter  the  spores  and  spread  the  disease. 
All  patients,  while  under  treatment,  should  wear  a  cap  of  muslin  or 
oiled  silk,  or  one  lined  with  paper,  in  order  to  prevent  infecting  others. 
In  institutions,  affected  children  should  invariably  be  isolated. 

To  destroy  the  fungus  almost  every  germicide  on  the  list  has  been 
advocated  at  one  time  or  another,  which  proves  that  the  disease  is  a  very 
obstinate  one,  and  that  no  one  application  is  invariably  successful.  Cure 
depends  more  upon  persistent  treatment  than  upon  the  drugs  used. 
Those  which  have  the  sanction  of  the  widest  use  are  the  tincture  of 
iodin,  the  bichlorid,  white  precipitate  and  oleate  of  mercury,  /S-naphthol, 
ehrysarobin,  creosote,  carbolic  acid  and  croton  oil.  As  a  vehicle  for  oint- 
ments, adeps  lanae  (lanoline)  is  greatly  to  be  preferred  to  vaseline  or 
lard.  Epilation  is  necessary  in  many  cases  as  an  accessory  to  the  appli- 
cation of  germicides,  particularly  in  older  children.  The  X-ray  has 
been  employed  by  Sabouraud,  Xoire  and  others.  The  greatest  care 
should  be  exercised  in  its  use  or  j^ermanent  baldness  may  result. 


CHAPTEE  VI 

DISEASES  OF  THE  EAR 
ACUTE  OTITIS 

Otitis  is  a  frequent  affection  during  infancy  and  early  childhood, 
attacks  usually  occurring  in  the  cold  season.  Of  all  the  inflammatory 
conditions  which  may  be  met  with  in  early  life,  there  is  perhaps  none 
which  more  frequently  gives  rise  to  obscure  febrile  symptoms  than  this. 

Etiology. — Acute  otitis  is,  as  a  rule,  a  secondary  disease,  and  is  gen- 
erally preceded  by  some  infectious  process  in  the  rhinopharynx.  The 
usual  avenue  of  infection  is  the  Eustachian  tube. 

While  it  is  most  commonly  seen  following  simple  rhinopharyngitis, 
the  most  severe  forms  of  otitis  follow  scarlet  fever,  epidemic  influenza, 
measles,  diphtheria,  or  pneumonia.     The  entrance  of  fluids  through  the 


ACUTE  OTITIS  939 

Eustachian  tube  from  the  nasal  douche  or  nasal  syringing  may  cause 
acute  otitis.  It  sometimes  results  as  an  extension  of  inflammation  from 
meningitis,  especially  the  cerebrospinal  form.  Otitis  is  very  common  in 
hospital  patients,  especially  poorly  nourished  infants.  In  them  it  is 
found  with  little  or,  more  frequently,  with  no  evidences  of  a  rhinopharyn- 
gitis. 

The  microorganisms  concerned  in  the  production  of  acute  otitis 
vary  somewhat  with  the  condition  of  which  it  is  a  complication.  In  the 
order  of  frequency  there  are  found  the  staphylococcus  aureus,  the  pneu- 
mococcus,  the  streptococcus,  and  the  influenza  bacillus.  Mixed  infections 
are  very  common.  In  cases  complicating  diphtheria,  the  Klebs-Loeffier 
bacillus  may  be  found  with  any  of  the  forms  mentioned,  or  may  occur 
alone.  In  chronic  cases  any  of  the  pyogenic  organisms  may  be  present, 
and  not  very  infrequently  the  tubercle  bacillus. 

Lesions. — The  ordinary  course  of  events  in  the  pathological  process 
is,  first,  acute  hyperemia  and  swelling  of  the  mucous  membrane  of  the 
rhinopharynx,  which  extends  into  the  Eustachian  tube,  causing  obstruc- 
tion more  or  less  complete.  The  inflammatory  process  may  be  limited  to 
the  tube,  or  it  may  extend  to  the  mucous  membrane  lining  the  middle 
ear. 

There  are  two  varieties  of  acute  inflammation  of  the  middle  ear:  (1) 
The  catarrhal  form,  which  usually  accompanies  simple  catarrh  of  the 
rhinopharynx  or  complicates  measles.  This  is  an  inflammation  of  the 
mucous  membrane  merely,  and  its  products  are  serum  and  mucus  or 
muco-pus.  It  is  generally  confined  to  the  lower  part  of  the  tympanic 
cavity,  and  is  the  form  most  frequently  seen  in  infants.  (2)  The  puru- 
lent or  phlegmonous  form,  which  affects  older  children  principally.  This 
is  a  much  more  serious  inflammation,  and  is  often  excited  by  the  infec- 
tious catarrh  of  scarlet  fever,  or  diphtheria.  In  this  variety  microor- 
ganisms find  their  way  into  the  middle  ear  in  great  numbers,  and  set  up 
an  inflammation  of  a  more  virulent  type,  which  may  involve  not  only 
the  mucous  membrane  lining  the  tympanum,  but  also  the  cellular  tissue 
in  the  upper  part  of  the  tympanic  cavity.  The  lining  membrane  of  the 
mastoid  cells  is  involved  in  many,  if  not  all,  of  the  cases. 

The  catarrhal  form  of  inflammation  frequently  subsides  in  a  few 
days  with  proper  treatment,  the  only  result  being  a  slight  deafness, 
which  is  temporary.  The  phlegmonous  form  causes  a  stoppage  of  the 
Eustachian  tube,  rupture  or  sloughing  of  the  tympanic  membrane,  and 
discharge  of  the  products  of  inflammation,  or  rarely  pus  finds  an  outlet 
by  burrowing  between  the  cartilages.  The  Inflammatory  process  may 
extend  to  the  bones,  causing  necrosis  of  the  ossicles  or  the  bony  walls  of 
the  tympanum.  The  remote  results  are  periostitis  and  necrosis  of  the 
petrous  bone,  pachymeningitis,  infectious  thrombosis  of  the  lateral  sinus, 


940 


DISEASES  OF  THE  EAK 


general  purulent  nieuingitis,  and  cerebral  abscess.     These  will  be  con- 
sidered under  Complications. 

Symptoms. — Tliese  are  usually  few  in  number,  but  present  great 
variability  as  regards  their  combination  and  intensity.  The  two  most 
constant  symptoms  are  pain  and  fever.  In  a  typical  case  in  an  infant, 
there  is  generally  at  the  beginning  some  discharge  from  the  nose,  slight 
congestion  of  the  pharynx  and  tonsils,  and  a  temperature  of  100°  to 
102°  F.  There  is  nothing  characteristic  about  this  catarrh.  After  two 
or  three  days  the  objective  symptoms  subside,  but  the  infant  continues 
to  be  restless,  worries  much  of  the  time,  wakes  frequently  at  night  with 
a  start,  nurses  poorly,  and  the  temperature  remains  elevated,  usually 
from  100°  to  103°  F.  (Fig.  150).     The  infant  seems  decidedly  ill,  and 


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Fig.  150. — Temperatuke  Chart  of  Acute  Otitis  Following  Infltjenza,  in  a  Child 

Three  Years  Old. 


yet  no  very  definite  symptoms  are  present.  Earely  there  is  marked  ten- 
derness about  the  ear,  and  the  child  refuses  to  lie  upon  the  affected  side, 
or  shows  signs  of  pain  when  the  ear  is  touched.  After  a  week  or  ten 
days  spontaneous  rupture  of  the  drum  membrane  takes  place,  and  sub- 
sidence of  the  constitutional  symptoms  follows.  In  some  cases  there  is 
seen  only  a  high  temperature,  ranging  from  101°  to  104°  F.,  which  per- 
sists for  several  days  without  outward  evidences  of  pain  or  other  signs 
of  inflammation,  and  the  discharge  is  the  first  symptom  which  leads  the 
physician  to  suspect  disease  of  the  ear.  In  other  cases  there  is  marked 
dulness,  apathy,  anorexia,  and  sometimes  nausea  and  vomiting,  but  for 
several  days  no  evidence  of  pain;  the  temperature  may  be  but  little  ele- 
vated. Thus,  in  most  of  the  attacks  seen  in  infancy,  pain  is  not  marked, 
and  it  is  this  fact  which  so  often  leads  to  the  obscurity  of  the  symptoms. 
In  older  children  the  symptoms  are  more  characteristic.     Pain  is 


ACUTE  OTITIS 


941 


usually  sharp  and  severe,  and  is  complained  of  early  in  the  attack.  The 
temperature  is  nearly  always  elevated  two  or  three  degrees,  and  occa- 
sionally it  is  103°  or  104°  F.  (Fig.  151),  with  severe  headache,  extreme 
restlessness,  and  even  delirium  or  convulsions,  so  that  meningitis  may  be 
suspected. 

The  inflammation  does  not  necessarily  go  on  to  suppuration  and  rup- 
ture. There  are  even  more  frequently  seen,  accompanying  ordinary 
head-colds  or  mild  attacks  of  influenza,  cases  in  which  the  pain  is  quite 
severe  for  twenty-four  or  thirty-six 
hours,  and  accompanied  even  by  a  mod- 
erate elevation  of  temperature,  and  yet 
which  rapidly  subside  without  further 
symptoms. 

In  infants  suffering  from  malnutri- 
tion or  marasmus,  otitis  often  comes  on 
without  any  objective  symptoms,  the 
first  thing  noticed  being  the  discharge. 

Of  all  the  symptoms,  fever  is  the 
most  constant,  and  is  present  in  all 
cases  except  those  just  mentioned. 
The  usual  range  of  temperature  is  from 
100°  to  102°  F.;  exceptionally  it  may 
])e  from  103°  to  105°  F.  The  course  of  Fig.  151.- 
the  temperature  is  irregular.  After 
spontaneous  rupture  or  incision  of  the 
drum  membrane  the  temperature  usu- 
ally falls,  but  often  not  immediately. 
Pain  is  more  marked  in  older  children 
than  in  infants,  because  in  the  latter 
the  drum  membrane  is  not  so  firm, 
yields  more  readily,  and  ruptures  ear- 
lier. Tenderness  is  sometimes  elicited  by  pressure,  especially  just  in  front 
of  the  external  auditory  meatus ;  there  may  be  increased  sensitiveness  of 
all  parts  of  the  ear  and  even  of  the  whole  side  of  the  head ;  but  no  reliance 
should  be  placed  upon  the  absence  of  such  symptoms  in  excluding  otitis. 
Children  often  complain  of  noises  in  the  ear.  Cerebral  symptoms  are 
infrequent,  and  occur  chiefly  in  cases  not  receiving  proper  early  treat- 
ment ;  they  may  indicate  meningeal  congestion,  or,  less  frequently,  local- 
ized meningitis  or  thrombosis. 

In  secondary  otitis,  especially  when  complicating  severe  scarlet  fever, 
diphtheria,  measles,  or  typhoid  fever,  all  subjective  symptoms  are  fre- 
quently wanting;  unless  the  ears  are  examined  the  disease  may  be  over- 
looked until  rupture  has  taken  place. 


1 

2 

3 

i 

5 

6      1 

> 

101° 
103° 
102° 
101° 
100° 
99° 
98° 

Hot 

li-& 

r-D 

un. 

-I 

— 

\l 

\ 

s 

s 

> 

..   . 

.„ 

_ 

._ 

_ 

_ 

_ 

_ 

_ 

^ 

_ 

_ 

_ 

-Temperature  Chart  of 
Acute  Otitis  Aborted  by  Early 
Paracentesis.  Boy  nine  years 
old;  attack  followed  a  mild  ca- 
tarrh; severe  pain  in  both  ears 
began  in  afternoon  of  second  day. 
Both  drum  membranes  found 
acutely  congested  and  bulging; 
incision  followed  by  free  hemor- 
rhage and  immediate  relief  of  pain. 
No  suppuration  occurred;  pa- 
tient well  on  fifth  day. 


942  DISEASES  OF  THE  EAR 

The  local  appearances  in  the  early  stage  are  marked  redness  and  con- 
gestion; later  there  is  distinct  bulging.  If  perforation  has  taken  place, 
its  site  may  or  may  not  be  visible,  but  its  existence  may  be  assumed  if 
bubbles  of  air  are  seen  deep  in  the  canal,  and  if,  in  the  absence  of  a  fu- 
runcle or  marked  eczema,  much  mucus  or  pus  is  present,  as  inflammation 
of  the  external  canal  seldom  causes  a  discharge.  In  the  catarrhal  form 
the  discharge  is  at  first  sero-mucus  and  quite  profuse;  later  it  is  puru- 
lent. In  the  phlegmonous  form  it  is  always  purulent,  and  liable  to  a 
sudden  arrest  with  an  increase  in  the  constitutional  symptoms.  The  pus 
sometimes  burrows  between  the  cartilages  and  escapes  externally  behind 
or  at  the  side  of  the  ear.  Earely  it  may  work  its  way  anteriorly  and 
cause  an  abscess  in  the  parotid  gland. 

Diagnosis. — Otitis  in  infancy  is  frequently  obscure,  because  the 
patient  is  too  young  to  direct  attention  to  the  seat  of  pain,  or  because  the 
pain  is  slight  or  absent.  The  temperature  is  almost  invariably  elevated, 
and  the  usual  problem  presented  is  to  discover  a  cause  for  this  fever. 
The  examination  of  the  ears  with  a  speculum  should  be  made  as  a  matter 
of  routine  in  all  children  with  fever,  especially  those  in  whom  the  cause 
of  the  fever  is  not  perfectly  clear.  Otherwise  many  cases  will  be  over- 
looked. A  leucocytosis  of  15,000  to  20,000  is  almost  invariably  found. 
Local  tenderness,  deafness,  or  noises  in  the  ears  are  significant  when 
present,  but  are  often  wanting.  Otitis  is  so  common  a  cause  of  high 
temperature  in  infants  during  the  cold  season,  that  one  should  always 
have  it  in  mind. 

Complications  and  Sequelae. — Eemote  consequences  are  most  likely 
to  be  seen  in  cases  following  scarlet  fever,  probably  because  of  their 
severity,  particularly  when  early  treatment  has  been  neglected. 

MastoicKtis. — This  is  the  most  frequent  complication  of  acute  otitis. 
In  infancy  the  mastoid  process  is  small  and  contains  but  a  single  cavity, 
the  mastoid  antrum,  which  communicates  directly  with  the  vault  of  the 
tympanum.  It  is  probable  that  in  every  severe  case  of  acute  suppurative 
otitis  there  is  some  pus  in  the  antrum.  This  is  usually  discharged  into 
the  middle  ear  after  the  tympanic  membrane  is  incised  or  ruptures  spon- 
taneously. The  principal  cause  of  mastoid  involvement  is  want  of  proper 
early  treatment  in  acute  otitis,  particularly  the  practice  of  allowing  these 
cases  to  take  their  natural  course  instead  of  securing  early  drainage  by 
incision  of  the  drum  membrane. 

The  important  symptoms  of  acute  mastoiditis  are  fever,  mastoid  ten- 
derness, and  swelling.  If  mastoiditis  develops  rapidly  after  acute  otitis 
the  temperature  may  be  high — 103°  to  105°  F.,  and  the  leucocytosis  is 
somewhat  greater;  if  it  develops  gradually  and  appears  late  the  tem- 
perature may  be  scarcely  above  100°  F.  Abrupt  cessation  of  an  ear  dis- 
charge should  always  arouse  suspicion.     It  is  always  difficult  to  de- 


ACUTE  OTITIS  943 

termine  the  presence  of  a  slight  amount  of  mastoid  tenderness,  but 
persistent  tenderness  of  one  side  only  is  significant.  It  is  often  most 
marked  close  behind  the  auricle  just  over  the  antrum.  Care  should  be 
observed  in  ascertaining  tenderness  to  make  pressure  only  over  .the  mas- 
toid. AVhen  there  is  eczema  or  furunculosis  of  the  canal  pushing  for- 
ward the  auricle  causes  pain.  The  early  swelling  is  due  to  edema  from 
periostitis ;  later  there  may  be  an  accumulation  of  piis  beneath  the  perios- 
teum. Post-auricular  abscess  causes  a  very  characteristic  swelling,  the 
ear  standing  out  from  the  head.  It  is  usually  due  to  spontaneous  rup- 
ture through  the  outer  bony  wall  just  over  the  antrum;  it  may  occur 
when  there  has  been  no  discharge  from  the  ear;  but  mastoiditis  prac- 
tically never  occurs  as  a  primary  hematogenous  infection  and  examina- 
tion of  the  drum  membrane  will  reveal  unmistakable  evidences  of  an 
otitis  media.  It  is  a  frequent  result  of  severe  cases  of  acute  mastoiditis 
not  operated  upon,  especially  in  young  children. 

The  characteristic  otoscopic  appearances  of  acute  mastoiditis  are, 
bulging  of  ShrapnelFs  membrane  and  drooping  of  the  upper  posterior 
wall  of  the  external  auditory  canal  due  to  edema. 

Meningitis. — This  is  very  rare  in  infants,  but  is  more  common  in 
older  children.  There  may  be  a  localized  pachymeningitis  with  the  for- 
mation of  pus — an  epidural  abscess — or,  less  frequently,  general  puru- 
lent meningitis.  It  may  be  secondary  to  other  lesions,  such  as  throm- 
bosis of  the  lateral  sinus,  or  the  rupture  of  a  cerebral  abscess,  but  is  usu- 
ally due  to  infection  through  the  roof  of  the  tympanum,  or  along  the 
Internal  auditory  meatus.  Meningitis  may  occur  either  with  acute  or 
chronic  cases.  Its  symptoms  are  those  of  a  severe  acute  meningitis ;  its 
duration  is  short;  its  termination  almost  invariably  in  death. 

Cerebral  Abscess. — This  is  due  to  a  direct  extension  of  the  infection 
from  the  bone,  veins,  or  dura  mater.  In  about  two-thirds  of  the  cases 
the  abscess  is  in  the  temporosphenoidal  lobe.  The  next  most  frequent 
seat  is  the  lateral  lobe  of  the  cerebellum.  Korner  states  that  disease  of 
the  mastoid  and  middle  ear  leads  to  cerebral  abscess,  and  disease  of  the 
labyrinth  to  cerebellar  abscess.  Abscesses  may  be  complicated  by  throm- 
bosis or  by  meningitis.  They  are  often  latent  until  just  before  death, 
which  more  frequently  occurs  from  the  development  of  purulent  menin- 
gitis than  from  any  other  cause.  They  are  rare  except  in  otitis  of  long 
standing.     (See  Cerebral  Abscess.) 

Thrombosis  of  the  lateral  sinus  may  be  simple  or  septic.  In  the 
former  there  is  occlusion  of  the  vessel  by  a  fibrinous  clot;  in  the  latter 
there  are  in  addition,  microorganisms. 

Simple  thrombosis  causes  no  important  symptoms.  Septic  throm- 
bosis is  relatively  infrequent  and  causes  very  marked  and  severe  symp- 
toms.   It  follows  operation  upon  the  mastoid^  or  occurs  as  a  complication 


944  DISEASES  OF  THE  EAR 

of  mastoiditis  quite  apart  from  operation.  The  temperature  is  usually 
of  a  high  and  widely  fluctuating  type,  and  there  may  also  be  chills  with 
older  children,  but  this  cannot  be  depended  on  as  evidence  of  throm- 
bosis in  infants  or  young  children.  In  some  cases  the  constitutional 
symptoms,  except  fever,  may  not  at  first  be  severe,  but  may  suddenly 
become  very  grave.  Marked  cerebral  symptoms  often  develop  rapidly, 
and  death  may  follow  in  from  twelve  to  twenty-four  hours.  At  autopsy 
there  may  be  found  a  soft  broken-down  clot  in  the  sinus,  which  may 
extend  into  the  jugular.  It  may  be  followed  by  secondary  lesions  of  a 
general  pyemia,  or  by  localized  or  general  meningitis.  Blood  cultures 
usually  give  positive  information,  but  it  is  often  necessary  to  make  sev- 
eral before  organisms  are  found. 

The  lahyrinth  is  infrequently  involved,  although  cases  are  recorded 
by  Pye,  Phillips,  and  others,  in  which  the  necrosis  and  discharge  of  the 
entire  labyrinth  has  occurred  after  scarlet  fever.  In  most  of  these  cases 
the  deafness  was  complete,  and  in  several  vertigo  was  present. 

Facial  paralysis  rarely  occurs  in  the  acute  cases,  but  accompanies  a 
considerable  proportion  of  the  chronic  ones, ,  It  is  especially  seen  in  the 
tuberculous  variety.  It  is  due  to  an  extension  of  the  inflammatory 
process  from  the-  bone  to  the  seventh  nerve,  where  it  passes  through  the 
canal.  The  symptoms  are  those  of  ordinary  peripheral  facial  palsy. 
The  prognosis  is  good  for  recovery  in  the  non-tuberculous  variety. 

Treatment. — Something  may  be  done  in  the  way  of  prophylaxis.  It 
is  of  the  first  importance  to  secure  a  normal  condition  of  the  mucous 
membrane  of  the  rhinopharynx  by  the  removal  of  enlarged  tonsils,  ade- 
noids, etc.  The  occasional  attacks  of  otitis  accompanying  these  con- 
ditions are  pretty  sure  to  be  followed  hj^  more  serious  trouble  unless  they 
are  relieved.  Eepeated  attacks  of  otitis  media  in  childhood  are  responsi- 
ble for  fully  eighty  per  cent  of  the  cases  of  chronic  catarrhal  deafness 
in  adult  life.  Whether  during  attacks  of  measles  or  scarlet  fever,  much 
can  be  done  to  prevent  otitis,  is  still  a  mooted  question.  We  believe  the 
risks  of  infection  of  the  middle  ear  when  judicious  nasal  syringing  is 
employed  are  less  than  when  nothing  is  done  to  cleanse  the  rhinopharynx. 

The  medical  treatment  of  acute  otitis  aims  at  the  relief  of  pain  and 
arrest  of  the  inflammation.  If  the  case  is  seen  in  the  early  stage  the 
introduction  of  a  few  drops  of  a  solution  of  epinephrin  into  the  nostrils 
and  ears  and  repeated  every  two  or  three  hours,  will  sometimes  abort 
an  attack.  Carbolic  acid  in  olive  oil  in  a  strength  of  ten  per  cent  has 
an  undoubted  effect  in  allaying  inflammation  if  applied  in  the  early 
stages.  This  may  be  aided  by  free  catharsis  and  the  application  of  dry 
heat.  Laudanum  should  not  be  dropped  into  the  ear  as  is  so  often  done 
in  domestic  practice;  but  there  is  no  objection  to  a  few  drops  of  a  four- 
per^cent  solution  of  cocaih,  which  may  relieve  intense  pain.    If  the  child 


ACUTE  OTITIS  945 

is  not  soou  comfortable,  an  opiate  slionld  be  given  wliich  may  iiot  only 
relieve  pain,  but  may  have  a  favorable  influence  upon  the  inflammation. 

A  continuance  of  pain  in  spite  of  these  measures,  with  an  increas- 
ing temperature,  calls  for  operative  interference.  But  a  more  reliable 
guide  is  the  appearance  of  the  drum  membrane.  If  in  addition  to  these 
symptoms  there  is  mastoid  tenderness  immediate  paracentesis  of  the 
drum  membrane  is  imperative.  An  early  incision  is  usually  followed  by 
a  discharge  of  blood  only;  but  tension  is  relieved,  pain  disappears,  and 
the  inflammation  often  quickly  subsides  without  the  formation  of  pus. 
(See  Fig.  151.)  Much  suffering  is  thereby  avoided;  the  wound  rapidly 
heals,  and  much  less  damage  is  done  than  by  allowing  the  disease  to  go  on 
to  a  spontaneous  rupture.  Later  incision  may  be  required  either  for  the 
relief  of  pain  or  for  the  evacuation  of  pus  to  prevent,  if  possible,  the  dis- 
ease from  spreading  to  the  bony  parts.  The  advantages  of  early  paracen- 
tesis in  acute  otitis  can  hardly  be  overstated.  Properly  performed,  it  is 
free  from  risk,  causes  little  or  no  shock,  and  should  be  advised  in  many 
cases  even  in  which  the  indications  are  not  so  clear  as  those  above  de- 
scribed. Incision  of  the  drum  membrane  should  be  favored  in  cases  of 
doubt  rather  than  waiting  for  more  definite  indications  with  the  attend- 
ant risks  of  delay. 

In  the  secondary  otitis  of  scarlet  fever,  measles,  and  diphtheria,  the 
indications  for  paracentesis  are  usually  to  be  derived  from  the  appear- 
ance of  the  drum  membrane  alone,  other  symptoms  being  absent  or 
masked  by  the  primary  disease. 

-  After  incision  or  spontaneous  rupture  of  the  drum  membrane,  to  pre- 
vent the  wound  from  closing  and  to  cleanse  the  parts,  the  ear  should  be 
syringed  every  two  or  three  hours  with  a  warm  saline  solution,  or  a 
saturated  solution  of  boric  acid.  A  bulb  ear-syringe  of  soft  rubber  or 
a  fountain  syringe  may  be  used.  The  external  auditory  canal  should 
be  carefully  dried  after  irrigation  to  prevent  maceration  and  the  develop- 
ment of  eczema. 

In  most  acute  cases  the  discharge  ceases  in  from  one  to  three  weeks ; 
should  it  continue  longer,  some  measures  for  checking  it  may  be  used. 
The  use  of  a  few  drops  of  a  1  to  3,000  solution  of  bichlorid  in  sixty-five 
per  cent  alcohol  after  syringing  is  of  some  value.  It  should  be  used  with 
a  medicine  dropper.  When  the  discharge  has  become  fetid,  syringing 
once  a  day  with  a  solution  of  peroxid  of  hydrogen  (1  to  2)  is  often 
useful.  A  persistent  discharge  often  depends  upon  the  fact  that  the 
child's  general  condition  is  poor,  and  improvement  in  this  is  more  im- 
portant than  any  variation  in  local  treatment. 

When  symptoms  pointing  to  acute  mastoiditis  are  present,  early 
free  incision  of  the  drum  membrane  is  indicated,  and  a  mastoid  ice- 
bag  should  be  applied  intermittently  for  twenty-four  to  thirty-six  hours. 


946  DISEASES  OF  THE  EAR 

In  addition,  in  older  children,  the  artificial  leech  may  he  placed  over  the 
antrum  or  the  mastoid  tip.  With  these  measures  the  inflammation  often 
subsides,  Eegarding  operation  upon  the  mastoid,  our  belief  is  that 
it  is  now  performed  too  frequently  and  with  insufficient  indications, 
especially  in  infancy  and  very  early  childhood.  The  operation  is  a  serious 
one,  and  at  this  age  its  immediate  risks  are  considerable.  We  have 
known  of  a  number  of  deaths  directly  connected  with  it,  and  of  others 
occurring  at  a  later  period,  where  the  child  was  worn  out  by  the  long 
after-treatment,  dying  perhaps  from  some  interourrent  disease  or  from 
exhaustion.  On  the  other  hand,  the  dangers  to  which  very  young  patients 
are  exposed  who  are  not  operated  upon  have  been  exaggerated.  In 
our  experience,  meningitis,  sinus  thrombosis,  and  cerebral  abscess  do 
not  occur  in  anything  like  the  proportion  of  cases  that  the  surgeons 
would  have  us  believe.^ 

While  fully  appreciating  the  value  of  the  operation,  and  being  quite 
sure  that  lives  are  often  saved  by  its  timely  performance,  we  would  in- 
sist that  it  be  done  only  with  very  positive  and  clear  indications.  In 
infants,  localized  tenderness  is  difficult  to  determine;  and  fever  after 
acute  otitis  may  be  due  to  many  other  conditions.  In  very  young  pa- 
tients we  should  therefore  insist  upon  other  symptoms  before  deciding 
to  operate.  The  risks  of  waiting  for  clearer  indications  are  much  less 
than  those  attendant  on  unnecessary  operation.  Often  the  cause  of  the 
temperature  is  found  in  the  lungs;  and  not  very  infrequently  a  mod- 
erate pulmonary  congestion  or  bronchitis  becomes  a  pneumonia  as  a  con- 
sequence of  the  prolonged  anesthesia  necessary  for  the  operation.  With 
infants  therefore  in  case  of  any  doubt,  as  to  diagnosis  or  the  progress 

*The  records  of  the  New  York  Foundling  Hospital,  with  a  resident  and 
constantly  changing  population  of  about  800  infants  and  young  children,  showed 
573  cases  of  acute  otitis  in  five  years  (1900  to  1904,  inclusive).  During  this 
period  there  were  three  extensive  epidemics  of  measles  with  a  total  of  1,034 
cases;  166  cases  of  scarlet  fever;  578  cases  of  diphtheria;  and  1,505  cases  of 
pneumonia.  With  the  573  cases  of  otitis,  acute  mastoiditis  was  recognized  and 
recorded  in  but  17  patients.  It  is  not  improbable  that  other  mastoid  inflam- 
mations were  overlooked.  In  this  institution,  however,  nearly  every  fatal  case 
comes  to  autopsy,  and  if  an  unrecognized  mastoiditis  had  led  to  a  fatal  result 
the  autopsy  records  should  show  it.  In  the  five-year  period,  900  autopsies  were 
made.  There  was  no  instance  recorded  of  abscess  of  the  brain  following  otitis. 
There  were  but  two  examples  of  acute  meningitis  following  otitis  with  mas- 
toiditis; but  there  were  14  cases  of  acute  meningitis  secondary  to  other  condi- 
tions— pneumonia,  10;  to  pericarditis,  2;  to  empyema,  1;  to  diphtheria,  1.  Dur- 
ing the  period  mentioned  there  were  11  mastoid  operations  performed  in  the 
hospital,  with  6  recoveries  and  5  deaths,  all  from  causes  directly  connected  with 
the  operation. 

If  mastoiditis  follows  the  otitis  which  complicates  the  acute  infectious  dis- 
eases of  early  childhood  as  often  as  has  been  claimed,  we  must  admit  that  a  very 
large  proportion  of  the  patients  may  get  well  without  operation. 


ACUTE  OTITIS  947 

ul'  llie  ease,  one  should  invariably  decide  against  operation,  or  at  least 
for  postponement.  With  older  children,  however,  conditions  are  some- 
what different;  diagnosis  is  easier  and  the  operative  risk  much  less. 

The  treatment  of  chronic  otitis  and  of  the  associated  conditions  is 
largely  surgical,  and  belongs  to  the  specialist;  but  it  is  extremely  im- 
portant that  the  general  practitioner  should  be  familiar  with  their  symp- 
toms, and  realize  the  danger  from  these  neglected  cases,  not  only  to  the 
function  of  hearing,  but  also  to  life  itself.  The  essential  thing  in  treat- 
ment is  that  the  operation  should  be  thorough  enough  to  secure  free 
drainage,  and  to  permit  thorough  cleansing  of  the  parts.  Too  much 
can  not  be  said  against  the  expectant  treatment  of  these  cases,  or  against 
the  practice  of  prolonged  poulticing. 


SECTION  IX 
THE   SPECIFIC  INFECTIOUS  DISEASES 

A  MORE  accurate  knowledge  of  the  causative  agents  of  the  various 
infectious  diseases  has  made  necessary  a  revision  of  the  opinions  once 
held  regarding  the  manner  in  which  they  are  communicated.  It  was 
formerly  believed  that  most  of  the  common  contagious  diseases  were  air- 
borne infections.  Smallpox  and  scarlet  fever  especially  were  cited  as 
examples  of  diseases  which  could  be  conveyed  by  air  currents  at  a  con- 
siderable distance  from  the  body.  It  was  believed  that  these  and  other 
contagious  diseases  were  frequently  carried  by  a  third  person.  It  is  now 
pretty  definitely  established  that  such  contagion  is  possible  only  for  a 
very  short  distance,  probably  but  a  few  feet  from  the  patient,  and  that 
communication  through  a  third  person  is  an  extremely  rare  occurrence. 
In  the  spread  of  contagious  diseases,  articles  of  clothing,  toys,  books,  fur- 
niture and  other  objects  which  had  been  in  contact  with  the  patient  were 
once  regarded  as  frequent  sources  of  infection.  While  it  cannot  be  de- 
nied that  these  are  sometimes  the  vehicles  of  contagion,  this  mode  of 
spreading  these  diseases  is  certainly  infrequent. 

Infection,  as  a  rule,  is  acquired  either  by  contact  with  or  close 
proximity  to  a  person  suffering  from  a  contagious  disease.  By  contact 
there  may  be  actual  transfer  of  the  organism  causing  the  disease.  By 
proximity  the  specific  poison  of  the  disease  which  is  discharged  from  an 
infected  person,  usually  in  the  form  of  minute  droplets  by  coughing  or 
sneezing,  may  be  inhaled.  In  this  way  whooping-cough,  epidemic  catarrh 
and  measles  in  the  early  stage  are  probably  most  frequently  commimi- 
cated.  Measles  and  scarlet  fever  are  often  spread  in  the  later  stages  by 
the  discharges  from  mouth,  nose,  eyes,  ears  or  glands. 

There  are  two  very  important  sources  of  infection  which  are  con- 
stantly overlooked.  The  first  is  the  unrecognized  case,  which  escapes 
notice,  in  scarlet  fever,  because  of  its  mild  character;  and  in  tubercu- 
losis, because  the  early  stage  is  so  prolonged.  The  second  source  is  the 
group  of  persons  known  as  "carriers."  To  the  latter  are  very  often 
traced  epidemics  of  typhoid  fever  and  diphtheria;  rarely,  epidemics  of 
cerebrospinal  meningitis  and  acute  poliomyelitis.  Carriers  are  persons 
who  harbor  the  organisms  of  infection,  usually  as  the  result  of  a  previous 
attack,  sometimes  because  they  have  been  in  close  contact  with  the  dis- 

949 


950  THE  SPECIFIC  INFECTIOUS  DISEASES 

ease,  but  are  not  themselves  at  the  time  suffering  from  it.  The  recog- 
nition and  segregation  of  these  carriers  constitute  one  of  the  most 
difficult  and  important  problems  in  connection  with  the  prevention  oO 
communicable  diseases. 

Infection  may  take  place  through  the  inhalation  of  dust  particles 
which  contain  the  specific  organism  of  the  disease.  The  bacilli  of  tuber- 
culosis, diphtheria  and  typhoid  may  survive  drying  and  become  a  part 
of  the  dust  of  the  room.  While  rarely  present  in  the  upper  air  of  the 
room,  they  may  be  found  in  places  where  dust  settles,  as  on  floors,  win- 
dow-sills, etc.  Infection  of  older  children  or  adults  by  actual  inhala- 
tion of  these  organisms  with  dust  is  probably  very  uncommon ;  but  small 
children,  playing  much  on  the  floor,  may  easily  acquire  infection  from 
dust  upon  hands,  toys,  etc.,  most  often  through  the  mouth. 

There  are  certain  disease  organisms  that  die  so  quickly  after  being 
discharged  from  the  body  that  infection  by  dust  is  most  improbable. 
Examples  of  this  are  the  B.  influenzae,  the  meningococcus  and  the  gono- 
coccus. 

Epidemic  catarrh  spreads  so  rapidly  in  epidemics  that  the  evidence  is 
stronger  in  this  disease  than  in  any  other  that  it  may  at  times  be  air- 
borne; but  it  is  more  frequently  spread  through  contact  or  near  prox- 
imity to  infected  persons  through  coughing,  sneezing,  etc.,  or  from 
handkerchiefs,  clothes,  drinking  utensils,  etc.,  which  have  been  in  con- 
tact with  patients. 

General  Care. — In  most  of  the  contagious  diseases  discussed  in  the 
following  pages  the  infectious  agent  is  confined  to  the  discharges  from 
the  patient's  mouth,  nose,  throat,  eyes,  ears,  sputum  or  glands.  If  the 
spread  of  these  diseases  is  to  be  prevented,  this  poison  should  be  destroyed 
as  soon  as  it  leaves  the  body.  The  physician  who  is  in  charge  of  a  patient 
with  an  infectious  disease  has  a  responsibility,  not  only  to  the  patient  and 
those  in  immediate  contact  with  him,  but  to  the  community.  As  the  same 
general  directions  should  be  followed  with  all  severe  communicable  dis- 
eases, they  may  well  be  outlined  in  this  introductory  chapter. 

The  Sich-room. — One  with  good  light  and  air,  so  situated  as  to  1)C 
easily  shut  off  from  the  rest  of  tlie  house  or  apartment,  should  be 
chosen.  An  open  fire  and  an  adjoining  bath-room  are  very  desirable. 
Carpets,  rugs,  u]:)holstered  furniture  and  all  hangings  should  be  removed. 
Only  the  simplest  and  most  necessary  furniture  should  be  left  behind 
and  such  books  or  toys  as  can  be  destroyed.  An  abundant  supply  of 
hot  water  should  be  provided  for,  a  large  slop  jar,  and  plenty  of  old 
mnslin  and  al)sorbent  cotton  to  be  used  in  place  of  handkerchiefs  for 
discharges,  and  a  supply  of  pa])or  bags,  in  which  these  can  be  placed  for 
removal.  Free  ventilation  should  be  secured,  and  windows  should  1)j 
screened  against  flies  and  mosquitoes.     The  sick-room  should  be  kept 


GENERAL  CARE  951 

scrupulously  clean;  especially  should  all  dust  be  wiped  up  daily  from 
floorS;,  window-ledges,  and  railings,  with  a  cloth  which  has  been  wrung 
from  a  1-1000  bichlorid  solution.  The  cloths  used  should  be  kept  in  the 
same  solution.  The  bed  linen  sliould  be  frequently  changed,  and  kept 
clean.  In  the  room  sliould  be  a  large  bowl  of  carbolic  acid,  1  to  40,  or 
some  similar  solution  for  cleansing  the  hands.  There  is  no  objection 
to  the  hanging  of  sheets  moistened  in  carbolic,  bichlorid,  or  other  disin- 
fectant solutions  before  the  door,  but  neither  this  nor  hanging  them 
about  in  the  sick-room  is  to  be  regarded  as  having  any  value  in  disin- 
fecting the  air  of  the  room.  They  create  a  false  sense  of  security,  and 
often  lead  to  the  neglect  of  thorough  cleanliness. 

The  nurse  should  wear  a  washable  cap  and  gown,  which  she  should 
remove  on  leaving  the  room.  Bubber  gloves  are  an  added  protection  in 
severe  infections.     The  nurse  should  not  eat  in  the  sick-room. 

The  pJiyslcian,  before  entering  the  sick-room,  should  remove  liis  coat 
and  don  a  cap  and  gown,  kept  hanging  outside  the  sick-room  for  his 
special  use.  He  should  carefully  wash  his  face  and  hands  before  leaving 
the  room. 

The  patient  being  the  source  of  infection,  special  care  should  be 
taken  with  everythijig  which  comes  in  contact  with  him.  The  outer 
clothing,  worn  when  he  was  taken  ill,  should  be  exposed  to  sunlight  for 
at  least  one  day  and  thoroughly  brushed  in  the  open  air.  Underclothing 
should  be  boiled  for  ten  minutes  and  placed  in  a  5-per-cent  solution  of 
carbolic  acid.  Bed-linen  should  be  soaked  in  the  carbolic  solution  and 
boiled  in  soapsuds  before  going  to  the  general  wash.  Handkerchiefs,  if 
used  at  all,  should  be  treated  in  the  same  way.  If  there  is  much  sputum 
it  should  be  received  in  paper  cups,  which  should  be  burned,  or  in  vessels 
containing  5-per-cent  solution  of  carbolic  acid.  All  discharges  from 
the  mouth,  nose,  eyes  and  ears  should  be  collected  on  old  muslin  or  ab- 
sorbent cotton,  thrown  into  paper  bags  and  burned.  Handkerchiefs 
should  not  be  used  for  this  purpose.  Special  disinfection  of  discharges 
from  the  bowels  is  not  needed  in  the  diseases  treated  in  this  Section, 
except  in  the  care  of  typhoid  cases.  All  remnants  of  food  should  be 
burned.  All  dishes,  knives,  forks,  spoons,  etc.,  should  be  boiled  in  soap- 
suds and  used  only  by  the  patient.  At  the  termination  of  quarantine 
the  patient  should  receive  a  complete  and  thorough  bath,  including  the 
hair,  with  soap  and  water,  and  entirely  clean  clothing  put  on  in  an 
adjoining  room.  Especial  care  should  be  given  to  cleanliness  of  the 
mouth  and  teeth. 

The  room  subsequent  to  the  illness  should  receive  the  most  thorough 
cleaning.  Floors,  woodwork  and  furniture  should  be  thoroughly 
scrubbed  with  soap  and  hot  water,  walls  should  be  wiped  down  with 
damp  cloths  wrung  from  1-1000  bichlorid  solution.     After  severe  infec- 


952  THE  SPECIFIC  INFECTIOUS  DISEASES 

tions  like  scarlet  fever  and  diphtheria,  repapering  or  repainting  should 
be  done.  Toys  and  books  used  in  the  sick-room  should  be  destroyed  or 
sent  to  hospitals  where  similar  infections  are  treated.  The  mattress  and 
blankets  should  be  sent  to  a  steam  disinfecting  place,  if  one  is  available ; 
if  not,  they  should  be  exposed  for  two  or  three  days  to  sunlight  and 
beaten  in  the  open  air,  to  remove  all  dust.  All  washable  bedding  should 
be  treated  as  heretofore  mentioned.  Not  only  the  sick-room  but  the 
adjoining  room  much  used  by  attendants  should  receive  special  cleaning. 
Fumigation  will  be  quite  unnecessary  if  the  above  directions  have  been 
thoroughly  carried  out.  Its  value  has  always  been  problematical;  it  is 
now  rapidly  being  abandoned  by  health  authorities.  Its  efficacy  is  in 
no  way  to  be  compared  to  the  special  cleanliness  heretofore  emphasized. 


CHAPTER  I 

SCARLET  FEVER 

(Scarlatina) 

Scarlet  fevee  is  an  acute,  contagious,  self-limited  disease,  one  at- 
tack usually  protecting  the  individual  through  life.  The  period  of  incu- 
bation is  usually  from  two  to  five  days ;  that  of  invasion,  from  twelve  to 
twenty-four  hours;  that  of  eruption,  from  four  to  six  days;  that  of 
desquamation,  from  three  to  six  weeks.  The  disease  may  be  communi- 
cated at  any  time  from  the  first  symptom  of  invasion  and  even  during 
the  existence  of  purulent  discharges  from  the  nose  or  other  mucous  or 
serous  membranes.  It  is  usually  ushered  in  by  vomiting,  fever,  and  sore 
throat,  and  .s  characterized  by  an  erythematous  rash  appearing  first 
upon  the  neck  and  spreading  rapidly  over  the  entire  body.  Its  chief 
complications  are  otitis,  adenitis,  and  membranous  inflammations  of  the 
pharynx,  which  frequently  extend  to  the  nose,  rarely  to  the  larynx.  The 
most  important  sequelae  are  otitis  and  nephritis.  The  constancy  of  the 
throat  infection  in  scarlet  fever  strongly  points  to  the  pharynx  as  the 
point  of  entry  of  the  infection. 

Etiology. — Analogy  leads  to  the  belief  that  scarlet  fever  is  due  to  a 
microorganism,  but  as  yet  its  nature  has  not  been  discovered.  The 
complications  are  usually  associated  with  the  development  of  a  strepto- 
coccus. Some  have  gone  so  far  as  to  claim  that  a  streptococcus  is  the 
cause  of  the  disease.  From  present  knowledge,  however,  it  appears  rather 
to  play  the  role  of  a  secondary  or  accompanying  infection,  for  the  devel- 
opment of  which  the  mucous  membranes  of  a  person  suffering  from 


SCARLET  FEVER 


953 


scarlet  fever  seem  to  afford  most  favorable  conditions.  To  the  strepto- 
coccus may  be  ascribed  the  membranous  inflammations  of  the  tonsils 
and  pharynx,  the  otitis,  the  inflammation  of  the  lymph  nodes  and  the 
cellular  tissue  of  the  neck,  and  probably  also  the  nephritis,  endocarditis, 
pneumonia,  and  joint  lesions.  In  many  of  the  above  conditions  the 
streptococcus  is  associated  with  other  pyogenic  germs,  and  in  some  cases 
with  the  diphtheria  bacillus. 

Predisposition. — The  susceptibility  of  children  to  the  scarlatinal 
poison  is  much  less  than  to  that  of  measles ;  still,  it  is  much  greater  than 
that  of  adults.  Billington  (N"ew  York)  records  observations  made  in 
twenty-six  families  living  in  tenements  where  little  or "  no  attempt  at 
isolation  was  made.  In  these  families  there  occurred  forty-three  cases 
of  scarlet  fever;  but  forty-seven  other  children,  although  unprotected  by 
previous  attacks  and  constantly  exposed,  did  not  contract  the  disease. 

Johannessen  reports  that  of  185  children  under  fifteen  years  who 
were  exposed,  twenty-eight  per  cent  contracted  the  disease;  while  of  314 
adults,  only  five  per  cent  contracted  the  disease.  It  may  be  stated  that, 
approximately,  not  more  than  one-half  of  the  children  exposed  take  the 
disease.  The  susceptibility  is  slight  in  early  infancy,  but  it  increases 
until  about  the  fifth  year,  after  which  it  steadily  diminishes.  Both  sexes 
are  equally  liable  to  scarlet  fever.  Epidemics  are  more  frequent  in  the 
fall  and  winter  than  in  summer,  and  cases  occurring  in  the  cold  months 
are  apt  to  be  more  severe.  Whitelegge,  in  6,000  cases,  found  the  highest 
mortality  in  the  month  of  October ;  and  in  Caiger's  report  of  1,008  cases 
this  was  also  the  month  showing  the  greatest  mortality. 

Incubation. — Of  113  cases  ^  in  which  the  period  of  incubation  could 
be  accurately  determined,  it  was  as  follows: 


24  hours  or  less 6  cases. 

2  days 15 


28 

25 

6 

15 


8  days 2  cases. 


q 

(( 

5      " 

11 

u 

1  case. 

14 

u 

1      « 

'>,! 

a 

1      « 

113  cases 

Thus  in  eighty-seven  per  cent  of  these  it  was  between  two  and  six 
days,  and  in  sixty-six  per  cent  between  two  and  four  days.  Speaking 
generally  if,  after  exposure,  a  week  passes  without  symptoms,  the  chances 
of  infection  are  very  small.  A  short  incubation  is  more  frequently  seen 
in  severe  than  in  mild  cases. 


^Part  of  these  are  from  personal  observation,  but  the  great  majority  are 
isolated  cases  scattered  through  medical  literature,  occurring  imder  circum- 
stances which  made  it  possible  to  determine  the  exact  length  of  the  incubation 
period. 


954  THE  SPECIFIC  INFECTIOUS  DISEASES 

Mode  of  Infection. — The  chief  source  of  infection  is  the  patient  him- 
self. It  is  the  mild  and  unrecognized  cases  which  act  as  carriers  to 
which  the  spread  of  the  disease  is  very  frequently  due.  It  is  somewhat 
doubtful  whether  the  poison  of  scarlet  fever  can  be  conveyed  by  the 
breathy  but  infection  is  chiefly  by  discharges  from  the  mucous  mem- 
branes involved.  Whether  it  can  be  conveyed  by  the  scales  during 
desquamation  or  by  the  excretions  of  the  patient — urine^  feces  and  per- 
spiration— is  a  question  of  grave  doubt.  It  has  not  been  demonstrated. 
Infection  may  take  place  from  the  carpets  or  furniture  of  the  sick- 
room and  from  the  clothing  of  the  patient.  Toys  or  books  may  be 
carriers  of  the  disease.  A  bouquet  of  flowers  sent  from  a  sick-room 
to  an  institution  has  been  known  to  be  a  vehicle  of  infection.  Cats^ 
dogs  and  other  domestic  animals  in  rare  instances  have  conveyed  the 
disease.  Scarlet  fever  is  sometimes  spread  by  milk.  The  simultaneous 
occurrence  of  a  considerable  number  of  cases  in  a  community  should 
lead  one  to  suspect  the  milk  supply.  All  of  these  sources  of  infection 
are  relatively  infrequent. 

The  transmission  of  the  disease  through  a  third  person  is  not  fre- 
quent^ but  numerous  instances  of  it  are  on  record.  The  persons  most 
likely  to  carry  it  are  the  nurse  and  the  physician,  the  latter  rarely  unless 
there  has  been  very  direct  contact  with  the  patient,  and  when  the 
interval  before  seeing  the  second  child  is  short.  The  transmission  of 
the  disease  by  one  who,  although  living  in  the  house,  does  not  come  in 
contact  with  the  patient,  is  extremely  improbable. 

Duration  of  the  Infective  Period. — There  is  no  evidence  to  show 
that  the  disease  is  communicable  during  the  period  of  incubation.  It  is 
slightly  contagious  from  the  beginning  of  invasion,  before  the  rash 
appears.  Infection  appears  to  be  most  active  at  the  height  of  the  febrile 
period — from  the  third  to  the  fifth  day. 

In  simple  cases,  the  average  duration  of  the  contagious  period  may 
be  placed  at  five  weeks,  or  until  discharges  from  mucous  membranes 
of  the  nose  and  throat,  the  ears  and  glandular  sinuses  have  ceased.  The 
infectious  nature  of  these  discharges  has  not  been  sufficiently  recog- 
nized. One  case  is  recorded  in  which  scarlatina  was  communicated 
through  a  purulent  nasal  discharge  after  eleven  weeks;  another  in  which 
the  opening  of  a  post-scarlatinal  empyema  in  a  surgical  ward  was  fol- 
lowed by  an  outbreak  of  scarlet  fever. 

In  winter  especially,  a  chronic  pharyngeal  catarrh  may  long  contain 
the  infective  agent.  Ashby  found,  on  careful  investigation,  that  from 
two  to  four  per  cent  of  patients  discharged  from  a  scarlet-fever  hospital 
subsequently  conveyed  the  disease.  Tliere  is  particular  danger  from  a 
child  who  has  recently  had  the  disease  sleeping  with  other  children.  Lino 
records  a  case  in  which  the  disease  was  contracted  in  this  way  after 


SCARLET  FEVER  955 

foiirtreii  weeks.  It  is  inipossiljle  to  say  that  at  any  specifie<l  time  a])so- 
lute  safety  exists.  All  patieuts  before  being  discliarged  from  a  hospital 
or  released  from  quarantine  in  private  practice,  should  be  carefully 
examined  as  to  the  condition  of  the  mucous  membranes,  and  quarantine 
continued  as  long  as  catarrhal  inflammations  are  present.  The  poison 
of  scarlatina  clings  more  tenaciously  to  clothing,  upholstery,  and  apart- 
ments than  that  of  any  other  infectious  disease,  possibly  excepting  tuber- 
culosis. 

Lesions. — The  only  characteristic  lesions  of  scarlatina  are  those  of 
the  skin  and  the  mucous  membranes  of  the  mouth  and  throat.  The  skin 
is  the  seat  of  an  acute  dermatitis  of  variable  depth  and  intensity.  There 
is  first  acute  hyperemia,  followed  by  an  exudation  of  serum  and  cells  in 
the  corium,  especially  about  the  blood-vessels  and  hair  follicles.  There 
results  a  death  of  the  epidermis  which  is  thrown  off  in  the  desquamation. 
The  mucous  membrane  of  the  mouth,  tongue,  and  throat  is  the  seat  of 
a  catarrhal,  membranous,  or  gangrenous  inflammation  which  rarely  in- 
vades the  larynx,  but  very  frequently  the  middle  ear  and  nose.  The 
entire  esophagus  is  often  the  seat  of  an  intense  congestion.  From  the 
ear  the  infection  may  extend  to  the  mastoid  cells,  the  meninges,  or  the 
brain,  and  from  the  nose  to  the  accessory  sinuses,  particularly  the  an- 
trum of  Highmore.  All  the  lymph  nodes  about  the  neck  may  be 
involved,  the  infection  ending  in  cell-hyperplasia,  suppuration,  or  ne- 
crosis. The  cellular  tissue  of  this  neighborhood  may  also  become  infil- 
trated, this  being  followed  sometimes  by  suppuration  and  occasionally 
by  gangrene. 

The  most  constant  change  throughout  the  body,  according  to  Pearce, 
is  hyperplasia  of  the  lymphoid  tissue,  which  is  seen  everywhere.  The 
other  lesions  are  degenerations  due  to  the  scarlatinal  poison  alone,  or 
in  conjunction  with  the  various  forms  of  secondary  infection,  or  to 
the  latter  alone.  The  most  important  are :  fatty  degeneration  of  the 
heart;  areas  of  focal  necrosis  in  the  liver;  acute  degeneration  of  the 
kidney  or  acute  difi'use  nephritis;  proliferation  of  the  cells  of  the 
Malpighian  bodies  of  the  spleen;  bronchopneumonia,  gangrene,  or 
abscess  of  the  lung;  pleurisy,  which  is  often  purulent;  endocarditis, 
pericarditis;  abscesses  in  the  cellular  tissue  and  inflammation  of  the 
joints.  These  visceral  changes  will  be  considered  more  fully  under 
Complications. 

Symptoms. — Invasion. — As  a  rule^  the  invasion  of  scarlet  fever  is 
abrupt,  the  symptoms  at  the  onset  usually  being  directly  in  proportion 
to  the  severity  of  the  attack.  In  the  majority  of  cases  there  is  vomiting, 
a  rapid  rise  in  temperature,  and  soreness  of  the  throat.  Often  the 
vomiting  is  repeated  ;  it  is  frequently  forcil)le,  and  witliout  nausea.  In 
severe  cases  the  rise  in  tem])erature  is  very  rapid,  to  10-1:°  or  10.5°  ¥.; 


956  TI-TE  SPECIFIC  INFECTIOUS  DISEASES 

in  the  mildest  eases  it  may  not  be  above  101°  F.  A  child  may  complain 
of  soreness  of  the  throat,  or  the  throat  symptoms  may  be  entirely  ob- 
jective. In  most  severe  cases  there  is  a  uniform  erythematous  blush 
covering  the  pharynx,  tonsils,  and  fauces,  but  on  the  hard  palate  it  ap- 
pears as  minute  red  points.  The  appearance  of  this  is  usually  coincident 
with  the  rise  in  temperature.  Occasionally  membranous  patches  may  be 
seen  upon  the  tonsils  the  first  day,  but  generally  not  before  the  third 
or  fourth  day.  In  mild  cases  the  throat  shows  only  a  very  moderate 
congestion.  Severe  cases  are  sometimes  ushered  in  by  convulsions, 
especially  in  very  young  children.  Diarrhea  is  not  uncommon  in 
summer.  There  is  general  prostration,  which  is  directly  proportionate 
to  the  height  of  the  fever. 

Eruption. — This  usually  appears  from  twelve  to  thirty-six  hours 
after  the  first  symptoms  of  invasion;  exceptionally,  not  until  the  third 
or  even  the  fifth  day.  A  later  appearance  than  this  is  somewhat 
doubtful,  for  the  rash  not  infrequently  recedes  and  reappears,  having 
been  overlooked  in  the  first  instance.  In  108  cases  tabulated  the  duration 
of  the  rash  was  as  follows : 

Two  days  or  less ; —  5  cases 

Three   to  seven  days 81     " 

Eight  to  eleven  days 16     " 

Over  eleven  days 4     " 

Recurring 2     " 

These  figures  are  confirmed  by  the  observations  of  most  writers, 
that  the  rash  lasts  from  three  to  seven  days.  The  full  development  of 
the  rash  is  generally  seen  in  from  twelve  to  twenty-four  hours  from  its 
first  appearance,  and  not  infrequently  the  whole  body  is  covered  in  the 
course  of  four  or  five  hours.  Its  first  appearance  is  almost  invariably 
upon  the  neck  and  chest.  Its  color  is  red  rather  than  scarlet,  and  on 
close  inspection  it  is  seen  to  be  made  up  of  very  minute  points  upon 
a  reddish  ground  giving  the  appearance  of  a  uniform  blush ;  or  the  back- 
ground may  be  wanting  and  only  the  punctate  eruption  shows.  These 
points  are  the  papillae  of  the  skin  and  hair  follicles.  The  rash  usually 
covers  the  entire  body  except  the  face.  Even  in  cases  with  intense 
eruption  the  central  part  of  the  face  usually  escapes,  though  elsewhere 
the  eruption  may  be  as  bright  as  upon  the  body.  There  is  often  a 
peculiar  pallor  about  the  mouth  which  is  characteristic.  The  appearance 
of  the  eruption  in  dark-skinned  races  is  much  modified  and  often  diffi- 
cult of  recognition.  In  the  negro  the  palms  and  soles  may  be  the  only 
places  where  the  eruption  can  be  distinguished.  Here  may  be  seen  a 
bright  red  blush  or  a  fine  papular  eruption. 

Variations   in   the  eruption   are   very   frequent   and   very  puzzling. 


SCARLET  FEVER  957 

They   occur   especially   in   the    mild   and    in    the   most    severe    cases. 

In  the  mild  cases  the  rash  is  not  seen  upon  the  face;  it  is  often 
faint  upon  the  body,  and  may  be  present  only  upon  certain  parts ;  when 
the  rash  is  faint  or  scanty  it  is  usually  mqst  marked  in  the  groins  and 
axillae,  or  over  the  buttocks  and  back  of  the  thighs;  it  may  last  only 
one  day,  and  sometimes  may  be  so  slight  as  to  escape  notice  altogether. 
The  eruption  may  be  absent  in  some  very  mild  cases,  in  certain  others 
where  the  throat  symptoms  are  severe,  and  in  malignant  cases.  In  the 
very  severe  cases  many  irregularities  are  seen,  both  as  to  the  time  of 
the  appearance  of  the  eruption  and  its  character.  Sometimes  it  occurs 
as  large,  irregular  patches ;  again,  it  is  macular,  closely  resembling  the 
rash  of  measles.  Not  infrequently  an  eruption  of  fine  vesicles  is  seen, 
especially  on  the  chest,  axillae  and  abdomen.  It  is  seen  both  in  mild 
and  severe  cases.  A  well-developed  bright  rash  indicates  strong  heart 
action,  and  a  sudden  recession  of  the  rash  is  a  sign  of  heart  failure. 
Often  a  rash  which  is  faint  and  doubtfnl  in  character  may  be  brought 
out  fully  by  a  hot  bath. 

With  the  eruption  at  its  height,  there  is  intense  itching  or  burning 
of  the  skin,  and  in  severe  cases  considerable  swelling,  chiefly  noticeable 
upon  the  hands  and  face. 

Desquamation. — Shortly  after  the  rash  has  faded,  about  the  eighth 
day,  there  begins  an  exfoliation  of  the  dead  epidermis,  known  as  des- 
quamation. This  is  even  more  characteristic  of  the  disease  than  is  the 
rash.  It  is  usually  first  seen  upon  the  neck  and  chest,  where  it  appears 
as  fine  flakes.  The  desquamation  of  the  trunk  is  completed  in  from 
one  to  three  weeks.  If  baths  and  inunctions  are  being  used,  it  may  be 
scarcely  perceptible.  It  continues  longest  where  the  epidermis  is  thick- 
est— -viz.,  upon  the  hands  and  f eet^ — and  here  it  lasts  from  four  to  seven 
weeks,  and  not  infrequently  eight  weeks.  The  appearance  of  the  fingers 
and  toes  during  desquamation  is  characteristic.  The  finger  tips  usually 
peel  first,  and  the  new  epidermis  is  pink  and  fresh-looking,  while  that 
which  has  not  yet  separated  is  of  a  dull  gray  color  and  loosened  at  the 
margin.  Occasionally  the  epidermis  of  a  considerable  part  of  a  finger 
may  be  loosened  at  once,  so  that  a  partial  cast  may  be  thrown  off  like 
the  finger  of  a  glove.  Sometimes  the  patient  comes  under  observation 
for  the  first  time  during  desquamation,  the  history  of  the  early  symp- 
toms being  doubtful  or  absent.  Such  desquamation  as  has  been  de- 
scribed, occurring  both  upon  the  hands  and  feet,  may  be  regarded  as 
conclusive  evidence  of  scarlet  fever. 

1.  Tlie  Mild  Gases. — The  symptoms  may  be  so  slight  as  to  be  entirely 
overlooked,  nothing  being  noticed  until  desquamation  occurs.  Usually, 
however,  there  is  a  rather  abrupt  invasion,  with  vomiting  and  a  tem- 
perature from  100°  to  103°  F.  The  tonsils  and  pharynx  are  congested, 
32 


958 


THE  SPECIFIC  INFECTIOUS  DISEASES 


while  the  palate  shows  a  punctate  redness  somewhat  like  the  cutaneous 
eruption.  The  papillae  of  the  tip  and  borders  of  the  tongue  are  en- 
larged. Nearly  always  within  twenty-four  hours  the  rash  makes  its 
appearance,  generally  first  upon  the  neck  and  chest.  Very  often  it  is 
not  seen  upon  the  face,  hut  is  abundant  on  the  rest  of  the  1)ody.  The 
rash  fades  on  the  third  or  fourth  day,  and  has  disappeared  by  the  fifth 
day.  There  is  very  little  prostration,  the  child  often  being  with  diffi- 
culty kept  in  bed. 

The  highest  temperature  is  coincident  with  the  full  eruption,  and 
is  usually  seen  during  the  first  thirty-six  hours  of  the  disease.  It  grad- 
ually falls  to  normal  by  the  third  or  fourth  day.  Some  examples  are 
.shown  in  Fig.  152.  In  the  mildest  cases  the  temperature  may  never  be 
above  100°  F. 

Desquamation  is  often  faint  over  the  body,  but  is  usually  unmistak- 


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Fig.  152. — Mild  Scarlet  Fever.  Three  cases  occurring  successively  in  the  same  family. 
Diagnosis  not  made  until  the  third  case  developed,  at  which  time  the  first  one  was 
found  to  be  desquamating  in  a  tj'pical  manner. 

able  over  the  hands  and  feet,  always  being  most  marked  where  the 
eruption  has  been  most  intense. 

The  mild  cases  are  usually  uncomplicated,  but  the  possibility  of  otitis 
and  of  late  nephritis  should  always  be  kept  in  mind,  as  these  may  occur 
even  with  the  mildest  attacks.  The  difficulties  in  diagnosis  in  mild 
attacks  of  scarlet  fever  are  often  great.  It  should  be  remembered  that 
these  cases  are  just  as  contagious  as  severe  ones,  and  that  from  a  mild 
attack  a  severe  one  is  often  contracted.  It  is  frequently  by  these  mild 
cases  that  this  disease  is  spread  in  schools.  In  dispensaries,  patients 
desquamating  from  scarlet  fever  are  often  seen  who  had  been  attending 
school  regularly  up  to  the  time  when  they  were  brought  for  treatment 
for  nephritis. 

2.  Cases  of  Moderate  Severity. — The  onset  is  sudden  with  vomiting, 
which  is  u.sually  repeated,  rarely  with  convulsions.  The  temperature 
rises  rapidly,  and  by  the  end  of  the  fir.'jf  twenty-four  hours  has  reached 
104°  or  105°  F.     The  ra.sh  generally  appears  within  the  first  twenty- 


SCARLET  FEVER 


959 


four  hours,  and  its  intensity  is  usually  in  direct  proportion  to'  the 
severity  of  the  attack.  Appearing  first  upon  the  neck  or  chest,  it  extends 
rapidly,  covering  the  entire  trunk  and  extremities,  often  in  a  few  hours. 
It  is  generally  typical  in  appearance,  being  made  up  of  minute  points, 
but  giving  the  appearance  of  a  uniform  blush,  which  has  been  compared 
to  a  boiled  lobster.  Little  change  takes  place  in  the  rash  for  four  or 
five  days.  After  this  it  fades  quite  rapidly,  and  disappears  by  the  sixth 
or  seventh  day. 

The  throat  resembles  that  of  the  mild  form,  except  that  the  redness 
is  more  intense  and  there  is  slight  swelling  of  the  tonsils,  fauces,  and 
uvula,  and  often  pain  upon  swallowing.  Occasionally  small  yellowish 
patches  are  seen  upon  the  tonsils  by  the  second  or  third  day,  but  these 
can  be  wiped  oft'  and  are  not  distinctly  membranous.  There  is  usually 
a  moderate  discharge 
of  a  sero-purulent 
character  from  the 
nose.  The  lymph 
glands  at  the  angle  of 
the  jaw  are  swollen 
and  quite  tender.  The 
tongue  may  be  coated 
in  the  center  and  show 
bright  red  points  at  its 
borders  and  tip,  or  it 
may  be  quite  red  and 
show  everywhere  the 
prominent  papillae — the  "strawberry  tongue'' ;  while  not  exclusively  seen 
in  scarlatina,  this  is  of  considerable  diagnostic  value.  It  is  rarely  seen 
before  the  third  day,  and  may  continue  several  days  or  even  weeks. 

During  the  height  of  the  fever,  restlessness,  thirst,  and,  not  infre- 
quently, slight  delirium  are  seen.  The  temperature  usually  reaches  the 
maximum  by  the  second  day,  and  falls  gradually,  but  even  in  uncompli- 
cated cases  the  fever  often  lasts  from  ten  to  fourteen  days  (Fig.  153). 
The  pulse  in  the  early  part  of  the  disease  is  rapid,  its  frequency  being  usu- 
ally out  of  proportion  to  the  height  of  the  temperature.  There  is  much 
prostration,  frequently  followed  by  quite  a  marked  degree  of  anemia. 

This  form  of  the  disease  rarely  proves  fatal  apart  from  complica- 
tions. The  complications  seen  most  frequently  in  this  form  of  scarlet 
fever  are  adenitis,  otitis,  and  pneumonia.  Nephritis  is'  the  only  com- 
mon sequel. 

3.  The  Severe  Cases. — The  severe  type  of  scarlet  fever  usually  de- 
clares itself  from  the  beginning.  The  incubation  is  short,  and  the  full 
rash  may  be  seen  within  a  few  hours  after  the  initial  symptoms.     It  is 


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Fig.  153. — Typical  Temperature  Curve  of  Uncom- 
plicated Scarlet  Fever  of  Moderate  Severity. 
Girl  three  years  old. 


960 


THE  SPECIFIC  INFECTIOUS  DISEASES 


usually  intense  and  covers  the  entire  body,  even  including  the  face.  In 
other  cases  the  eruption  is  delayed,  often  scanty,  and  may  disappear  in 
a  few  hours.  The  disease  assumes  one  of  two  fairly  distinct  types;  one 
is  characterized  by  the  severity  of  the  general  toxemia,  the  other  by  the 
l)redomi  nance  of  the  throat  symptoms.  In  the  first  group  the  toxemia 
is  shown  by  the  height  of  the  temperature,  the  severity  of  the  nervous 
symptoms,  and  the  profound  cardiac  depression.  The  temperature 
quickly  rises  often  to  105°  or  106°  F.,  and  usually  remains  steadily  high 
until  the  death  of  the  'patient.  The  nervous  symptoms  are  great  pros- 
tration and  delirium,  which  is  sometimes  active,  but  more  often  low  and 
muttering.  The  pulse  is  very  rapid,  160  to  180  being  not  uncommon; 
it  is  weak,  compressible,  often  irregular,  and  the  muscular  sounds  of  the 
heart  are  feeble.    The  urine  is  scanty  and  almost  invariably  albuminous. 


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Fig.  154. — Typical  Tempebature  Curve  of  Severe  Scarlet  Fever  Ending  in 
Recovery.  Prolonged  course  due  to  severe  throat  symptoms  lasting  from  second  to 
sixth  day,  otherwise  uncomplicated;  boy  twelve  years  old. 


Hemorrhages  from  the  mouth,  the  nose,  or  other  mucous  membranes 
are  occasionally  seen.  The  duration  of  the  disease  in  this  form  is  gen- 
erally from  five  to  seven  days.  Exceptionally  the  symptoms  develop  with 
greater  intensity,  and  death  follows  in  three  or  four  days.  A  shorter 
duration  than  this,  the  so-called  malignant  scarlet  fever,  is  rare. 

In  the  second  group  with  predominant  throat  symptoms,  the  first 
three  or  four  days  may  show  nothing  more  than  cases  of  the  moderate 
type.  Membranous  patches  appear  upon  the  tonsils  and  spread  to  the 
soft  palate,  uvula,  and  pharynx,  sometimes  to  the  nose  and  through  the 
Eustachian  tube  to  the  ear,  very  rarely  involving  the  larynx.  The  mu- 
cous membrane  of  the  mouth  is  intensely  congested,  and  often  partly 
covered  by  membrane;  there  are  sordes  on  the  lips  and  teeth,  and  there 
may  be  superficial  ulcers,  which  bleed  readily.  The  glands  of  the  neck 
swell  rapidly,  often  to  a  great  size,  and  the  cellular  tissue  about  them 
is  infiltrated.  The  head  is  thrown  back  to  relieve  the  dyspnea  which 
the  pressure  from  this  swelling  occasions.     There  is  an  abundant  dis- 


SCARLET  FEVER 


961 


charge  from  the  nose  and  month;  the  breath  is  very  offensive.  The 
general  symptoms  are  those  of  a  severe  septicemia.  The  temperature 
is  steadily  high,  usually  between  103°  and  105°  F.,  for  about  a  week, 
after  which  in  cases  ending  in  recovery  it  slowly  falls  unless  com- 
plications develop  (Figs.  154,  156,  157) ;  but  even  in  uncomplicated 
cases  the  fever  sometimes  continues  for  three  weeks.  In  fatal  cases  the 
temperature  may  be  steadily  high  till  death  (Fig.  155),  or  it  may  fluc- 
tuate widely.  The  pulse  is  rapid,  Aveak,  and  irregular.  There  is  com- 
plete anorexia.  There  is  low  delirium  or  apathy,  and  sometimes  all  the 
symptoms  of  the  typhoid  condition  are  present. 

Signs  of  a  bronchopneumonia  may  be  found  in  the  chest,  and  by 


Fig.  155. — Severe  Scarlet  Fever,  Septic  Type  ;  Death  on  Fourteenth  Day.  Intense 
angina;  otitis;  nephritis;  necrotic  inflammation  of  cervical  lymph  glands;  girl  seven 
years  old;  death  from  heart  failure. 


the  end  of  the  first  week  or  early  in  the  second,  acute  otitis  often  de- 
velops. The  urine  is  rarely  free  from  albumin,  but  the  amount  present 
is  not  usually  great ;  there  may  be  hyaline  and  epithelial  easts,  and  some- 
times blood.  In  some  cases  the  throat  symptoms  predominate ;  in  others, 
those  of  general,  sepsis,  but  more  frequently  the  two  are  combined  and 
are  directly  proportionate  to  each  other.  In  still  other  cases,  instead 
of  the  membranous  inflammation  of  the  throat,  it  may  be  of  a  gan- 
grenous character,  and  extensive  sloughing  may  take  place  in  the  pharynx 
or  the  cellular  tissue  of  the  neck,  sometimes  exposing  or  even  opening  the 
great  vessels. 

The  duration  of  the  symptoms  in  cases  with  severe  angina  is  from 
seven  to  fourteen  days.  There  is  increasing  prostration  and  finally  a 
septic  stupor,  with  death  from  exhaustion,  from  heart  failure,  or  from 
some  complication — bronchopneumonia,  pleurisy,  nephritis,  hemor- 
rhages following  sloughing,  pericarditis,  or  endocarditis.    In  cases  which 


962  THE  SPECIFIC  INFECTIOUS  DISEASES 

recover,  the  acute  symptoms  nearly  always  continue  for  a  full  month; 
and  after  escaping  the  dangers  of  sepsis  and  the  early  complications, 
the  child  has  still  to  run  the  gauntlet  of  all  the  late  complications — 
nephritis,  pneumonia,  endocarditis,  pyemia,  etc.  A  case  may  prove  fatal 
as  late  as  the  end  of  the  seventh  week;  nearly  all  such  results  are  due 
to  nephritis  or  to  its  complications. 

4.  Surgical  Scarlet  Fever. — The  existence  of  a  special  form  of  scar- 
let fever  occurring  in  patients  with  recent  wounds  or  those  who  have 
been  subjected  to  surgical  operations,  while  stoutly  maintained  by  sev- 
eral writers,  has  been  vigorously  denied  by  others.  The  question  is  one 
difficult  of  solution  on  account  of  the  close  similarity  at  times  existing 
between  the  symptoms  of  scarlet  fever  and  sepsis,  and  the  necessity  of 
deciding  in  an  undoubted  case  wliether  the  infection  with  scarlet  fever 
was  dependent  upon  or  coincident  with  the  wound. 

Hamilton,  from  a  study  of  ITi  reported  cases,  reached  the  conclusion 
that  proof  of  the  existence  of  a  special  form  of  scarlet  fever  rests  upon 
the  reports  of  cases,  usually  meager,  and  careful  analysis  of  these  would 
lead  one  to  consider  them  rather  as  septic,  tban  as  scarlatinal  infections; 
that  when  there  was  undoubted  evidence  of  scarlet  fever,  there  was  no 
proof  that  it  was  in  any  way  due  to  the  coincident  wound,  and  that  there 
is  as  yet  no  convincing  proof  in  the  literature  tbat  surgical  scarlet  fever 
is  anything  more  than  scarlet  fever  in  the  wounded.  On  the  other  hand. 
there  have  been  oliserved  clinically  cases  wbich  seem  to  admit  of  no  other 
reasonable  explanation  than  tliat  an  altrasion  of  tlie  skin,  a  recent 
wound,  or  even  possibly  a  varicella  vesicle,  may  be  the  point  of  entry 
of  the  scarlatinal  infection,  instead  of  the  more  usual  portal,  tbe 
pbarynx. 

Relapses,  Recurrences,  and  Second  Attacks. — As  a  rule,  one  attack 
of  scarlatina  gives  immunity  through  life.  The  exceptions  are  very  few, 
but  are  well  authenticated.  We  have  seen  but  once  an  undoubted  in- 
stance of  a  second  attack  in  the  same  individual. 

Eelapses  or  recurrences  within  a  brief  period  after  the  first  attack 
are  more  frequent.  There  are  to  be  excluded  the  cases  of  pseudo-relapses 
in  which  tbe  rash,  having  temporarily  subsided  for  two  or  three  days, 
reappears;  also  those  where  the  rash  varies  in  intensity  from  time  to 
time;  and,  lastly,  the  cases  in  which,  occurring  late  in  the  disease,  it  is 
due  to  septicemia  or  pyemia.  They  are  comparable  to  the  relapses  of 
typhoifl  fever.  They  occur  most  frequently  dnring  rlesquamation,  be- 
tween the  seventh  and  twenty-fourth  days.  There  may  be  not  only 
a  new  eruption,  but  a  rise  of  temperature,  sore  throat,  and  vomiting,  just 
as  in  the  initial  attack.  These  recurrences  are  sometimes  shorter  and 
milder  than  the  first  attack,  but  this  is  by  no  means  uniform,  since 
Korner  mentions  eight  cases  where  the  second  attack  prnverl  fatal. 


SCARLET  FEVER  963 

In  considering  the  subject  of  second  attacks,  the  liability  to  errors  in 
diagnosis  must  be  borne  in  mind  and  only  cases  included  which  have  pre- 
sented typical  symptoms. 

Special  Symptoms,  Complications,  and  Sequelae. — Temperature.— 
The  temperature  curve  of  this  disease  is  quite  characteristic.  There 
is  usually  seen  an  abrupt  rise,  the  maximum  being  reached  on  the  sec- 
ond day;  there  follows  a  period  of  variable  duration,  generally  lasting, 
according  to  the  severity  of  the  case,  from  two  to  five  days,  in  which  the 
fluctuations  are  very  narrow;  then  a  gradual  decline  to  normal,  which 
is  reached  in  the  milder  cases  in  about  a  week;  in  those  which  are  more 
severe,  in  about  two  weeks.  This  typical  curve  (Figs.  151  and  152)  is 
seen  in  the  great  proportion  of  uncomplicated  cases  which  end  in  recov- 
ery. Deviations  from  it,  therefore,  are  important  as  indicating  that 
some  complication  exists.  The  explanation  is  usually  to  be  found  in  the 
development  of  otitis,  adenitis,  nephritis,  pneumonia,  etc.  Severe  throat 
symptoms  prolong  the  temperature  but  do  not  usually  modify  its  course. 
In  very  severe  cases  ending  fatally  the  high  temperature  is  prolonged. 
In  any  case,  a  rise  after  the  third  day  is  unfavorable. 

Throat. — Three  distinct  forms  of  angina  are  seen  in  scarlatina :  sim- 
ple or  erythematous,  membranous,  and  gangrenous. 

1.  Erythematous  Angina. — This  can  hardly  be  ranked  as  a  com- 
plication, as  it  is  nearly  as  constant  as  the  scarlatinal  rash.  Usually 
there  is  only  the  intense  general  lilush  over  the  entire  pharynx  with 
the  fine  red  points  upon  the  hard  palate;  but  there  may  be  seen  upon 
the  tonsils  grayish-yellow  spots  resembling  those  of  follicular  tonsil- 
litis, which  can  be  wiped  off,  leaving  a  clean  surface.  This  simple 
angina  is  at  its  height  with  the  maximum  temperature,  and  fades  as 
the  temperature  falls. 

2.  ilembranous  Angina. — These  cases  were  formerly  classed  as  scar- 
latinal diphtheria.  Cultures,  however,  have  shown  that  the  great  ma- 
jority of  these  inflammations  are  not  true  diphtheria,  but  are  due  to  the 
streptococcus. 

The  lesions  of  this  form  of  angina  are  considered  in  the  chaptier  on 
Membranous  Tonsillitis.  Usually  on  the  second  or  third  day  of  the 
ilisease  an  exudation  appears  upon  the  tonsils,  and  in  the  milder  cases  it 
covers  only  the  tonsils.  In  the  most  severe  form  it  may  be  seen  withii) 
twnty-four  hours  of  the  onset,  sometimes  before  the  eruption  appears. 
Beginning  upon  the  tonsils,  the  membrane  rapidly  spreads  to  the  entire 
pharynx,  the  mucous  membrane  of  the  nose,  the  mouth,  the  Eustachian 
tube,  and  even  to  the  middle  ear.  In  color  it  may  be  gray,  greeni.«!h,  or 
almost  black.  Tlie  infiltration  of  the  cellular  tissue  of  the  neck  and 
'  the  enlarged  lymph  glands  produce  great  external  swelling,  which  may 
extend  like  a  collar  from  ear  to  ear.     The  breath  has  a  foul  odor,  the 


964  THE  SPECIFIC  INFECTIOUS  DISEASES 

nasal  discharge  is  thiu  and  fetid,  and  nasal  respiration  is  obstructed,  so 
that  the  mouth  is  open  constantly.  It  is  surprising  that  the  larynx  is 
so  seldom  invaded. 

These  local  changes  are  accompanied  by  constitutional  symptoms  of 
great  severity,  which  are  due  to  a  general  streptococcus  septicemia; 
bronchopneumonia  and  nephritis  are  very  frequent,  otitis  is  almost  con- 
stant, and  suppuration  of  the  lymphatic  glands  is  not  uncommon.  The 
eruption  is  often  irregular  and  late  in  appearing. 

The  frequency  with  which  diphtheria  coexists  with  scarlatina  varies 
greatly.  In  hospital  practice  the  proportion  often  runs  as  high  as  thirty 
or  forty  per  cent.  In  private  practice  it  is  much  lower.  The  strepto- 
coccus angina  is  usually  seen  at  the  height  of  the  disease ;  true  diphtheria 
may  occur  at  any  time,  even  during  convalescence.  The  only  positive 
means  of  differentiation  is  by  cultures,  which  should  invariably  be  made 
from  the  throat  of  every  patient  admitted  to  a  scarlet-fever  hospital,  and 
of  every  case  in  private  practice  showing  any  exudate  upon  the  tonsils. 

3.  Gangrenous  Angina. — This  is  seen  only  in  the  worst  cases  of  scar- 
let fever.  The  process  may  be  gangrenous  from  the  outset,  or  preceded 
by  a  membranous  inflammation.  It  is  sometimes  insidious  in  its  de- 
velopment. There  is  a  fetid  odor  to  the  breath,  an  irritating  discharge 
from  the  nose  and  mouth,  with  very  great  glandular  swelling.  The  ton- 
sils are  gray  or  grayish-black  in  color,  and  large  masses  of  necrotic 
tissue  may  be  removed  with  the  forceps  from  the  tonsils,  uvula,  fauces, 
or  pharynx,  and  sometimes  sloughing  occurs  in  the  cellular  tissue  of  the 
neck.  Blood-vessels  of  considerable  size  are  sometimes  opened,  and 
serious  or  even  fatal  hemorrhage  may  result.  The  constitutional  symp- 
toms are  those  of  great  asthenia,  prostration,  and  profound  cachexia, 
followed  almost  invariably  by  a  fatal  termination. 

Lymph  Nodes. — These  are  swollen  in  all  cases  accompanied  by  severe 
angina.  The  inflammation  may  be  simply  an  acute  hyperplasia,  or  it 
may  go  on  to  suppuration  and  necrosis.  Abscess  does  not  often  occur 
at  the  height  of  the  disease,  but  the  early  swelling  may  almost  completely 
subside  only  to  recur,  and  suppuration  may  take  place  even  as  late 
as  the  fifth  or  six  week  of  the  disease.  It  may  be  confined  to  the 
glands  or  be  complicated  by  suppuration  in  the  cellular  tissue  of  the 
neck. 

Cellulitis  of  the  Neck. — This  usually  occurs  toward  the  end  of  the 
first  week,  and  is  associated  with  grave  throat  symptoms.  Eapid  and 
extensive  infiltration  occurs,  the  skin  becomes  tense  and  brawny,  the 
head  is  held  l)ack,  and  there  may  be  cousideralile  dyspnea.  The  infil- 
tration may  l)e  only  in  tlie  neighborhood  of  the  lymph  glands  or  it 
may  be  diffuse.  Unless  relieved  by  early  incision,  the  diffuse  form  may 
result   in   suppuration   and    extensive   sloughing,   which   may   be    deep 


SCARLET  FEVER 


9G5 


enough  to  lay  bare  the  large  vessels  of  the  neck.  This  is  a  complication 
of  the  gravest  jjossible  import.  Death  may  occur  from  septicemia  be- 
fore or  after  sloughing  or  from  hemorrhage  due  to  opening  by  ulcera- 
tion of  the  external  carotid  or  some  of  its  branches;  or  there  may  be 
associated  thrombosis  of  the  jugular  vein,  leading  to  thrombosis  of  the 
•lateral  sinus,  meningitis,  or  pyemia. 

Ears. — The  otitis  is  due  to  direct  extension  of  the  infection  from 
the  rhinopharynx.  It  is  the  most  frequent  complication  of  scarlatina, 
and  in  doubtful  cases  may  have  some  diagnostic  importance.  As  a  rule, 
the  younger  the  child  the  greater  the  liability  to  otitis.  It  is  more  fre- 
quent in  winter  than  at  other  seasons,  and  is  closely  connected  with  the 
severity  of  the  throat  symptoms.     Of  4,397  cases  reported  by  Finlayson, 


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Fig.  156. — Severe  Scarlet  Fever;  Otitis;  Mastoiditis;  Death.  Typical  symptoms 
and  temperature  curve  until  fourteenth  day;  secondary  rise  of  temperature  from 
otitis;  double  paracentesis  on  the  fifteenth  day;  mastoid  operation  on  the  sixteenth 
day;   death  twelve  hours  later  from  septicemia;  boy  five  years  old. 


otitis  occurred  in  10  per  cent,  and  of  1,008  cases  reported  by  Caiger, 
in  13  per  cent.  In  Burkhardt's  statistics  the  proportion  was  as  high 
as  33  per  cent.  Of  cases  accompanied  by  severe  throat  symptoms  otitis 
is  present  in  fully  75  per  cent. 

As  a  rule,  both  ears  are  affected.  Otitis  is  most  frequent  early  in  the 
second  week,  but  may  occur  at  any  time,  even  during  convalescence. 
When  it  develops  at  the  height  of  the  disease  there  are  in  some  cases 
no  new  symptoms ;  in  others  there  is  pain  and  deafness .  and  a  rise  in 
the  temperature,  which  may  fall  after  paracentesis  or  rupture  of  the 
drum  membrane,  or  there  may  be  extension  to  the  mastoid  (Fig.  156). 
The  otitis  is  often  overlooked  unless  the  ears  are  regularly  examined. 
The  form  of  inflammation  may  be  catarrhal  or  purulent,  the  latter  l:)eing 
often  accompanied  by  necrotic  changes. 

Bezold  mak"s  tlie  following  report  upon  185  cases  showing  tbe  dis- 


966 


THE  SPECIFIC  INFECTIOUS  DISEASES 


astrous  consequences  of  scarlatinal  otitis:  "In  30  there  was  entire 
destruction  of  the  membrana  tympani;  in  59  the  perforation  comprised 
two-thirds  or  more  of  the  membrane;  in  15  there  was  total  loss  of  hear- 
ing on  one  side,  and  in  6  of  the  cases  upon  both  sides;  in  77  of  the  cases 
the  hearing  distance  for  low  voice  was  less  than  twenty  inches." 

As  a  cause  of  permanent  deafness  and  deaf-mutism,  no  disease  of 
childhood  compares  in  importance  with  scarlet  fever.  May  has  collected 
statistics  of  5,613  deaf-mutes,  of  whom  533  owed  their  condition  to 
otitis  following  scarlet  fever. 

Kidneys. — Albuminuria  accompanies  nearly  all  the  severe  cases  of 
scarlet  fever.  In  many  this  is  simply  the  ordinary  febrile  albuminuria 
due  to  acute  degeneration  of  the  kidneys.  In  those  with  severe  throat 
complications,  and  in  nearly  all  the  septic  cases,  there  is  an  acute  diffuse 
nephritis;  the  interstitial  changes  may  be  very  marked  and  the  kidneys 


Fig.  157.-Scablbt  Fever  of  Moderate  Severity  Followed  by  Fatal  Nephritis. 
Early  symptoms  typical  and  uncomplicated ;  twenty-first  day  vomiting ;  twenty-fifth 
day  uremic  convulsions;  death  twenty-sixth  day.  No  dropsy;  urine  never  below 
10  ounces  in  twenty-four  hours;  girl  ten  years  old. 


contain  minute  abscesses.  This  occurs  at  the  height  of  the  febrile 
process  and  is  rarely  accompanied  by  dropsy;  but  albumin,  casts,  and 
even  blood  may  be  found  in  the  urine.  The  most  severe  and  the  most 
characteristic  renal  complication,  and  that  generally  designated  as 
post-scarlatina  J  nephritis,  is  a  diffuse  nephritis,  with  changes  in  the 
glomeruli  as  the  most  striking  feature.  It  usually  develops  during  the 
third  or  fourth  week  of  the  disease,  and  may  follow  mild  as  well  as 
severe  cases  (Fig.  157).  The  onset  may  be  gradual,  with  dropsy  and 
urinary  changes,  usually  accompanied  by  a  slight  rise  of  temperature; 
or  it  may  be  abrupt,  without  dropsy  but  with  convulsions,  suppression 
of  urine,  and  very  high  temperature. 

The  characteristic  urine  is  of  a  reddish  or  smoky  color  and  scanty. 
It  contains  a  large  amount  of  albumen,  often  sufficient  to  render  the 
urine  solid  upon  boiling.  Under  the  microscope  there  are  seen  red 
blood-cells,  pus  cells,  epithelial  cells,  and  casts  of  every  variety.  Death 
may  take  place  from  acute  uremia,  or  the  attack  may  l)e  followed  by 


SCARLET  FEVER  96T 

permanent  damage  to  the  kidneys.  It  is  more  fully  described  with  the 
Diseases  of  the  Kidney. 

Joints. — Acute  articular  rheumatism  may  occur  coincidently  with 
the  development  of  the  scarlatinal  rash,  and  occasionally  during  con- 
valescence in  patients  who  have  a  predisposition  to  that  disease.  Acute 
swelling  of  the  joints  is  sometimes  of  pyemic  origin.  In  pyemic  ar- 
thritis the  large  joints  are  usually  involved  and  the  lesions  are  apt  to 
be  multiple.  Joint  disease  may  occur  as  a  sequel  of  scarlet  fever, 
when  it  is  secondary  to  disease  of  the  bone  or  to  periarticular  abscesses 
opening  into  the  joint. 

The  foregoing  include  but  a  small  proportion  of  the  joint  complica- 
tions seen  in  scarlet  fever.  The  most  frequent  and  most  characteristic; 
form  of  inflammation  is  scarlaiinal  synovitis,  often  improperly  called 
scarlatinal  rheumatism.  It  occurs  in  different  epidemics  with  varying 
frequency.  Carslaw  (Glasgow),  in  533  cases  of  scarlet  fever,  met  with 
synovitis  in  60  patients.  It  is  seldom  seen  in  children  under  three  years 
of  age,  and  is  most  frequent  after  five  years.  It  may  occur  in  mild  as 
well  as  in  severe  cases.  According  to  Ashby,  synovitis  develops  toward 
the  end  of  the  first  or  the  beginning  of  the  second  week.  The  symptoms 
are  generally  mild,  and  are  followed- by  prompt  recovery.  Suppuration 
is  rare.  Any  of  the  joints  may  be  attacked,  but  those  of  the  wrist,  hand, 
elbow,  or  knee  are  most  frequently  affected.  The  symptoms  are  redness, 
moderate  pain,  swelling,  which  is  usually  due  to  synovial  distention,  and 
sometimes  a  slight  rise  in  temperature.  The  duration  is  generally  but 
three  or  four  days,  and  in  most  cases  there  is  spontaneous  recovery.  Be- 
sides these  milder  cases  there  occurs  a  much  more  severe  form,  which 
may  develop  later,  even  during  convalescence.  It  is  not  very  acute,  but 
is  accompanied  by  fever,  and  both  the  fever  and  swelling  may  continue 
for  many  weeks.  Recovery  may  be  complete  or  some  joint  disability 
may  remain  and  chronic  arthritis  may  follow. 

Lungs. — The  pulmonary  complications  of  scarlet  fever  are  neither 
so  frequent  nor  so  important  as  those  of  measles.  Bronchopneumonia 
is  usually  found  at  autopsy  in  septic  cases  where  death  has  occurred 
later  than  the  third  or  fourth  day,  but  it  is  not  generally  recognizable 
so  early  by  physical  signs. 

In  septic  cases  pleuropneumonia  sometimes  occurs  early  in  the 
disease  and  at  other  times  late,  generally  associated  with  nephritis,  but 
(iccasionally  without  it.  It  is  not  infrequently  a  direct  cause  of  death. 
I'^mpyema  may  follow  pleuropneumonia  or  occur  w^ith  pyemia  or  neph- 
ritis, but  with  the  latter,  simple  serous  pleurisy  is  more  common. 
Edema  of  the  lungs  occurs  chiefly  with  nephritis,  in  w^hich  it  is  the 
most  common  cause  of  death. 

Heart. — Cardiac  murmurs  are  frequent  at  the  height  of  the  disease; 


968  THE  SPECIFIC  INFECTIOUS  DISEASES 

in  fact  they  are  heard  in  almost  all  severe  cases.  Endocarditis  and  peri- 
carditis are  oftenest  seen  in  septic  cases,  and  with  post-scarlatinal  neph- 
ritis. Endocarditis  may  be  simple  or  malignant,  and  may  lead  to  em- 
bolism during  convalescence.  Some  degenerative  changes  in  the  cardiac 
muscle  are  probably  present  in  all  the  severe  cases.  Acute  dilatation 
may  result,  which  is  sometimes  a  cause  of  death. 

Blood. — In  all  cases  there  is  a  rapidly  progressing  anemia  that  lasts 
into  convalescence.  The  reduction  in  the  red  cells  in  an  average  case  is 
about  one  million.  The  chief  interest,  however,  attaches  to  the  number 
and  character  of  the  white  cells.  In  mild  cases  there  may  be  only  a 
moderate  increase  in  their  number,  usually  to  from  10,000  to  14,000. 
It  is  in  cases  of  moderate  severity  that  the  characteristic  changes  are 
found.  In  these  there  is  a  decided  leucocytosis  which  appears  early, 
attains  its  maximum  about  the  fourth  day,  and  gradually  declines  until 
the  normal  is  reached,  which  may  not  be  until  the  third,  fourth,  or  fifth 
week.  The  maximum  is  usually  about  30,000  to  35,000 ;  although  it  may 
be  as  high  as  75,000.  During  the  first  week  the  polymorphonuclear 
neutrophiles  form  from  90  to  95  per  cent  of  these  cells;  the  eosinophiles 
as  well  as  the  lymphocytes  are  diminished.  After  the  fifth  or  sixth  day, 
there  is  a  rapid  increase  in  the  eosinophiles  which  attain  their  maximum 
— sometimes  20  per  cent  of  the  total  leucocytes — ^between  the  fourteenth 
and  twenty-first  days.  After  the  third  week  they  gradually  diminish. 
Exceptionally  there  is  found  in  convalescence  a  relative  lymphocytosis, 
which  may  be  as  high  as  50  per  cent.  Complications,  nephritis  excepted, 
usually  cause  actual  as  well  as  relative  increase  in  the  polymorphonuclear 
neutrophiles.  In  malignant  and  rapidly  fatal  cases  there  is  usually  a 
very  small  proportion  of  eosinophiles,  and  little  if  any  leucocytosis, 
though  exceptionally  it  may  be  high.  Much  has  recently  been  written 
regarding  the  so-called  "inclusion  bodies"  which  are  found  in  the  leu- 
cocytes in  this  disease.  It  seems  clear  that  they  are  not  specific  and 
that  their  presence  is  not  diagnostic  of  scarlet  fever.  They  are  regu- 
larly found  in  all  but  the  mildest  cases  before  the  fourth  day;  but  they 
are  found  also  in  other  conditions,  e.  g.,  pneumonia,  sepsis  and  ery- 
sipelas. 

Digestive  System. — Functional  disturbances  are  very  frequent,  and, 
in  fact,  are  seen  in  most  of  the  cases,  but  organic  changes  are  rare. 
Vomiting  is  the  mode  of  onset  in  the  majority  of  cases,  but  rarely  con- 
tinues throughout  the  attack.  Diarrhea  may  be  associated  with  it  un- 
der both  conditions.  The  tongue  is  nearly  always  coated,  and  clears  off 
in  quite  a  characteristic  way,  which,  with  tlie  prominent  papillae,  gives 
rise  to  the  "strawberry"  appearance.  Catarrhal  stomatitis  is  a  very 
frequent  complication,  and  in  many  cases  of  severe  membranous  angina 
the  same  process  is  seen  in  the  buccal  cavity. 


SCARLET  FEVER  'JG9 

Nervous  System. — Nervous  complications  and  sequ(4ae  are  seeu  less 
frequently  with  scarlatina  than  with  most  of  the  infectious  diseases  of 
such  severity.  Convulsions  are  frequent  at  the  outset,  and  generally 
indicate  a  severe  attack,  though  not  invariably  so.  Occurring  late  in 
the  disease,  they  are  usually  due  to  uremia.  Meningitis  may  occur  as 
a  complication  of  otitis,  in  pyemic  cases,  and  sometimes  with  post- 
scarlatinal nephritis.  Paralysis  from  peripheral  neuritis  is  rarely  seen. 
Hemiplegia  sometimes  occurs  from  meningeal  hemorrhage,  or  from  em- 
bolism secondary  to  endocarditis  and  associated  with  nephritis.  Chorea 
was  noted  as  a  sequel  in  only  three  of  533  cases  reported  by  Carslaw.  In 
a  report  of  187  cases  of  epilepsy,  Wildermuth  states  that  it  followed 
scarlet  fever  in  13  cases.  Insanity  has  been  occasionally  observed,  the 
usual  form  being  acute  mania,  with  complete  recovery  in  a  few  weeks  or 
months. 

Gangrene. — Cases  of  symmetrical  gangrene  after  scarlet  fever  have 
been  reported.  The  parts  generally  affected  are  the  buttocks,  thighs, 
and  arms,  but  it  may  occur  almost  anyAvhere.  The  pathology  of  these 
cases  is  obscure.  The  process  usually  begins  in  several  places  simul- 
taneously, or  in  rapid  succession,  and  advances  steadily  till  death 
occurs. 

Other  Infectious  Diseases. — Diphtheria  is  most  frequently  seen,  and 
may  be  present  even  when  there  is  no  distinct  membrane. 

Scarlatina  may  also  be  complicated  by  measles,  varicella,  or  facial 
erysipelas,  and  occasionally  by  variola  or  typhoid  fever.  The  symptoms 
are  often  an  irregular  commingling  of  those  belonging  to  the  two 
diseases.  They  may  begin  simultaneously,  or  more  frequently  one  de- 
velops as  the  other  is  subsiding. 

Diagnosis. — The  characteristic  symptoms  of  scarlet  fever  are  the 
abrupt  onset,  usually  with  vomiting,  the  marked  elevation  of  tempera- 
ture, the  erythematous  condition  of  the  throat,  the  punctate  eruption  on 
the  hard  palate,  with  the  appearance  of  the  rash  within  twenty-four 
hours,  and  later  the  characteristic  appearance  of  the  tongue.  The  diffi- 
culties of  diagnosis  usually  depend  upon  irregularities  in  the  eruption. 
The  variations  are  seen  in  the  mildest  and  in  the  most  severe  cases. 
In  the  former  the  rash  may  be  of  short  duration,  often  less  than  a  day, 
and  in  consequence  easily  overlooked;  or  it  may  be  present  only  upon 
certain  parts  of  the  body  instead  of  being  diffuse.  In  every  doubtful 
case  the  groins,  axillae,  and  loins  should  be  closely  scrutinized  for  a  punc- 
tate eruption.  In  very  severe  attacks  the  rash  may  appear  late  or  recede 
after  being  fully  out,  or  it  may  be  hemorrhagic  or  in  irregular  blotches. 
In  any  case,  too  much  stress  should  not  be  placed  upon  the  rash  alone. 

Until  we  have  some  exact  means  of  laboratory  diagnosis  as  in 
typhoid  fever,  malaria,  and  diphtheria,  an  absolute  diagnosis  will  in 


970  THE  SPECIFIC  INFECTIOUS  DISEASES 

certain  cases  be  impossible.  Sometimes  the  diagnosis  remains  doubtful 
until  the  end,  although  occasionally  confirmatory  evidence  may  be  ob- 
tained even  in  convalescence.  Thus,  a  patient  may  desquamate  in  a 
manner  so  typical  as  to  leave  no  doubt  as  to  the  nature  of  the  preceding 
illness;  again,  the  occurrence  of  a  characteristic  sequel,  such  as  nephritis 
in  the  third  or  fourth  week,  may  testify  strongly  for  scarlatina  as  the 
primary  disease;  and,  finally,  the  outbreak  of  undoubted  cases  among 
children  is^ho  have  been  in  contact  with  the  patient  is  practically  con- 
clusive, always  provided  other  sources  of  infection  can  be  excluded. 
Desquamation,  however,  follows  so  many  other  eruptions  that  when 
slight  or  irregular,  one  should  not  rely  upon  it  as  an  evidence  of  scarlet 
fever,  but  only  upon  a  typical  exfoliation  upon  the  hands  and  feet.  It 
is  a  point  of  some  practical  importance  not  to  oil  the  skin  of  a  patient 
when  awaiting  desquamation  for  diagnosis,  as  this  alters  very  much  the 
characteristic  appearances.  In  some  puzzling  epidemics  the  length  of 
the  incubation  may  be  of  material  assistance  in  the  diagnosis;  when 
this  is  regularly  more  than  a  week,  one  may  be  pretty  sure  that  he  is 
not  dealing  with  scarlet  fever. 

Scarlet  fever  with  severe  throat  symptoms  and  doubtful  eruption 
can  be  distinguished  from  diphtheria  only  by  cultures.  Measles  is 
distinguished  by  the  length  of  the  invasion,  the  catarrhal  symptoms, 
and  the  slowly  spreading  eruption,  but  most  of  all  by  Koplik's  spots. 
]\Iuch  more  difficult  is  it  to  distinguish  between  mild  scarlatina  and 
rubella.  In  rubella  the  important  thing  is  that,  although  the  rash  may 
be  well  marked,  often  covering  the  body,  the  constitutional  symptoms 
are  few  or  entirely  absent.  In  scarlet  fever  Avith  an  eruption  of  the 
same  intensity  there  is  almost  invariably  a  considerable  elevation  of 
temperature,  usually  102°  or  103°  F.,  and  a  bright-red  throat. 

There  are  so  many  skin  eruptions  which  may  resem]3le  that  of  scarlet 
fever,  that  it  is  always  hazardous  to  make  the  diagnosis  of  this  disease 
from  the  eruption  alone.  This  is  especially  true  of  sporadic  cases 
occurring  in  infants ;  there  is  seen  at  this^  age  a  great  variety  of  erup- 
tions, usually  associated  with  digestive  disturbances,  which  closely  simu- 
late a  scarlatinal  rash;  but  most  of  them  are  of  short  duration.  A 
scarlatiniform- erythema  is  occasionally  seen  after  diphtheria  antitoxin, 
also  in  influenza,  t}q3hoid  fever,  pneumonia,  and  varicella,  which  may 
cause  them  to  be  mistaken  for  scarlet  fever,  or  may  lead  to  the  con- 
clusion that  both  diseases  are  present.  The  same  is  the  case  with  the 
septic  erythema  occurring  in  surgical  patients.  Belladonna,  quinin, 
and  occasionally  antipyrin,  the  salicylates  and  aspirin  may  produce 
eruptions  more  or  less  closely  resembling  that  of  scarlet  fever.  This 
is  also  true  of  some  cases  of  urticaria  and  other  forms  of  skin  disease. 
Eruptions  resembling  scarlet  fever  may  also  arise  from  irritation  due 


SCARLET  FEVER  971 

to  clothing,  to  heat,  to  the  local  aiiplication  of  irritants  to  the  chest, 
such  as  camphorated  oil,  etc.  There  is  little  doubt  that  many  of  the 
cases  reported  as  relapsing  scarlatina  are  really  examples  of  recurring 
erythema,  particularly  as  some  of  the  latter  are  followed  by  a  desquama- 
tion which  is  vei'v  similar  to  that  after  scarlatina. 

Prognosis. — There  is  no  disease  in  which  it  is  more  difficult  to  fore- 
tell the  outcome  than  in  scarlet  fever.  Cases  apparently  of  the  mildest 
type  not  infrequently  develop  serious  symptoms  and  even  complications 
that  could  not  be  foreseen.  Symptoms  indicating  a  bad  prognosis  are, 
^■ery  high  temperature,  especially  one  which  continues  to  rise  for  the 
first  three  or  four  days,  and  severe  nervous  and  throat  symptoms.  The 
most  common  cause  of  death  is  the  disease  itself,  the  scarlatinal  toxemia. 
From  this  cause  more  than  half  the  deaths  occur.  Xext  are  the  com- 
plications, cardiac,  pulmonary,  renal,  otitic,  mastoid  and  cerebral,  given 
in  the  order  of  their  frequency.  The  mortality  of  scarlet  fever  varies 
much  in  different  epidemics.  In  some,  nearly  all  the  cases  are  of  a 
mild  type,  and  the  mortality  may  be  as  low  as  3  or  4  per  cent;  in 
others,  a  severe  or  malignant  type  prevails,  and  it  may  be  as  high  as 
40  per  cent.  The  disease  is,  as  a  rule,  more  fatal  in  the  youngest 
infants,  becoming  less  so  as  age  advances. 

The  following  are  the  mortality  records  from  various  European 
sources : 

Ashby,  Manchester  Hospital 681  cases;  mortality,  12.2  per  cent. 

Koren,  a  single  epidemic 426      "              "          14.0    "       " 

Bendz,  Copenhagen 22,036      "              "          12.2"       " 

Ollivier,  three  Paris  hospitals  for  five  years..  893      "              "          14.0    "       " 

Fleischmann,  five  epidemics 1,356      "              "          10.0    "       " 

The  general  mortality  of  the  disease  may  therefore  be  assumed  to  be 
from  12  to  14  per  cent;  it  is,  however,  much  higher  than  this  among 
young  children,  as  shown  by  the  following  figures : 

New  York  Infant  Asylum 116  cases  under  5  years;  mortality,  20  per  cent. 

Ashby,  Manchester  Hospital 259     "  "      5      "  "  23    "       " 

Bendz not  stated     "      5      "  "  13    "       " 

Heubner 136  cases      "      7      "  "  30    "       " 

Fleischmann not  stated     "      4     «  "•        43    "       " 

Under  five  years  of  age  the  average  mortality  from  scarlet  fever  is, 
therefore,  between  20  and  30  per  cent. 

Prophylaxis. — Even  the  mildest  cases  should  be  isolated  for  four 
weeks.  If  complicatioiis  exist,  such  as  otitis,  rhinitis,  pharyngitis,  em- 
pyema, or  suppurating  glands,  tlie  quarantine  should  be  continued  until 
these  conditions  are  cured.  Patients  should  not  be  allowed  to  mingle 
with  other  children  for  at  least  a  month  after  all  symptoms  have  sub- 


972  THE  SPECIFIC  INFECTIOUS  DISEASES 

sided,  and  should  be  forbidden  to  sleep  with  other  children  for  three 
months.  Children  in  the  family  who  have  not  been  exposed  to  the 
disease  should  be  immediately  sent  away;  and  those  who  have  been 
exposed,  separately  quarantined  for  at  least  a  week. 

After  recovery,  the  patient,  before  he  is  released  from  quarantine, 
should  have  one  thorough  bath,  the  entire  body,  including  the  hair  and 
scalp,  being  scrubbed  with  soap  and  water,  and  every  particle  of  cloth- 
ing changed. 

The  nurse  should  be  quarantined  with  the  patient,  and  should  not 
mingle  with  other  members  of  the  family  until  a  complete  change  of 
clothing  has  been  made  and  hands  and  face  thoroughly  washed.  The 
nurse  and  all  others  in  close  contact  with  a  severe  case  should  use  fre- 
quently an  antiseptic  gargle  and  a  nasal  spray.  The  care  of  the  room 
during  and  after  the  attack  has  been  considered  in  the  introductory 
pages  of  this  Section. 

Schools  are  hot-beds  for  the  spread  of  scarlet  fever.  The  greatest 
sources  of  danger  are  the  mild  or  walking  cases  in  which  the  disease  has 
not  been  recognized,  and  the  clothing  of  patients  who  have  had  a  severe 
form  of  the  disease.  As  a  rule,  a  child  should  be  kept  from  school  six 
weeks  from  the  beginning  of  the  attack,  and  the  certificate  of  a  physician 
should  be  required  before  readmission.  Other  children  in  the  house- 
hold should  not  be  allowed  to  attend  schools  of  any  kind  during  the 
period  of  active  symptoms;  they  should  be  kept  at  home  on  the  average 
for  a  month.  This  precaution  is  necessary,  first,  because  they  might 
carry  the  disease  from  the  patient  at  home;  secondly,  because  otherwise 
they  might  themselves  attend  school  while  suffering  from  the  disease 
in  a  very  mild  form  or  during  the  period  of  invasion.  When  the  sick 
child  is  completely  isolated,  the  danger  from  the  first  source  is  very 
slight.  During  severe  epidemics  it  frequently  becomes  necessary  to 
close  all  schools. 

In  general,  it  is  to  be  remembered  that  the  danger  is  first  from 
the  patient,  secondly  from  the  room,  and  thirdly  from  the  nurse.  Spe- 
cial attention  should  always  be  given  to  the  complete  and  immediate 
isolation  of  the  first  case  which  appears  in  an  institution  or  community, 
which  should  apply  to  mild  as  well  as  severe  forms  of  the  disease. 

Treatment. — There  is  as  yet  no  specific  for  scarlet  fever.  The  physi- 
cian's duty  in  the  average  case  consists  in  ( 1 )  establishing  proper  quar- 
antine and  the  carrying  out  of  adequate  means  of  disinfection;  (2) 
the  hygienic  care  of  the  patient;  (3)  directing  the  diet;  (4)  watching 
for  complications,  especially  otitis  and  nephritis.  It  should  be  borne 
in  mind  that  otitis  is  rarely  accompanied  by  pain  or  tenderness,  and  is 
recognized  only  by  an  examination  of  the  ears;  also  that  severe  and 
fatal  nephritis  may  follow  mild  as  well  as  severe  cases. 


SCARLET  FEVEE  973 

Mild  attacks  require  no  medicine.  Children  should  be  kept  in  bed  at 
least  a  week  after  the  fever  has  subsided,  and  upon  a  diet  chiefly  of  milk 
and  farinaceous  food  with  plenty  of  water  for  a  period  of  three  weeks- 
This  is  an  important  matter  in  the  prevention  of  nephritis.  During 
the  height  of  the  eruption,  the  intense  itching  of  the  skin  may  be  allayed 
by  sponging  with  a  bicarbonate  of  soda  solution,  or  by  inunctions  with 
vaseline,  or  by  the  free  use  of  rice  or  talcum  powder.  Plenty  of  fresh 
air  should  always  be  secured  in  the  sick-room.  As  soon  as  the  fever 
and  rash  have  disappeared,  daily  warm  baths  with  soap  and  water  should 
be  used,  after  which  the  entire  body  should  be  anointed  with  vaseline, 
with  the  purpose  of  facilitating  desquamation. 

The  temperature  does  not  usually  require  interference  when  it  only 
occasionally  rises  to  10-1°  or  104.5°  F.  Biit  if  there  is  hyperpyrexia,  or 
a  temperature  which  ranges  from  104°  to  105.5°  F.  or  over,  antipyretic 
measures  are  called  for.  Hydrotherapy  is  much  safer  and  more  certain 
than  drugs.  Sometimes  sponging  is  sufficient,  but  in  the  great  propor- 
tion of  cases  the  pack  or  bath  is  required.  The  use  of  water  in  the 
reduction  of  temperature  is  especially  indicated  in  septic  cases  with 
typhoid  symptoms,  and  in  those  with  pronounced  cerebral  symptoms. 
The  temperature  of  the  water  employed  will  depend  upon  the  duration 
of  its  application.  It  is  generally  better  to  use  prolonged  sponging  or 
bathing  with  tepid  water  than  water  at  a  lower  temperature  for  a 
shorter  period. 

The  nervous  symptoms  are  frequently  better  controlled  by  ice  to  the 
head  and  by  cold  sponging  than  by  medication.  Antipyretic  drugs  may 
occasionally  be  useful  to  control  restlessness  and  promote  sleep,  and  in 
mild  cases  to  effect  a  moderate  reduction  in  temperature.  Phenacetin  is 
usually  to  be  preferred. 

As  soon  as  the  pulse  becomes  weak  or  rapid  and  irregular,  or  the 
first  sound  of  the  heart  feeble,  stimulants  should  be  given,  no  matter  at 
what  stage  of  the  disease.  In  septic,  or  malignant  cases,  or  in  those 
accompanied  by  severe  angina,  adenitis,  or  cellulitis,  stimulants  should 
be  used  freely.  Digitalis  is  especially  valuable  when  the  pulse  is  weak 
and  the  tension  low.  It  may  be  given  alone  or  combined  with  caffein; 
one  minim  of  the  fluid  extract  of  digitalis,  and  gr.  ^  of  caffein  being 
the  initial  doses  for  a  child  of  five  years. 

The  erythematous  sore  throat  requires  no  treatment  except  the  use 
of  a  bland  gargle.  If  there  is  a  profuse  nasal  discharge,  gentle  nasal 
syringing  with  a  warm  saline  or  boric-acid  solution  may  be  used  with 
the  hope  of  preventing  infection  of  the  middle  ear.  The  local  treatment 
of  the  throat  is  the  same  as  that  of  other  cases  of  severe  angina. 

]\Iilder  forms  of  adenitis  require  no  local  treatment.  When  severe, 
the   glands   should   be    covered   with   ichthyol,   and   an   ice-bag  applied 


974  THE  SPECIFIC  INFECTIOUS  DISEASES 

continuously.  Poulticing  almost  invariably  does  harm.  If  an  abscess 
forms,  early  incision  should  be  made. 

The  ears  of  patients  with  severe  throat  symptoms  should  be  examined 
daily  in  order  that  there  may  be  no  delay  in  performing  paracentesis 
should  this  become  necessary.  Any  unusual  rise  in  temperature  should 
direct  attention  to  the  ears.  The  indications  for  the  operation  are  the 
same  as  in  other  severe  forms  of  otitis. 

The  physician  should  be  constantly  on  the  watch  for  the  develop- 
ment of  nephritis,  not  only  during  the  febrile  period,  but  also  during 
convalescence.  Eepeated  examinations  of  the  urine  are  absolutely 
necessary.  These  are  facilitated  by  having  a  rack  of  test  tubes  and 
the  ordinary  reagents  for  detecting  albumin  in  the  sick-room,  so  that 
the  physician  may  himself  examine  daily  a  fresh  specimen  of  urine. 
The  nurse  should  be  instructed  to  measure  and  record  accurately 
the  twenty-four  hours'  urine  throughout  the  attack.  The  treatment 
of  scarlatinal  nephritis  has  been  considered  in  the  chapter  devoted  to' 
Diseases  of  the  Kidney.  Diffuse  cellulitis  of  the  neck  calls  for  free, 
early  incision  as  the  only  means  of  preventing  extensive  sloughing. 

On  the  assumption  that  streptococci,  though  not  the  cause  of  the 
disease,  are  still  responsible  for  most  of  the  serious  complications  of 
scarlet  fever,  sera  prepared  by  means  of  several  different  strains  of  this 
organism  have  been  produced  and  extensively  used  but  without  any  uni- 
form or  striking  success.  One  has  been  produced  by  Moser  (Vienna), 
concerning  whose  effects  there  is  much  more  favorable  evidence.  Escher- 
ich,  Bokay,  and  other  reliable  Continental  observers  in  their  reports  have 
declared  that  its  effects  are  not  less  striking  than  those  obtained  from 
diphtheria  antitoxin.  It  must  be  given  in  very  large  doses,  from  100  to 
200  c.  c.  The  value  of  streptococcus  serum  has  not  yet  been  demon- 
strated in  this  country. 

Transfusion  and  the  intramuscular  injection  of  blood  or  of  blood 
serum  from  patients  convalescent  from  scarlet  fever  have  been  em- 
ployed by  Zingher  (New  York)  and  others  in  very  severe  forms  of 
scarlatinal  toxemia.  The  beneficial  results  which  have  followed  have  in 
some  instances  been  so  striking  that  they  can  hardly  be  considered  acci- 
dental. In  desperate  cases  this  should  be  tried  whenever  practicable. 
Considerable  amounts  of  blood  must  be  used,  from  100  to  300  c.  c, 
according  to  the  age  of  the  patient.  Some  benefit  also  under  similar 
conditions  seems  to  follow  the  injection  of  normal  blood  from  healthy 
persons. 

During  convalescence,  the  urine  should  be  frequently  examined. 
Antiseptic  gargles  and  a  nasal  spray  should  be  used  as  long  as  a  purulent 
discharge  from  the  nose  or  pharynx  continues. 


MEASLES  975 

"CHAPTER  II 

MEASLES 
(Rubeola,  Morbilli) 

Measles  is  an  epidemic  contagious  disease,  more  widely  prevalent 
than  any  other  eruptive  fever;  very  few  persons  reach  adult  life  with- 
out contracting  it.  One  attack  usually  confers  immunity.  It  is  highly 
contagious  even  from  the  heginning  of  the  invasion,  and  spreads  with 
great  rapidity  from  the  patient  to  all  susceptible  persons  exposed.  The 
infectious  agent,  however,  does  not  cling  to  clothing  or  apartments 
as  does  that  of  scarlet  fever.  Measles  has  a  usual  incubation  period  of 
from  eleven  to  fourteen  days;  a  gradual  invasion  of  three  or  four  days 
with  symptoms  of  an  acute  coryza,  and  a  maculopapular  eruption  which 
appears  first  upon  the  face  and  spreads  slowly  over  the  body,  and  which 
lasts  from  four  to  six  days.  This  is  followed  by  a  fine  bran-like  des- 
quamation, which  is  complete  in  about  a  week.  The  mortality  is  low, 
except  among  infants  and  delicate  children,  in  whom  it  may  reach  30 
or  even  40  per  cent.  In  institutions  for  infants  and  young  children 
no  epidemic  disease  is  more  to  be  dreaded  than  measles,  not  only  on 
account  of  its  severity,  but  from  the  frequency  with  which,  in  such  sub- 
jects, it  is  complicated  by  bronchopneumonia. 

Etiology. — Little  is  as  yet  known  of  the  essential  cause  of  measles. 
Anderson  and  Goldberger,  and  since  them  a  number  of  others,  have 
succeeded  in  inoculating  monkeys  with  the  blood  and  also  with  the  nasal 
and  buccal  secretions  from  patients  with  measles  and  have  produced  a 
disease  attended  by  fever,  eruption  and  respiratory  symptoms  which 
are  believed  to  be  identical  with  measles  in  the  human  subject.  They 
have  successfully  carried  the  strain  of  infection  by  blood  inoculations 
through  six  generations  of  monkeys.  The  virus  obtained  by  Anderson 
and  Goldberger  passes  through  the  Berkfeld  filter,  resists  drying  and 
freezing  for  twenty-four  hours,  but  is  destroyed  by  a  temperature  of 
.55°  C.  Blood  from  patients  with  measles  was  found  to  be  infective  at 
least  twenty-four  hours  before  the  eruption  and  for  twenty-four  hours 
after  its  appearance.  Later  than  this  its  infectivity  is  much  lessened 
and  soon  disappears.  The  secretions  from  the  mouth  and  nose  were 
infective  for  the  monkey  only  when  collected  during  the  stage  of  erup- 
tion. The  experiments  suggest  a  rapid  loss  of  infectivity  with  the 
beginning  of  convalescence.  Attempts  to  convey  the  disease  to  animals 
by  inoculating  with  scales  from  desquamating  patients  were  unsuc- 
cessful. 


976  THE   SPECIFIC    INFECTIOUS    DISEASES 

Clinical  observations  indicate  that  the  virus  of  measles  is  more  read- 
ily diffused  than  that  of  most  communicable  diseases ;  also  that  its  viabil- 
ity is  less  than  most  pathogenic  organisms.  Only  a  short  exposure  is 
required  to  communicate  the  disease. 

Predisposition. — Infants  under  six  months  do  not  r3adily  contract 
measles,  but  all  other  children  are  extremely  susceptible.  In  an  epidemic 
reported  by  Smith  and  Dabney,  110  unprotected  children,  between  thc,^ 
ages  of  eight  and  eighteen  years,  were  exposed  and  only  two  escaped. 
In  one  institution  epidemic  observed  by  us  there  were  62  children  over 
two  years  of  age;  five  were  protected  by  a  previous  attack  and  escaped; 
of  the  remaining  57  children,  55  took  the  disease.  There  w^ere  also  in 
the  institution  113  children  under  two  years  old;  of  this  number  78 
per  cent  took  the  disease;  but,  although  a  number  were  exposed,  not 
one  child  under  six  months  old  contracted  measles.  We  have,  however, 
seen  in  one  instance  a  typical  attack  of  measles  in  an  infant  of  seven 
months,  the  disease  having  been  contracted  in  this  case  from  the  mother. 
Tlie  age  of  the  persons  affected  depends  much  upon  the  lengih  of  time 
since  the  last  outbreak  of  the  disease.  In  an  epidemic  occurring  in  the 
Island  of  Guernsey,  where  the  disease  had  not  prevailed  for  many  years, 
all  ages  were  affected,  the  youngest  being  twelve  days  old,  and  the  oldest, 
a  man  and  wife,  each  aged  eighty  years.  Instances  have  been  reported 
by  Somer,  Gautier  and  others  in  which  the  eruption  of  measles  has  either 
been  present  at  birth  or  has  developed  witliin  a  few  hours  after  birth, 
when  the  mother  was  suffering  from  the  disease  at  the  time. 

Except,  then,  in  early  infancy,  the  probabilities  are  very  strong  that 
every  child  exposed  to  measles  will  contract  the  disease.  Occasionally, 
however,  one  is  seen  who  seems  insusceptible,  no  matter  how  close  the 
exposure. 

Epidemics  of  measles  are  more  frequent  and  more  severe  during  the 
winter  and  spring  months.  They  are  least  frequent  and  mildest  during 
the  summer  and  autumn  months. 

Incubation. — In  144  cases,^  in  which  the  period  of  incubation  could 
be  definitely  traced,  it  was  as  follows: 

Incubation  of  less  than  nine  days 3  cases. 

"  "  nine  or  ten  days 22      " 

"  "  eleven  to  fourteen  days 95      " 

"  "  fifteen  to  seventeen  days 19      " 

"  "  eighteen  to  twenty-two  days 5      " 

Thus  in  66  per  cent  of  the  cases  the  incubation  was  between  eleven  and 
fourteen  days,  and  in  only  one  case  was  it  less  than  a  week.     The  eon- 

^ About  twenty-five  of  these  are  taken  from  our  own  records;  the  remainder 
are  mainly  isolated  cases,  scattered  through  medical  literature.  The  incubation 
is  reckoned  from  the  time  of  exposure  to  the  beginning  of  catarrhal  symptoms. 


I  MEASLES  977 

stancy  of  the  incubation  period  is  strikingly  shown  in  some  epidemics. 
Tims  in  the  one  reported  by  Smith  and  Dabney  in  an  institution  in 
Virginia,  exactly  eleven  days  after  the  rash  appeared  in  the  first  case, 
the  disease  developed  in  twenty  cliildren — no  cases  having  occiirred  in 
ilie  interval. 

Duration,  of  the  Infective  Period. — This  is  much  shorter  than  in  scar- 
lot  fever,  and  the  average  duration  may  be  placed  at  two  and  a  half 
weeks.  The  minimum  period  of  isolation  should  be  ten  days  after 
the  appearance  of  the  eruption.  It  should  be  extended  if  there  persist 
discharges  from,  the  nose  and  throat  or  a  cough.  Haig-Brown  discharged 
fifty-eight  cases  on  or  before  the  twenty-ninth  day  of  the  disease,  and 
in  no  instance  was  measles  spread  by  these  children.  Eansom,  however, 
records  one  instance  in  which  it  was  communicated  thirty-one  days  after 
the  appearance  of  the  rash. 

Measles  is  highly  contagious  from  the  very  beginning  of  the  catarrhal 
symptoms.  A  case  occurred  under  our  observation  in  which  a  child 
conveyed  the  disease  four  days  before  the  rash  appeared;  and  many 
such  have  been  observed.  An  instance  is  known  to  us  where,  of  thirteen 
little  girls  at  a  children's  party,  only  one  (protected  by  a  previous 
attack)  escaped  measles;  the  source  of  infection  was  a  child  who  showed 
no  rash  until  the  following  day.  The  period  during  which  the  disease 
is  most  contagious  is  still  a  matter  of  dispute,  the  general  belief  being 
that  it  is  coincident  with  the  most  severe  catarrhal  symptoms  and  the 
beginning  of  the  eruption. 

.  With  the  fading  of  the  eruption  and  the  subsidence  of  the  catarrh,  the 
communicability  of  measles  diminishes  rapidly.  It  is  generally  pro- 
portionate to  the  severity  of  the  catarrhal  symptoms,  and  when  these 
are  protracted  it  is  probable  that  the  disease  may  be  communicated  for 
a  much  longer  period  than  in  the  usual  case. 

Mode  of  Infection. — Measles  is  usually  spread  by  direct  exposure 
to  an  affected  person.  The  infectious  agent  is  chiefly  disseminated  by 
the  minute  droplets  which  are  given  off  during  coughing  and  sneezing, 
jirobably  also  by  the  discharges  from  any  affected  mucous  membrane. 
Proximity  to  a  patient  seems  necessary  to  contagion,  but  not  actual  con- 
tact. Infection  from  the  scales  during  desquamation  probably  does  not 
occur.  It  is  very  infrequent  that  measles  is  conveyed  through  the 
medium  of  clothing,  furniture,  or  a  third  person.  Though  a  good  many 
instances  are  on  record  in  which  the  disease  has  been  carried  by  a  third 
person,  this,  after  all,  very  rarely  happens  and  we  think  never  unless  the 
contact  both  with  the  sick  and  the  well  child  is  very  close  and  the  interval 
short. 

Lesions. — The  only  constant  lesions  of  measles  are  those  of  the  skin 
and  the  mucous  membranes,  chiefly  of  the  respiratory  tract.     According 


978  THE  SPECIFIC  INFECTIOUS  DISEASES 

to  Xeumanu,  the  jarocess  in  the  skin  is  of  an  inflammatory  character, 
but  is  more  superficial  than  in  scarlet  fever.  There  is  congestion,  accom- 
panied by  an  exudation  of  round  cells  about  the  small  blood-vessels,  and 
also  about  the  sweat  and  sebaceous  glands,  and  the  papillae.  To  this 
exudation  and  the  edema,  the  swelling  of  the  skin  is  due.  It  occurs 
everywhere,  but  is  especially  noticeable  upon  the  face.  / 

The  changes  in  the  mucous  membranes  are  quite  as  much  a  par^of 
the  disease  as  are  those  of  the  skin.  There  is  a  catarrhal  inflammation 
affecting  the  conjunctivae,  nose,  pharynx,  larynx,  trachea,  and  large 
bronchi,  which  varies  in  intensity  with  the  severity  of  the  attack.  In  the 
most  severe  forms  in  infants  and  in  young  children,  this  inflammation 
extends  with  great  uniformity  to  the  small  bronchi,  and  usually  to  the 
air  vesicles,  causing  Ijronchopneumonia.  In  severe  cases,  the  lesion  in 
the  pharynx  and  larynx  also,  instead  of  being  catarrhal,  may  be  mem- 
branous ;  the  larynx  being  much  more  frequently  involved,  and  the  ears 
much  less  so,  than  in  scarlet  fever.  Freeman  has  described  areas  of  focal 
necrosis  in  the  liver  similar  to  those  found  in  diphtheria;  they  were 
present  in  four  of  twelve  cases  examined.  The  lesions  of  the  lungs  and 
of  other  organs  will  be  more  fully  considered  under  the  heading  of 
Complications. 

The  bacteria  which  are  associated  with  the  lesions  of  the  respiratory 
tract  are  the  staphylococcus  and  the  streptococcus,  separately  or  together, 
and  either  form  may  be  associated  with  the  pneumococcus  (see  Bac- 
teriology of  Bronchopneumonia).  Measles  produces  conditions  in  the 
mucous  membranes  of  the  respiratory  tract  which  are  especially  favor- 
able for  the  development  of  these  bacteria.  They  are  present  in  the 
mouth  in  great  numbers;  they  may  cause  pneumonia,  otitis,  and  other 
local  inflammations,  and  the  ^pneumococcus  or  streptococcus  may  produce 
a  general  septicemia. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  measles  is  gradual, 
both  the  fever  and  catarrhal  symptoms  increasing  steadily  up  to  the 
appearance  of  the  eruption.  The  characteristic  symptoms  of  the  inva- 
sion are  those  of  a  severe  coryza — suffusion  of  the  eyes,  increased  lachry- 
mation,  photophobia,  sneezing,  and  a  discharge  from  the  nose.  The 
hoarse,  hard  cough  indicates  that  the  catarrhal  process  has  involved 
the  larynx  and  trachea,  as  well  as  the  visible  mucous  membranes.  Fre- 
quently the  patient  complains  of  some  soreness  of  the  throat,  and  on 
inspection  tliere  is  seen  moderate  congestion  of  the  tonsils,  fauces,  and 
pharynx.  On  the  hard  palate  are  frequently  seen  small  red  spots. 
Much  more  characteristic  are  the  minute  white  spots  upon  the  mucous 
membrane  of  the  cheeks,  known  as  Koplik's  sign  (see  Diagnosis).  The 
constitutional  symptoms  are  indefinite,  and  may  be  met  with  in  almost 
any  disease.     These  are  dulness,  headache,  pains  in  the  back,  and  the 


MEASLES 


979 


usual  symptoms  of  malaise ;  there  is  rarely  vomiting  or  diarrhea.  Drow- 
siness is  a  frequent  symptom,  and  is  regarded  by  the  laity  as  charac- 
teristic. 

The  exceptional  cases  in  which  the  invasion  is  abrupt  are  puzzling. 
There  may  be  a  sudden  accession  of  fever  with  vomiting,  and  even  con- 
vulsions, as  in  a  case  lately  under  our  observation.  Not  infrequently, 
when  the  disease  prevails  epidemically,  the  invasion  is  sudden,  Avith  high 
fever  and  pulmonary  symptoms  which  are  so  severe  as  to  mask  every- 
thing else  until  the  rash  makes  its  appearance,  the  case  up  to  that  time 
being  often  regarded  as  one  of  primary  pneumonia  or  of  grippe.  The 
duration  of  the  stage  of  invasion — i.  e.,  from  the  beginning  of  the 
catarrh  until  the  eruption — in  270  cases  which  we  have  analyzed  was 
as  follows : 


1  day  or  less 35  cases. 

2  days 47      " 

3  " 64      " 

4  "    64      " 

5  "    29      " 


6  days 20  cases. 

7  "     .; 6      " 

8  «     2      " 

9  "     , 2      " 

10     "     1  case. 


From  this  table  it  will  be  seen  that  the  length  of  the  period  of 
invasion  varies  considerably — more,  we  think,  in  infants  and  very  young 
children  (most  of  these  were  under  three  years  old)  than  in  those  who 
are  older.  In  the  greater  number  of  cases  it  lasts  from  two  to  four 
days. 

Eruption. — The  rash  usually  appears  on  the  third,  fourth,  or  fifth 
day  of  the  disease — in  the  largest  number  upon  the  fourth  day.  As  a 
rule,  it  is  first  seen  on  the  back  or  behind  the  ears,  on  the  neck,  or  at  the 
roots  of  the  hair  over  the  forehead.  It  appears  as  small,  dark-red  spots, 
which  are  at  first  few,  scattered,  and  not  elevated,  resembling  flea-bites. 
In  twenty-four  honrs  the  macules  are  much  more  numerous,  and  many  of 
them  have  become  papules.  They  frequently  group  themselves  in  cres- 
centic  forms.  They  are  usually  separated  by  areas  of  normal  skin,  but 
where  the  rash  is  intense  they  are  frequently  coalescent.  From  the  time 
of  its  first  appearance  to  the  full  development  of  the  rash  on  the  face. 
is  usually  about  thirty-six  hours,  but  may  be  from  one  to  three  days. 
With  a  full  eruption  there  is  seen  considerable  swelling  of  the  face, 
especially  about  the  eyes,  and  the  features  are  sometimes  scarcely 
recognizable.  On  the  second  day  of  the  rash  it  begins  to  appear  upon 
the  neck  beneath  the  chin,  the  upper  part  of  the  chest  and  back ;  on  the 
third  day  the  trunk  is  covered,  and  scattered  spots  are  seen  upon  the 
extremities.  The  rash  appears  last  upon  the  lower  extremities,  and  by 
the  time  ;it  is  fully  out  upon  them  it  has  usnally  begnn  to  fade  from 
the  face.     In  mild  cases  it  remains   discrete,  bnt  in  severe  ones  it  is 


080  THE  SrECIFlC  IX-FECTIOUS  DISEASES 

frequent!}^  confluent  upon  the  face  and  upon  the  extensor  surfaces  of 
the  extremities.  As  a  rule^  it  covers  the  entire  hodj,  even  the  palms 
and  soles. 

The  eruption  fades  slowly  in  the  order  of  its  appearance,  and  there 
is  left  behind,  in  typical  cases,  a  slight  brownish  staining  of  the  skin 
which  often  remains  for  a  week  or  more.  The  duration  of  the  rash  is 
from  one  to  six  days,  the  average  being  four  days. 

There  are  many  cases  in  which  the  rash  does  not  follow  the  typical 
course  described:  (1)  Instead  of  spreading  gradually,  the  entire  body 
may  be  covered  in  a  few  hours.  (2)  The  rash  may  be  hemorrhagic. 
This  condition  was  present  in  about  five  per  cent  of  our  cases.  The 
whole  eruption  may  be  hemorrhagic,  or  it  may  be  so  only  upon  certain 
parts — usually  the  abdomen  or  extremities.  In  such  circumstances 
small  petechial  spots  take  the  "place  of  the  macules — ^the  '^'Tslack  measles" 
of  the  older  writers.  It  is  in  most  cases  a  bad,  but  by  no  means  a 
fatal  symptom.  AYe  have  seen  it  in  several  cases  that  were  not  especially 
severe.  (3)  The  rash  may  be  very  faint,  and  of  short  duration,  being 
scarcely  elevated  at  all.  (4)  It  may  consist  of  very  minute  papules, 
closely  resembling  the  rash  of  scarlet  fever.  It  is  to  be  remembered, 
however,  that  the  irregular  eruptions  of  scarlet  fever  much  more  fre- 
quently resemble  measles  than  vice  versa.  (5)  It  may  be  very  scanty, 
and  late  in  its  appearance;  particularly  in  cases  of  great  severity  and 
hyperpyrexia — the  so-called  malignant  cases.  (6)  Temporary  recession 
of  the  eruption  may  occur  at  any  time  during  the  height  of  the  disease, 
and  is  usually  due  to  heart  failure.  A  recurrence  of  the  eruption  after 
it  has  run  its  usual  course  is  something  which  we  have  never  seen ; 
although  such  cases  have  been  reported,  they  must  be  regarded  as  very 
exceptional. 

During  the  first  two  days  of  the  eruption,  the  local  and  constitutional 
symptoms  increase  in  severity,  both  usually  reaching  their  maximum  at 
the  time  of  the  full  development  of  the  rash  upon  the  face.  The  skin 
is  swollen,  and  the  seat  of  intense  itching  and  burning.  The  eyes  are 
very  red  and  sensitive  to  light,  and  there  is  swelling  of  the  conjunctivae 
with  an  abundant  production  of  mucus  or  muco-pus,  causing  the  lids  to 
adhere.  There  is  pain  on  swallowing,  also  swelling  of  the  glands  at  the 
angle  of  the  jaw  or  in  the  postcervical  region.  The  cough  is  frequent 
and  very  annoying.  There  is  complete  anorexia,  and  often  diarrhea. 
The  tongue  is  coated,  and  may  show  at  its  margin  enlarged  papillae, 
somewhat  resembling  the  "strawberry"  appearance  of  scarlet  fever. 
As  the  rash  fades  the  temperature  declines  rapidly,  often  reaching  the 
normal  in  two  or  three  days.  The  catarrhal  symptoms  now  subside,  and 
soon  the  patient  is  convalescent.  "Within  a  day  or  two  after  the  fever 
has  ceased,  the  rash  disappears. 


MEASLES 


981 


OAV 

1 

2 

3 

4 

5 

6 

1 

8 

1- 

ui 

I 
z 

I 

£ 

105° 
10i° 
103° 
102° 
101° 
100° 

99° 

98" 

M     E 

M     E 

M     E 

M     E 

M     E 

K     E 

M     E 

M     E 

X 

A 

j] 

J 

h 

/ 

J 

V 

s 

1 

^ 

X 

^ 

^ 

Fig.  158. — Temperature  Curve  in 
Uncomplicated  Measles,  Show- 
ing THE  Gradual  Rise  and  Criti- 
cal Fall.     Patient  ten  years  old; 

X 
X  =  first  eruption ;    ^   =  full  erup- 
tion on  the  face. 


Desquamation. — This  begins  almost  as  soon  as  the  rash  has  subsided, 
and  is  first  noticed  on  the  face  and  neck,  where  the  eruption  first  ap- 
peared. The  nature  of-  the  desquamation  is  invariably  fine,  brann}- 
scales,  never  in  large  patches,  as  in  scarlet  fever.  It  is  often  quite 
indistinct  and  may  be  overlooked.  Its  usual  duration  is  from  five  to 
ten  days.  It  may,  however,  be  pro- 
longed for  two  weeks.  The  amount  of 
desquamation  varies  considerably  in 
the  different  cases.  It  is  most  marked 
in  those  in  which  there  has  been  an  in- 
tense eruption.  There  is  frequently 
noticed  at  this  time  an  odor  about  the 
patient  which  is  quite  characteristic  of 
measles.  During  this  stage  the  cough 
often  persists  and  the  eyes  remain  weak 
and  very  sensitive  to  light,  but  in  other 
respects  the  patient  usually  feels  per- 
fectly well. 

1.  The  Mild  Cases. — The  mildest 
cases  are  distinguished  by  low  tempera- 
ture, which  at  the  height  of  the  erup- 
tion usually  reaches  103°  or  103°  F.,  but  rarely  lasts  more  than  four 
days.  The  eruption  is  often  scanty,  and  is  never  confluent.  The  swell- 
ing, itching,  and  other  cutaneous  symptoms  are  wanting,  as  is  also  the 
intense  red  color  of  the'  skin.  The  rash  is  frequently  obscure,  and,  with- 
out the  other  symptoms,  hardly  suf- 
ficient for  diagnosis.  The  catarrhal 
symptoms  are  more  uniform  than 
the  rash,  but  these  are  very  mild  as 
compared  with  the  usual  form.  The 
duration  of  the  rash  is  shorter,  des- 
quamation is  scarcely  perceptible, 
and  there  are  no  complications. 

2.  The  Cases  of  Moderate  Sever- 
ity.— The  course  of  measles  is  much 
more  regular  in  children  over  three 
years  old  than  in  infancy.  In  the 
former,  the  symptoms  of  invasion 
come  on  gradually,  and  the  tempera- 
ture rises  steadily  until  tlic  a]>pearance  of  the  eruption,  which  is  in  most 
cases  on  the  third  or  fourth  day  of  the  disease.  Figs.  158  and  159 
represent  the  typical  temperature  curve  in  average  uncomplicated  cases. 
Such  a  curve  was  seen  in  44  per  cent  of  173  cases  in  which  careful 


DAY 

1 

2 

3 

i 

5 

6 

1 

s 

9 

I 
Z 

I 
< 

10C° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 

M      E 

M      E 

M      E 

M     E 

M    E 

M    E 

M     f 

M     f 

M     E 

X 

X 

^ 

A 

f 

kI\ 

A 

V 

\n 

A 

1/ 

L 

/ 

J 

u 

\/\ 

^ 

y 

i/ 

V 

u 

Fig.  159. — Typical  Curve  in  Uncom- 
plicated Measles,  with  Gradual 
Rise  and  Gradual  Fall.  Patient 
three  years  old. 


982 


THE  SPECIFIC  INFECTIOUS  DISEASES 


observations  were  made.  Sometimes  the  decline  in  the  fever  is  very 
rapid,  almost  a  crisis,  as  in  Fig.  158,  but  more  often  it  falls  gradually, 
as  in  Fig.  159.  In  such  cases  the  duration  of  the  fever  is  from  five  to 
nine  days,  the  average  being  about  a  week.  The  other  symptoms  follow , 
very  closely  the  course  of  the  fever.  The  maximum  temperature  is 
nearly  always  coincident  with  the  full  rash  upon  the  face,  at 'this  time 

usually  being  in  uncompli- 
cated cases  from  103°  to 
104°  F.  in  older  children, 
and  101°  to  105°  F.  in  in- 
fants and  3'oung  children. 

A  not  very  uncommon 
temperature  curve  is  that  of 
Fig.  160,  where  the  onset  of 
the  disease  is  marked  by  a 
sudden  rise  to  103°  or  even 
104°  F.,  with  a  fall  nearly 
or  quite  to  normal  on  the 
second  day,  after  which  the 
fever  rises  gradually,  as  in 
the  first  group.     This  curve  was  seen  in  five  per  cent  of  our  cases. 

3.  The  Severe  Cases. — In  Fig.  161  is  shown  a  type  of  the  disease 
which  is  more  frequent  in  infants  than  in  older  children,  the  important 
features  being  the  late  eruption  and  the  continug,nce  of  the  high  fever 
for  several  days  after  the  rash  has  begun  to  fade.     Such  a  prolonged 


DAY 

1 

2 

3 

1 

5 

0 

7 

8 

9 

10 

11 

12 

M     E 

U      E 

M      E 

M      E 

M      E 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

H      E 

106 

105° 

X 

X 

X 

X 

t 

101" 

\ 

A 

I 
Z 

103 

/ 

\ 

'\ 

t 

/ 

\i 

\ 

X 

< 

102° 

\ 

/ 

/ 

Y 

\ 

^ 

/ 

l/ 

\ 

\ 

/ 

y 

\ 

\ 

\ 

/ 

\A 

V 

r 

98° 

V 

V 

\ 

/ 

Fig.  160. — A  Not  Infreqijent  Temperature 
Curve  in  Measles,  Showing  Abrupt  Inva- 
sion, BUT  Subsequent  Course  Typical.  Un- 
complicated case;    patient  nine  months  old. 


DAY 

1 

2 

3 

4 

5 

G 

7 

8 

9 

10 

11 

12 

13 

u 

15 

16 

17 

I 
z 

I 
< 

„ 

M      E 

M      E 

M      E 

M      E 

M     E 

M      E 

M      E 

M      E 

M      E 

M     E 

M      E 

M     E 

M     E 

M     E 

M     E 

M      E 

M     E 

105° 
104-° 
103" 
102° 
101° 
100° 
99° 
98° 

X 

'< 

i 

A 

A 

A 

\ 

X 

\ 

J 

\h 

} 

1/  ^ 

} 

A 

A 

A 

\\ 

/ 

\ 

V 

i 

\\ 

V 

/ 

V  \ 

\ 

A 

\ 

^ 

Y 

\ 

V 

i/' 

l/ 

y 

\ 

\ 

f\ 

/ 

%, 

y 

» 

V 

\/ 

V 

y^ 

,  r 

\r 

Fig.  161. — Measles    with    Proionged    Invasion.     Continuance    of   high    temperature 
after  full  eruption  due  to  severe  bronchitis  and  diarrhea;  child  two  years  old. 


course  and  so  high  a  temperature  are  almost  invariably  due  to  some 
complication,  usually  Ijroncliopnenmonia.  AA'lu'u  the  pneumonia  goes 
on  to  the  production  of  areas  of  consolidation,  the  fever  Tisually  con- 
tinues for  three  and  sometimes  for  four  weeks,  even  though  terminating 
in  recovery. 


MEASLES 


983 


DAY 

1 

2 

3 

1 

5 

u 

7 

8 

9 

10 

I 
Z 

I 
< 

106" 
105' 
lOJ' 
103" 
102' 
lOl' 

loo' 

U9 
US' 

M     E 

M      E 

M      E 

M      E 

M     E 

M      E 

M     E 

M      E 

M      £ 

X 

1 

y\ 

i 

A 

/ 

) 

r^ 

J 

V 

v 

V 

1 

/ 

v 

1 1 

V 

V 

V 

V 

/ 

w 

V 

w 

1 

Fig.  162. — Fatal  Attack  of  Measles, 
Complicated  by  Bronchopneumonia. 
Very  severe  symptoms  from  the  onset; 
patient  eighteen  months  old;  death  on 
tenth  day. 


Figs.  1G2  and  163  illustrate  two  types  of  the  disease  which  are  often 

seen  when  measles  is  complicated  by  pneumonia.     In  cases  like  that 

shown  in   Fig.   162   the  onset  is 

abrupt    A\itli    higli    temperature, 

prostration,        and        pulmonary 

symptoms    nut    unlike    those    of 

j)rinniry  pneumonia.     A  tempera- 
ture   curve    resembling   this    was 

soon  in  2S  of  173  cases.    The  rash 

is  often  late  in  appearance;  it  is 

faint  and  altogether  irregular;  it 

may  recede  after  the  first  day  and 

reappear  after  an  interval  of  one 

or     two     days.       The     catarrhal 

symptoms   are    not   marked,    but 

the    whole    force    of    the    disease 

seems   to  be  expended  upon  the 

lungs.     The  diagnosis  of  these  cases  presents  great  difficulties,  and  very 

often  it  would  not  be  made  Imt  for  the  fact  that  there  are  other  cases  of 

measles  in  the  family  or  the  institution.     This  form  is  usually  seen  in 

infants,  and  it  is  usually  fatal. 

In  other  cases  marked  ])y  a  sudden  severe 
onset,  the  system  seems  to  be  overpowered  by 
the  poison  of  the  disease  itself.  There  is  pro- 
foniid  depression,  and  hyperpyrexia,  and  the 
]»atieiit  may  die  from  toxemia  with  cerebral 
symptoms  before  the  appearance  of  the  rash  or 
just  as  it  is  beginning  to  show  itself.  Some- 
times the  pulmonary  symptoms  are  entirely 
wanting;  at  others  the  rash,  if  it  appears,  is 
hemorrhagic. 

In  still  another  group  of  cases  the  onset  is 
not  violent,  and  for  the  first  two  days  the  attack 
may  appear  to  be  of  only  average  severity;  but 
there  may  then  develop,  often  quite  suddenly, 
pulmonary  symptoms  of  such  intensity  as  to 
cause    death    within   twenty-four    hours.      The 

on  fourth  day;   rash  on     eruption,  if  Seen  at  all,  is  faint  and  not  char- 
last    day;     patient   eight  '^ 
months  old.                         acteristic   (Fig.  163). 

A  secondary  rise  in  the  temperature  after  it 

has  once  fallen  to  normal  was  seen  in  8  of  173  cases,  being  due  to  the 

development  of  otitis,  ileocolitis,  or  pneumonia.       , 

Complications  and  Sequelae. — The  most  frequent  and  most  important 


DAT                     1 

1 

2 

3 

4 

5 

M      E 

M     £ 

M     E 

M     E 

M     E 

t 

X 

107 

\f\ 

f 

\J 

i 

t 

'' 

If 

I 

I 
Z 

101 

1 

/ 

I 

I 
< 

103 

/ 

A 

/ 

102 



-/- 

* 

lOl' 

loo' 

/■ 

J- 

/ 

99' 
98 

/ 

Fig.  163. — Fatal  Attack 
OF  Measles  Complica- 
ted BY  Bronchopneu- 
monia. Early  invasion 
mild,  but  rapid  develop- 
ment of  severe  symptoms 


9S4  THE  SPECIFIC  IXFECTIOU.S  DISEASES 

complication  of  measles  is  bronchopneumonia,  and  next  to  this  are  ileo- 
colitis, otitis,  and  membranous  laryngitis.  Most  of  the  others  are  in- 
frequent; all  complications  are,  relatively  infrequent  in  children  over  four 
years  old. 

Lungs.— The  greatest  danger  in  measles  arises  front  ^pulmonary 
complications,  and  the  frequency  is  greatest  in  children  under  two 
years  of  age.  In  two  institution  epidemics,  embracing  about  300  cases, 
Jiearly  all  in  children  under  three  years  old,  bronchopneumonia  occurred 
in  about  40  per  cent  of  the  cases.  Of  those  who  had  pneumonia,  70 
per  cent  died.  Fortunately,  such  a  record  as  this  is  never  seen  outside 
of  institutions  for  young  children.  Of  2,477  cases,  embracing  several 
epidemics  of  measles  among  children  of  all  ages,  pneumonia  occurred 
in  10  per  cent.  Our  own  experience  in  the  post-mortem  room  fully 
bears  out  the  statement  of  Henoch,  that  a  certain  amount  of  pneumonia 
is  found  in  almost  every  fatal  case.  Pneumonia  is  more  frequent  and 
its  mortality  is  higher  in  spring  and  winter  epidemics  than  in  those 
occurring  at  other  seasons.  It  may  develop  at  any  time  from  the  begin- 
ning of  invasion  until  convalescence,  but  it  most  frequently  begins  about 
the  time  of  full  eruption. 

Lobar  pneumonia,  although  rare,  occasionally  occurs  as  a  complica- 
tion in  children  over  three  years  old.  In  some  epidemics  many  of  the 
cases  of  pneumonia  are  complicated  by  severe  pleurisy,  which  adds  much 
to  the  danger  from  the  disease.  This  form  is  frequently  followed  by 
empyema.  Pneumonia  is  always  to  be  suspected  when  the  temperature 
continues  high  after  the  full  appearance  of  the  rash. 

Bronchitis  of  the  large  tubes,  always  accompanied  by  tracheitis,  is 
seen  in  every  case  of  measles,  possibly  excepting  a  few  of  the  very 
mildest.  This  is  so  constant  a  feature  as  hardly  to  be  ranked  as  a 
complication.  In  nearly  all  of  the  severe  cases  the  bronchitis  extends 
to  the  medium-sized  and  smaller  tubes. 

Larynx. — A  mild  catarrhal  laryngitis  accompanies  almost  every  case 
of  measles.  Severe  catarrhal  laryngitis  is.  present  in  about  ten  per  cent 
of  the  cases;  it  may  give  symptoms  which  closely  resemble  those  of 
membranous  laryngitis,  and  the  two  are  no  doubt  often  confused. 

Membranous  laryngitis  is  especially  seen  in  the  epidemics  of  insti- 
tutions. As  a  cause  of  death  in  older  children  it  ranks  next  to  pneu- 
monia. When  it  develops  at  the  height  of  the  disease,  it  is  sometimes 
due  to  the  streptococcus;  but  when  it  develops  at  a  later  period,  it  is 
usually  due  to  the  diphtheria  bacillus.  The  streptococcus  inflamma- 
tion is  in  most  cases  associated  with  similar  changes  in  the  pharynx  or 
tonsils,  but  not  always.  True  diphtheria,  occurring  as  a  complication 
of  measles,  not  infrequently  begins  in  the  larynx.  The  streptococcus 
inflammation  may  be  as  serious  in  this  connection  as  is  true  diphtheria. 


MEASLES       ,  (^§^ 

from  the  probability,  which  amounts  almost  to  a  certainty,  of  the  de- 
velopment of  bronchopneumonia.  No  complication  is  more  to  be 
dreaded  than  this.  The  diagnosis  between  the  two  forms  may  some- 
times be  made  by  the  time  of  development,  but  only  with  certainty  by 
cultures.  We  once  saw  in  measles,  where  no  false  membrane  was  present 
in  the  rest  of  the  larynx,  a  necrotic  inflammation  Avith  almost  entire 
destruction  of  the  vocal  cords — a  condition  which  may  be  compared  to 
that  seen  in  the  tonsils  or  epiglottis  in  scarlatina. 

Throat. — A  catarrhal  angina  is  part  of  the  disease,  and  is  as  charac- 
teristic of  measles  as  is  the  eruption  upon  the  skin.  There  is  acute  con- 
gestion and  swelling  of  the  tonsils,  uvula,  palate,  and  pharynx.  In  a 
certain  proportion  of  cases,  very  much  less  frequently  than  in  scarlatina, 
the  development  of  membranous  patches  is  seen  upon  the  tonsils  and 
adjacent  mucous  membranes.  These  occur  in  two  or  three  per  cent  of 
the  cases.  They  are  to  be  regarded  in  the  same  light  as  similar  condi- 
tions complicating  scarlet  fever,  with  this  difference,  that  in  measles 
there  is  much  greater  likelihood  of  the  extension  of  the  disease  to  the 
larynx,  while  extension  to  the  nose  and  ears  is  much  less  probable. 
True  diphtheria,  however,  may  complicate  measles,  and  cases  of  mem- 
branous inflammation  of  the  tonsils  or  pharynx  developing  late  in 
measles  are  usually  due  to  the  Klebs-Loeffler  bacillus. 

Although  in  most  cases  the  inflammations  of  the  pharynx  and  ton- 
sils which  accompany  measles  are  not  serious  when  they  are  due  to  the 
streptococcus,  they  are  sometimes  quite  as  severe  as  any  that  accompany 
scarlet  fever.  They  may  cause  death  from  general  sepsis  apart  from 
any  affection  of  the  larynx. 

Digestive  System. — Gastric  disorders  are  not  more  common  than  in 
other  febrile  diseases;  but  diarrhea  is  very  frequent,  and  in  summer  it 
may  be  even  more  serious  than  the  pulmonary  complications.  All  forms 
of  diarrhea  are  seen,  from  that  which  results  from  simple  indigestion 
to  the  severe  types  of  ileocolitis.  This  complication  is  most  often  seen 
in  children  under  two  years  old.  The  most  severe  intestinal  symptoms 
are  not  usually  seen  at  the  height  of  the  primary  fever;  but,  beginning 
at  this  time,  they  often  increase  in  severity,  and  are  most  marked 
in  the  second  and  third  weeks  of  the  disease. 

Catarrhal  stomatitis  is  present  in  almost  every  case  of  measles;  less 
frequently  the  herpetic  form  is  seen.  Ulcerative  stomatitis  is  not  un- 
common, particularly  in  institutions.  One  of  the  worst  complications 
of  measles,  but  fortunately  a  rare  one,  is  gangrenous  stomatitis,  or 
noma.  This  usually  occurs  in  inmates  of  institutions,  or  in  children 
with  bad  surroundings  who  were  previously  in  wretched  condition.  It 
is  nearly  always  fatal. 

Gangrenous   inflammations   of   other  parts  of  the  body  are   some- 


986  THE  SPECIFIC  INFECTIOUS  DISEASES 

times  seen  after  measles,  especially  of  the  ear,  the  vulva,  or  the  prepuce. 

Nervous  System. — Convulsions  are  seldom  seen  at  the  onset  of 
measles.  During  the  progress  of  the  disease  they  are  not  so  rare,  and 
may  occur  in  connection  with  otitis,  meningitis,  or  severe  broncho- 
pneumonia— chiefly  in  infants. 

Meningitis  is  rare,  but  either  the  simple  or  the  tuberculous  form 
may  occur,  more  often,  however,  as  a  sequel  than  as  a  complication. 
Mental  disturbance,  usually  of  a  temporary  character,  occasionally  fol- 
lows measles.  In  the  epidemic  of  108  cases  reported  by  Smith  and  Dab- 
ney,  insanity  was  noted  three  times,  all  the  cases  terminating  in  recovery. 
Epilepsy  and  chorea  are  rare  sequelae. 

Ears. — Otitis  is  a  frequent  complication  in  some  cjiidemics;  in 
others  it  is  seldom  seen.  In  one  hospital  epideuiic  it  was  noted  in  14 
per  cent  of  the  cases.  This  epidemic  occurred  in  early  spring  and 
affected  very  young  children,  both  of  which  circumstances  are  favor- 
able for  the  development  of  otitis.  Usually  Ijoth  ears  are  affected,  but 
the  otitis  of  measles  is,  as  a  rule,  less  serious  than  that  of  scarlet  fever. 

Eyes. — Simple  catarrhal  conjunctivitis  accompanies  nearly  every 
case  of  measles.  In  the  severe  form  there  is  a  mucopurulent  catarrh, 
which  may  attain  any  degree  of  severity.  In  neglected  cases,  and  among 
children  who  are  poorly  nourished,  especially  in  asylums,  the  disease  is 
apt  to  extend  to  the  cornea.  Chronic  conjunctivitis  often  persists  after 
measles,  particularly  in  the  class  of  children  just  mentioned. 

Lymph  Nodes. — Swelling  of  the  lymphatic  glands  of  the  neck  is 
frequent,  but  not  generally  severe,  and  rarely  terminates  in  suppuration. 
CUironic  enlargement  may  continue  for  months,  and  sometimes  the 
glands  may  become  tuberculous.  Similar  changes  and  similar  conse- 
quences may  occur  in  the  glands  of  the  tracheobronchial  group. 

Kidneys. — The  infrequency  of  renal  complications  in  measles  is  iu 
striking  contrast  to  scarlet  fever.  Transient  febrile  albuminuria  is  not 
uncommon,  but  a  serious  degree  of  nephritis,  either  clinically  or  at 
autopsy,  we  have  never  seen,  and  literature  furnishes  but  few  cases. 

Heart. — Both  endocarditis  and  pericarditis  have  occurred  in  the 
course  of  measles,,  but  they  belong  to  the  rare  complications.  The  same 
may  be  said  of  changes  in  the  muscular  walls  of  the  heart. 

SJcin. — As  complications,  erysipelas,  furunculosis,  impetigo,  and 
pemphigus  have  been  noted  ;  but  all  are  rare. 

Hemorrhages.— A^soc-iated  Avith  the  hemorrhagic  typo  of  tlie  erup- 
tion, severe  and  even  fatal  hemorrhages  may  occur  from  the  nuicous 
membranes,  and  the  latter  are  sometimes  seen  without  the  hemorrhagic 
eruption. 

Blood. — In  cases  which  have  been  studied  early  in  the  stage  of  incuba- 
tion a  lymphocytic  loucocytosis  has  been  observed.    This  is  succeeded  by  a 


MKASLKS  -V  !)S7 

leiicopenia  in  which,  there  is  a  reduction  in  the  lymphocytes  both  actual 
and  relative.  This  condition  is  marked  one  or  two  days  before  the  erup- 
tion— sometimes  even  earlier — and  continues  during  the  height  of  the 
disease.  A  decided  leucoeytosis  during  this  time  or  later  points  to  a 
complication. 

Other  Infectious  Diseases. — Measles  in  instituLions  is  often  compli- 
cated by  diphtheria.  Scarlet  fever  or  varicella  occasionally  occurs  dur- 
ing measles^  though  it  is  rare  that  the  two  eruptions  are  exactly  simul- 
taneous. Epidemics  of  measles  and  whooping-cough  frequently  occur 
together  or  follow  each  other.  The  relation  of  measles  to  tuberculosis 
seems  to  be  particularly  close.  In  some  cases  general  or  pulmonary 
tuberculosis  follows  directly  in  the  wake  of  measles,  which  seems  to 
furnish,  especially  in  the  lungs,  conditions  which  are  favorable  for  the 
development  of  latent  tuberculosis.  As  a  late  manifestation  the  most 
common  one  is  tuberculosis  of  the  bones,  occurring  as  hip-joint  disease, 
caries  of  the  spine,  etc.  An  attack  of  measles  in  a  child  with  latent  tuber- 
culous antecedents  should,  therefore,  always  be  looked  upon  with  appre- 
hension. 

Diagnosis. — A  sign  of  the  greatest  diagnostic  value  is  the  buccal 
eruption.  Although  it  appears  that,  this  was  described  many  years  ago 
by  Flindt,  of  Denmark,  it  is  to  Koplik  that  the  credit  belongs  for  its 
independent  discovery  and  for  the  appreciation  of  its  diagnostic  signifi- 
cance. The  unit  of  the  eruption  is  a  bluish-white  speck  upon  a  red 
ground;  only  a  few  of  these  are  present  for  the  first  twenty-four  or 
thirty-six  hours;  after  this  the  mucous  membrane  may  be  fairly  pep- 
pered with  them.  Often  they  are  not  seen  except  by  careful  search,  for 
which  s-trong  sunlight  is  necessary;  artificial  light  is  not  satisfactory. 
The  spots  are  best  seen  on  the  inside  of  tlie  cheeks  opposite  the  molar 
teeth,  and  in  most  cases  only  there;  but  they  may  l)e  present  on  almost 
any  part  of  the  buccal  mucous  membrane.  Their  diagnostic  value  is 
due  to  the  fact  tliat  tliey  are  nearly  always  j^resent,  that  they  are  not 
found  in  other  diseases,  and  that  they  usually  appear  two  or  three  days 
Ijefore  the  skin  eruption.  This  generally  disappears  at  the  time  of  full 
eruption. 

We  have  records  of  an  epidemic  of  187  cases  in  an  institution  in 
which  careful  notes  were  made  regarding  this  buccal  eruption:  it  was 
unmistakably  present  in  169  cases,  absent  in  8,  doubtful  in  10.  Li  78 
cases,  fever,  rash,  and  Koplik's  sign  were  all  present  at  the  first  obser- 
vation. In  54  patients  the  sign  was  noted  one  day  before  the  rash;  in 
2."),  two  days  before;  in  4,  three  days  before;  in  3, 'four  days  before; 
and  in  2,  five  days  before.  Tn  2  the  spots  were  not  seen  until  after  the 
skin  eruption ;  in  one  case  they  were  present  without  any  eruption.  As 
this  patient  had  been  exposed  and  had  a  prolonged  fever,  it  seems  fair 


988  THE  SPECIFIC  INFECTIOUS  DISEASES 

to  regard-  the  case  as  one  of  measles.  In  only  one  case  was  the  buccal 
eruption  seen  before  any  elevation  of  temperature. 

These  facts,  amply  confirmed  by  other  observations,  indicate  that 
Koplik's  sign  is  of  value  in  enabling  us  to  make  a  diagnosis  from  one 
to  three  days  before  it  is  possible  by  the  skin  eruption,  also  in  furnish- 
ing a  means  of  distinguishing  measles  from  the  other  eruptive  fevers, 
as  well  as  from  rashes  due  to  drugs,  antitoxin,  etc. 

Other  important  symptoms  are  the  coryza,  the  gradual  rise  in  tem- 
perature, and  the  eruption  which  appears  first  upon  the  neck  and  face, 
and  slowly  extends  over  the  body.  Cases  which  present  the  greatest  diffi- 
culties in  diagnosis  are  usually  the  very  severe  ones  and  those  in  infants. 

Prognosis. — This  depends  upon  the  age  and  previous  condition  of 
the  patient,  the  character  of  the  epidemic,  and  the  season  of  the  year. 
Except  in  children  under  three  years  of  age,  the  deaths  from  measles 
are  few;  but  in  institutions  containing  young  children.,  no  epidemic 
disease  is  so  fatal. 

The  general  mortality  of  the  disease  is  from  4  to  6  per  cent;  but  in 
epidemics  in  institutions  for  young  children  it  has,  in  our  experience, 
ranged  from  15  to  35  per  cent.  The  following  table  gives  the  figures  of 
an  epidemic  in  one  institution : 

From  six  to  twelve  months 42  cases;  mortality,  33  per  cent. 

"      one  to  two  years .  51     "  "  50     "      " 

"      two  to  three  years 27     "  "  30     "      " 

"      three  to  fom-  years 20     "  "  14     "      " 

"      four  to  five  years 3     "  "  0     "      " 

In  any  single  case  the  important  symptoms  for  prognosis  are  the 
temperature  and  the  character  of  the  eruption.  An  initial  temperature 
above  103°  F.,  or  one  which  remains  high  until  the  eruption  appears,  is 
a  bad  symptom.  So  also  is  one  which  rises  after  a  full  eruption,  or 
which  does  not  fall  as  the  rash  fades.  The  following  table  shows  the 
highest  temperature  and  mortality  in  161  hospital  cases: 

Highest  temperature  not  over  102°  F.  6  cases;  mortaUty,    0  per  cent. 

"  "  102°  to  103.5°  F.  14     "  «  7     "      " 

«  «  104°  "  104.5°  F.  49     "  "  16     "      " 

"  "  105°  "  105.5°  F.  65     "  "  40     "      " 

"  "  106°  F.  or  over..  27     "  "  80     "      " 

A  favorable  eruption  is  one  of  a  bright  color,  covering  the  body, 
remaining  discrete,  and  spreading  gradually.  It  is  unfavorable  for  the 
eruption  to  appear  late,  to  be  very  faint,  scanty,  or  hemorrhagic,  or  to 
recede  suddenly,  as  this  is  usually  due  to  a  weak  heart. 

Of  51  fatal  cases,  the  cause  of  death  was  bronchopneumonia  in  45, 
ileocolitis  in  4,  and  membranous  laryngitis  in  2.     More  than  lialf  the 


MEASLES  989 

deaths  occurred  during  the  second  week,  the  earliest  being  upon  the 
fifth  day  of  the  disease. 

The  ultimate  result  of  an  attack  of  measles  may  not  be  evident  for 
some  time.  Cases  in  which  the  temperature  persists  for  two  or  three 
weeks  without  assignable  cause  after  the  disease  is  apparently  over, 
should  be  watched  with  the  greatest  solicitude.  The  explanation  of  this 
is  most  frequently  to  be  found  in  the  lungs,  although  the  physical  signs 
are  often  obscure.  The  condition  may  be  either  pneumonia  or  pulmonary 
tuberculosis.  Even  though  the  attack  of  measles  may  not  have  been  in 
itself  severe,  seeds  are  often  sown  the  full  fruits  of  which  are  not  seen 
until  long  afterward.  Chronic  glandular  enlargements  which  may  or 
may  not  be  tuberculous,  chronic  bronchitis,  chronic  laryngitis,  subacute 
or  chronic  nasal  catarrh,  hypertrophy  of  the  tonsils,  and  adenoid  growths 
of  the  pharynx — all  are  frequent  sequelae. 

Prophylaxis. — Measles  is  often  regarded  by  the  laity  as  so  mild  a 
disease  that  its  prevention  is  thought  to  be  of  little  importance,  and  no 
effort  is  made  to  limit  its  extension.  The  great  probability  that  every 
person  at  some  time  in  his  life  will  have  the  disease,  is  no  justification 
of  unnecessary  exposure.  Although  in  older  children  measles  is  usually 
mild,  this  is  not  so  in  infants,  who  should  be  carefully  protected  from 
exposure.  Special  care  should  also  be  taken  to  avoid  the  exposure  of 
delicate  children  or  those  with  a  strong  tendency  to  pulmonary  disease 
or  to  tuberculosis.  In  institutions  it  is  of  the  utmost  importance  to 
secure  prompt  and  complete  isolation  of  the  first  case  which  appears. 

The  disease  being  nearly  always  spread  by  the  patient,  it  follows 
that  while  early  isolation  is  more  important,  there  is  not  required  the 
same  thorough  disinfection  of  apartments  which  should  follow  every 
case  of  scarlet  fever.  In  an  institution,  the  ward  or  cottage  from  which 
a  case  has  been  removed  should  be  quarantined  for  at  least  sixteen  days 
after  the  appearance  of  the  last  case,  and  absolute  security  can  not  be 
said  to  exist  until  the  end  of  three  weeks.  The  same  rule  should  be 
applied  in  private  families  where  children  who  have  been  exposed  should 
be  quarantined  apart  from  the  patient,  but  not  sent  away.  In  ordi- 
nary circumstances  the  quarantine  of  a  case  of  measles  should  be  placed 
at  two  and  a  half  weeks,  or  ten  days  from  the  beginning  of  the  eruption. 
It  should  be  continued  longer  if  there  is  otitis,  or  a  nasal  discharge. 

Thorough  cleansing  and  disinfection  of  the  sick-room  should  be  done 
before  it  is  again  occupied  by  children,  and  it  should  remain  vacant 
at  least  two  weeks.  Children  should  be  kept  from  all  schools  while 
the  disease  is  in  their  homes,  chiefly  because  they  are  otherwise  liable 
to  spread  the  disease  while  suffering  from  the  early  symptoms  of 
invasion. 

Treatment. — Measles  is  a  self-limited  disease,  and  there  are  no  known 
33 


990  THE  SPECIFIC  INFECTIOUS  DISEASES 

measures  by  which  it  can  be  aborted,  its  course  shortened,  or  its  severity 
lessened.  The  indications  are  therefore  to  treat  serious  symptoms  as 
they  arise,  and,  as  far  as  possible,  to  prevent  complications,  which  are 
the  principal  cause  of  death. 

While  the  bed  should  be  screened  to  protect  the  sensitive  eyes  of  the 
patient  it  is  not  desirable  to  exclude  sunlight  from  the  sick-room.  Every 
child  with  measles  should  be  put  to  bed  and  kept  there  witE,4ight  cover- 
ing during  the  entire  febrile  period.  There  can  be  no  possible  advantage 
in  causing  a  child  to  swelter  by  thick  covering,  under  the  delusion  that 
the  disease  may  be  modified  thereby.  The  food  should  be  light,  fluid, 
and  given  at  regular  intervals.  If  the  conjunctivitis  is  severe,  iced 
cloths  should  be  applied  to  the  eyes,  which  should  be  kept  clean  by 
the  frequent  use  of  a  solution  of  boric  acid,  the  lids  being  prevented 
from  adhering  by  the  application  of  vaseline  or  some  simple  ointment. 
The  intense  itching  and  burning  of  the  skin  may  be  relieved  by  inunc- 
tions of  plain  or  carbolized  vaseline,  or  by  bathing  with  a  solution  of 
bicarbonate  of  soda.  The  cough,  when  distressing,  may  be  allayed  by 
small  doses  of  opium,  either  in  the  form  of  codein  or  the  brown  mix- 
ture. The  restlessness,  headache,  and  the  general  discomfort  which 
accompany  the  height  of  the  fever  may  be  relieved  by  an  occasional  dose 
of  phenacetin.  As  soon  as  the  rash  has  subsided,  a  daily  warm  bath 
should  be  given,  followed  by  inunctions  to  facilitate  desquamation. 

The  important  indications  to  be  met  in  the  severe  cases  are  very 
high  temperature,  cardiac  depression,  and  nervous  symptoms — dulness, 
stupor,  sometimes  coma,  or  convulsions.  In  some  of  tlie  cases  there  is 
in  addition  dyspnea  and  cyanosis,  sliowing  severe  acute  pulmonary  con- 
gestion. For  the  nervous  symptoms  and  liigh  temperature,  nothing  is  so 
reliable  as  the  cold  bath  or  pack  and  the  nearly  continuous  use  of  ice 
to  the  head.  AVe  do  not  think  there  is  any  evidence  that  the  use  of  cold 
increases  the  liability  to  pneumonia;  but  cold  extremities,  feeble  pulse, 
and  cyanosis,  when  associated  Math  high  temperature,  call  for  the  hot 
mustard  bath,  although  ice  should  still  be  applied  to  the  head.  The  indi- 
cations for  stimulants  and  the  methods  of  using  them  are  the  same  as  in 
bronchopneumonia,  which  is  usually  present  in  cases  requiring  them. 

To  diminish  the  chances  of  pneumonia,  it  is  necessary  that  every 
patient  should  be  kept  in  bed  during  the  attack,  and  care  exercised  to 
avoid  exposure.  But  still  more  important  is  it  in  hospitals  and  institu- 
tions where  most  of  the  cases  of  pneumonia  occur,  to  allow  the  patients 
plenty  of  air  space,  never  crowding  them  together  in  small  wards.  If 
possible,  cases  complicated  by  pneumonia  should  be  separated  from  sim- 
ple cases.  The  pneumococcus  and  the  streptococcus  are  found  in  the 
mouth  in  such  numbers  that  systematic  disinfection  of  the  mouth  may 
prove  of  some  value. 


RUBELLA  991 

The  danger  of  diphtheria  as  a  complication  may  be  greatly  lessened 
if  during  epidemics  of  measles  in  institutions  every  case  receives  an 
immunizing  dose  of  diphtheria  antitoxin. 

The  bronchitis  and  bronchopneumonia  of  measles  should  be  man- 
aged as  when  they  occur  as  primary  diseases,  since  the  coexistence  of 
measles  furnishes  no  new  indications.  The  same  is  true  of  the  diarrhea, 
conjunctivitis,  otitis,  membranous  laryngitis,  pharyngitis,  anci  tonsillitis. 
Should  cultures  show  the  presence  of  the  diphtheria  bacillus,  the  case 
should  be  treated  like  one  of  diphtheria. 

During  convalescence  the  eyes  should  be  used  very  carefully  for  at 
least  several  Aveeks.  Should  the  cough  and  slight  fever  persist,  with  or 
without  physical  signs  in  the  chest,  the  patient  should,  if  possible,  be 
sent  away  to  a  warm,  dry,  elevated  district,  as  the  development  of 
tuberculosis  is  always  to  be  feared.  Cod-liver  oil  should  be  given  con- 
tinuously throughout  the  succeeding  cool  season,  and  iron  and  other 
tonics  according  to  indications.  The  cough  itself  should  be  treated  as 
Avhen  it  follows' an  ordinary  bronchitis,  creosote  being  more  generally 
useful  than  any  other  drug. 


CHAPTEE  III 
RUBELLA 

{German  Measles;  Rotheln) 

EuBELLA  is  a  contagious  eruptive  fever  which  is  rarely  seen  except 
when  prevailing  epidemically.  It  is  characterized  by  a  short  invasion, 
with  mild,  indefinite  symptoms,  usually  lasting  but  a  few  hours,  and  by 
an  eruption  which  is  generally  well  marked  but  of  variable  appearance. 
The  constitutional  symptoms  are  very  mild,  and  the  disease  rarely  proves 
fatal,  not  often  being  even  serious.  For  a  long  time  rubella  was  con- 
founded with  measles  and  scarlet  fever,  as  the  eruption  sometimes  resem- 
bles one  and  sometimes  the  other  disease.  Its  identity  is  now  fully  estab- 
lished, and,  as  Striimpell  well  says,  its  existence  is  doubted  only  by  those 
who  have  never  seen  it. 

Eubella  is  not  a  simple  affection  of  the  skin  ;.  it  prevails  independently 
either  of  measles  or  of  scarlet  fever;  its  incubation,  eruption,  invasion, 
and  symptoms  differ  materially  from  those  of  both  these  diseases;  it 
attacks  indiscriminately  and  with  equal  severity  those  who  have  had 
measles  and  scarlet  fever  and  those  who  have  not,  nor  does  it  protect 
in  any  degree  against  cither  of  them ;  it  never  produces  anything  Ijut 


992  THE  SPECIFIC  INFECTIOUS  DISEASES 

rubella  in  those  exposed  to  its  contagion ;  it  occurs  but  once  in  the  same 
individual. 

Etiology. — Eubella  is  beyond  question  contagious,  but  is  decidedly 
less  so  than  either  measles  or  scarlet  fever;  so  that  some  observers 
have  doubted  its  contagion  altogether.  It  can  be  communicated  at  any 
time  during  its  course,  but  is  especially  contagious  during  the  early 
stage.  Epidemics  usually  prevail  in  the  winter  or  spring.  As  in  the 
other  eruptive  fevers,  a  striking  immunity  is  seen  in  infants  under  six 
months  old;  but,  with  this  exception,  all  ages  are  liable  to  the  disease. 

The  incubation  of  rubella  varies  considerably;  the  usual  period  is 
from  fourteen  to  twenty-one  days,  although  the  limits  are  from  ten  to 
twenty-two  days. 

Symptoms. — Invasion. — This  is  rarely  more  than  half  a  day,  and  in 
many  cases  no  prodromata  whatever  are  noticed,  the  rash  being  the  first 
thing  to  attract  attention.  In  a  few  cases  there  are  mild  catarrhal  symp- 
toms, with  general  malaise  and  slight  fever.  At  other  times  there  may 
be  vomiting,  convulsions,  delirium,  epistaxis,  rigors,  headache,  or  dizzi- 
ness; but  all  are  to  be  regarded  as  very  exceptional. 

Eruption. — Frequently  a  child  wakes  in  the  morning  covered  with 
the  rash,  no  symptoms  having  been  previously  noticed.  It  generally  ap- 
pears first  upon  the  face,  and  spreads  rapidly  to  the  whole  body,  the  lower 
extremities  being  last  covered.  Less  than  a  day  is  usually  required  for 
its  full  development.  Exceptionally  the  eruption  comes  first  upon  the 
chest  and  back,  and  sometimes  nearly  the  whole  body  is  covered  almost 
at  once.  The  rash  is  occasionally  observed  in  the  roof  of  the  mouth 
before  it  is  visible  on  the  face.  In  a  considerable  number  of  cases  the 
entire  body  is  not  covered ;  but  the  rash  is  more  constantly  seen  upon  the 
face  than  upon  any  other  part  of  the  body. 

Its  character  is  subject  to  considerable  variation.  The  eruption  is 
most  frequently  composed  of  very  small  maculopapules ;  they  are  of  a 
pale-red  color,  and  vary  in  size  from  a  pin's  head  to  a  pea.  The  spots 
are  usually  discrete,  but  may  cover  the  greater  part  of  the  body.  On  the 
face  it  is  frequently  confluent,  and  often  appears  here  as  large,  irregular 
blotches  of  a  red  color.  From  this  description  the  rash  will  be  seen  to 
resemble  that  of  measles  more  than  that  of  any  other  disease.  Very 
often,  however,  there  is  a  fairly  uniform  red  blush  which  bears  a  close 
resemblance  to  the  rash  of  scarlet  fever;  but  even  in  such  cases  there 
will  nearly  always  be  found  upon  some  part  of  the  body,  usually  the 
wrists,  fingers,  or  forehead,  some  typical  maculopapules.  Between  these 
two  extremes  all  variations  are  seen.  The  color  of  the  eruption  is  some- 
times dark  red,  and  rarely  it  has  been  noted  to  be  hemorrhagic.  The 
degree  of  elevation  above  the  surface  is  also  variable;  sometimes  this  is 
so  marked  as  to  give  to  the  skin  a  "shotty"  feel,  while  in  others  the 


RUBELLA  993 

elevation  is  scarcely  perceptible.  The  duration  of  the  eruption  is  usually 
three  days.  Occasionally  it  lasts  only  two  days,  and  it  may  last  but  one ; 
it  is  rare  for  it  to  remain  as  long  as  four  days.  It  fades  in  the  order 
of  its  appearance,  and  more  rapidly  than  the  eruption  of  measles.  A 
slight  brown  pigmentation  of  the  skin  sometimes  remains  for  a  few  days 
after  the  rash. 

The  highest  temperature  is  coincident  with  the  full  eruption;  this 
does  not  usually  exceed  101°,  and  often  it  is  only  100°  F.  As  a  rule, 
the  temperature  continues  but  two  days,  falling  as  the  eruption  fades. 
Very  often  the  fall  to  normal  is  abrupt.  Earely  more  severe  cases  are 
seen  in  which  the  fever  lasts  for  two  or  three  days,  being  101°  or  103°  F. 
during  the  invasion,  and  rising  to  103°  F.  or  more  during  the  full  erup- 
tion. The  other  symptoms  are  in  most  cases  even  less  marked  than  the 
fever.  Occasionally  catarrhal  symptoms  resembling  a  mild  attack  of 
measles  are  present,  or  a  sore  throat  suggesting  mild  scarlet  fever;  but 
more  frequently  all  these  symptoms  are  absent.  The  eruption  is  usually 
out  of  all  proportion  to  the  other  signs  of  disease. 

Swelling  of  the  post-cervical  glands  is  one  of  the  most  constant  fea- 
tures of  rubella.  In  most  epidemics  it  is  seen  in  nearly  all  cases;  but 
as  a  symptom  for  differential  diagnosis  it  is  not  of  great  importance,  as 
it  is  not  imcommon  in  measles  and  scarlet  fever.  The  glandular  swelling- 
is  most  marked  at  the  height  of  the  disease;  it  is  never  very  great,  and 
subsides  slowly  without  suppuration.  Vomiting  and  diarrhea  are  rare. 
Swelling  and  itching  of  the  skin  are  usually  present  and  sometimes 
marked.    There  is  no  leucocytosis  in  this  disease. 

Forchheimer  has  described  an  eruption  on  the  mucous  membrane  of 
the  throat,  or  "enanthem,"  which  he  believes  to  be  characteristic.  It 
consists  of  minute,  bright,  rosy-red  points,  seen  on  the  uvula  and  soft 
palate,  rarely  on  the  hard  palate.  It  is  present  only  during  the  first 
twenty-four  hours. 

Desquamation. — This  is  exceedingly  variable.  It  is  sometimes  en- 
tirely wanting;  writers  who  have  observed  some  fairly  typical  epidemics 
have  stated  that  it  did  not  occur.  In  most  cases,  however,  some  des- 
quamation is  present,  though  it  may  be  so  slight  as  to  be  discovered  only 
by  a  close  examination.  It  is  usually  in  the  form  of  fine  scales  over  the 
body  and  extremities.  In  a  few  cases  it  is  more  pronounced,  and  may 
be  in  larger  flakes  or  patches. 

Prognosis. — There  are  few  diseases  so  free  from  danger  as  rubella. 
Complications  and  sequelae  are  very  seldom  seen,  and  when  present  are 
usually  of  the  mildest  character. 

Diagnosis. — The  principal  interest  attaching  to  rubella  is  in  its  diag- 
nosis. This  is  a  matter  of  extreme  difficulty,  and  often  it  is  an  impossi- 
bility.   The  characteristic  thing  about  the  disease  is  a  well-marked  erup- 


994  THE  SPECIFIC  IXFECTIOCS  DISEASES 

tion  with  very  few  other  symptoms.  Cases  so  closely  resemble  mild 
scarlet  fever  that  the  differentiation  by  symptoms  may  be  impossible;  it 
must  be  made  by  the  circumstances  in  which  the  disease  occurs,  espe- 
cially a  prevailing  epidemic.  Scarlet  fever  with  a  low  temperature  and 
abundant  rash  should  always  be  regarded  with  suspicion ;  also  an  abun- 
dant rash  with  little  or  no  desquamation.  The  longer  period  of  incuba- 
tion in  rubella  is  often  of  much  assistance.  Koplik's  sign  furnishes  a 
valuable  means  of  distinguishing  measles  from  rubella.  The  difficulties 
in  diagnosis  can  be  appreciated  only  by  one  who  has  seen  epidemics  of 
measles  and  scarlet  fever  in  institutions,  and  has  watched  the  exceed- 
ingly mild  course  of  undoubted  cases  of  these  diseases  which  have  there 
occurred. 

It  is  always  hazardous  to  make  the  diagnosis  of  rubella  unless  the 
disease  is  prevailing  epidemically.  Sporadic  cases  in  which  this  diagnosis 
is  made  are,  we  believe,  almost  invariably  instances  of  mild  measles  or 
scarlet  fever.  The  first  cases  of  rubella  in  an  epidemic  are  usually  over- 
looked. The  continued  absence  in  succeeding  cases  of  the  characteristic 
symptoms  and  complications  of  measles  or  scarlet  fever  should  suggest  to 
the  physician  that  he  is  probably  dealing  with  rubella. 

Treatment. — None  whatever  is  required  for  the  disease  excepting 
isolation,  which  should  be  complete  until  the  diagnosis  is  positively  deter- 
mined; after  this  it  is  hardly  necessary.  The  individual  symptoms  and 
complications  are  to  be  treated  as  they  arise. 


CHAPTER  IV 
VARICELLA 
(Chicken-pox) 

Varicella  is  an  acute,  contagious  disease,  characterized  by  a  cuta- 
neous eruption  of  papules  and  vesicles  and  by  mild  constitutional  symp- 
toms, serious  complications  and  sequelae  being  very  rare.  Although  long 
confounded  with  varioloid,  its  existence  as  a  distinct  disease  has  been 
generally  admitted  for  many  years. 

Etiology. — It  is  well  established  that  the  contagium  of  the  disease  is 
contained  in  the  vesicles,  as  it  may  be  communicated  by  inoculation  with 
their  contents.  The  specific  poison,  however,  has  not  yet  been  isolated. 
Varicella  is  contracted  by  exposure  to  another  case  or  through  the  me- 
dium of  a  third  person.  It  affects  children  of  all  ages,  one  attack  being 
as  a  rule  protective.     It  is  very  contagious,  resembling  measles  in :  this 


VARICELLA  995 

respect.  The  period  of  incubation  is  quite  uniformly  from  fourteen  to 
sixteen  days. 

Symptoms. — ^Slight  fever  and  general  indisposition  may  be  noticed 
for  twenty-four  hours  before  the  appearance  of  the  eruption,  but  in  most 
cases  the  eruption  is  the  first  symptom.  It  usually  appears  first  upon 
the  face  or  trunk,  as  small,  red,  widely  scattered  papules.  The  papules  in 
most  cases  come  in  crops,  new  ones  continuing  to  appear  for  three  or 
four  days,  even  uj)on  the  same  part  of  the  body.  The  earlier  ones  have 
generally  begvm  to  dry  up  by  the  time  the  later  ones  appear,  so  that  all 
stages  of  the  eru]3tion  may  be  present  at  0]ie  time  in  the  same  region, 
this  being  one  of  the  diagnostic  features.  The  papules  are  at  first  very 
small,  but  gradually  increase  in  size,  and  are  surrounded  by  an  areola 
from  one-fourth  to  half  an  inch  in  width.  Many  of  them  go  no  further 
than  this  stage,  but  the  majority  become  vesicular.  The  vesicles  are  usu- 
ally flat,  and  vary  a  good  deal  in  size — the  largest  being  about  one-fourth 
of  an  inch  in  diameter.  The  process  of  drying  up  generally  begins  at  the 
center;  this  causes  a  slight  depression,  giving  the  vesicle  a  somewhat 
umbilicated  appearance.  The  areola  is  most  distinct  at  the  time  of  the 
fully  formed  vesicle,  and  fades  as  the  latter  dries.  Crusts  now  form, 
which  fall  off  in  from  five  to  twenty, days,  depending  upon  the  depth  to 
which  the  skin  has  been  involved.  In  the  majority  of  cases  no  mark  is 
left,  but  after  the  most  severe  attacks,  when  the  true  skin  has  been  in- 
volved, scars  remain,  and  occasionally  there  is  quite  deep  pitting.  Such 
marks  are  few  in  number,  and  are  most  likely  to  occur  upon  the  face. 

Sometimes,  especially  upon  hands  and  feet,  the  vesicle  appears  with- 
out having  been  preceded  by  a  papule ;  often  there  is  no  areola,  and  the 
vesicle  resembles  a  drop  of  water  upon  healthy  skin.  In  most  cases  pus- 
tules are  not  seen,  but  they  may  develop  in  consequence  of  irritation  or 
infection,  the  result  of  scratching,  or  in  children  who  are  poorly  nour- 
ished. Under  these  circumstances  deeper  ulceration  may  occur,  lasting 
for  weeks.  In  rare  cases  there  may  be  a  necrotic  inflammation  about  the 
site  of  the  pock,  a  condition  to  which  is  sometimes  given  the  name  vari- 
cella gangrenosa.  It  is  not  peculiar  to  varicella,  and  is  described  else- 
where under  the  head  of  Gangrenous  Dermatitis. 

The  pocks  are  usually  most  abunrlant  over  the  back  and  shoulders, 
hi  mild  cases  only  twenty  or  thirty  may  be  found  upon  the  entire  body, 
but  in  severe  cases  the  skin  in  certain  regions  may  be  nearly  covered. 
The  eruption  is  never  confluent.  The  pocks  are  usually  seen  on  the 
hairy  scalp,  and  often  on  the  mucous  membrane  of  the  mouth  or  pharynx 
— a  point  of  some  diagnostic  value.  In  the  latter  situation  the  appear- 
ance is  first  as  a  tiny  vesicle,  and  later  as  a  superficial  ulcer  resembling 
that  of  herpetic  stomatitis.  ]\Iarfan  and  Plalle  have  described  cases  of 
varicella  of  the  larynx.     Croupy  symptoms  were  present,   and  in  one 


996  THE  SPECIFIC  INFECTIOUS  DISEASES 

case  which  proved  fatal  from  pneumonia  a  tiny  ulcer  was  found  on  the 
vocal  cords. 

The  temperature  is  highest  when  the  eruption  is  most  rapidly  appear- 
ing, this  usually  being  the  second  or  third  day.  In  an  average  case  it 
reaches  only  101°  or  102°  P.,  and  lasts  but  two  days;  in  severe  cases  it 
may  rise  to  101°  or  105°  ¥.,  and  lasts  for  four  or  five  d^ys.  It  falls' 
gradually  to  normal  as  the  rash  fades.  The  other  symptoms  are  mild 
and  not  characteristic. 

Complications. — The  most  important  complication  is  erysipelas, 
which  develops  about  the  pocks,  particularly  when  they  are  deep  and  at- 
tended with  some  ulceration.  We  have  known  of  several  fatal  cases  from 
this  cause.  Adenitis,  either  simple  or  suppurative,  and  abscesses  in  the 
cellular  tissue,  are  occasionally  seen.  Nephritis  is  very  infrequent,  but  a 
number  of  cases  are  recorded.  It  may  occur  at  the  height  of  the  dis- 
ease, but  more  often  at  a  later  period,  like  the  nephritis  of  scarlet  fever. 
Varicella  is  quite  frequently  complicated  by  other  infectious  diseases. 
We  have  seen  coincident  scarlet  fever  in  a  number  of  cases.  Severe  nerv- 
ous lesions  occasionally  follow  varicella,  the  most  frequent  being  enceph- 
alitis. We  have  seen  transverse  myelitis  develop  in  a  boy  of  seven  after 
an  attack  of  varicella. 

Diagnosis. — The  diagnosis  of  varicella  is  usually  easy,  provided  the 
following  points  are  kept  in  mind :  first,  that  the  eruption  comes  out 
slowly  and  in  crops,  so  that  papules,  vesicles,  and  crusts  may  be  seen  upon 
the  skin  in  close  proximity;  secondly,  that  the  umbilication  is  due  only 
to  the  mode  of  drying  up  of  the  vesicle,  which  begins  at  the  center; 
thirdly,  the  appearance  of  the  pocks  upon  the  mucous  membranes,  and 
the  history  of  exposure.  It  is  distinguished  from  urticaria  and  other 
forms  of  skin  disease  by  the  presence  of  fever  and  often  by  the  lesions  in 
the  mouth.  Cutaneous  inoculations  from  fresh  vesicles,  as  first  practiced 
by  Kling,  apparently  protect  against  varicella.  At  the  site  of  inocula- 
tion small  localized  lesions  are  produced,  but  there  are  no  general  symp- 
toms. 

Treatment. — Although  it  is  usually  a  trivial  disease,  isolation  of  cases 
of  varicella  should  be  enforced  in  schools  and  in  institutions  containing 
many  infants.  In  the  home,  unless  other  children  are  delicate  or  in 
poor  condition,  quarantine  is  unnecessary.  The  disease  may  probably  be 
conveyed  as  long  as  the  crusts  are  present,  hence  isolation  should  be 
maintained  until  they  have  fallen  off.  In  most  cases  constitutional 
symptoms  of  the  disease  are  so  mild  as  to  require  no  treatment. 

Locally,  the  itching,  when  annoying,  may  be  allayed  by  sponging 
with  a  solution  of  bicarbonate  of  soda,  a  one-per-cent  solution  of  car- 
bolic acid  or  the  use  of  carbolized  vaseline.  When  the  crusts  have  formed, 
this  ointment  or  vaseline  containing  two  per  cent  ichthyol  should  be 


VACCINATION  997 

applied.  Care  is  necessary  to  keep  the  skin  clean,  arid,  in  the  case  of 
infants,  to  prevent  scratching.  In  severe  cases  the  urine  should  invari- 
ably be  examined. 


CHAPTER  V 

VACCINIA— VACCINATION 

Vaccinia  (cowpox)  is  a  febrile  disease  induced  in  man  by  inocula- 
tion with  the  virus  obtained  either  directly  from  the  cow  (bovine  virus) 
or  from  a  person  who  has  been  inoculated  (humanized  virus).  The  dis- 
ease is  not  contagious  in  the  ordinary  sense  of  the  term,  but  is  communi- 
cated by  inoculation  either  accidental  or  intentional. 

The  protection  against  smallpox  which  vaccination  affords. is  one  of 
the  best  attested  facts  in  medicine.  Its  effect  when  systematically  prac- 
ticed is  graphically  shown  in  the  accompanying  chart  (Fig.  164).  It  is 
the  imperative  duty  of  the  physician  to  see  to  it  that  every  young  infant 
is  vaccinated. 

Re-vaccination. — Regarding  the- duration  of  the  protective  power  of 
a  single  vaccination,  positive  statements  are  impossible.  Nearly  all 
writers  are  agreed  that  vaccination  should  be  done  in  infancy,  again  at 
puberty,  and  a  third  time  at  about  the  age  of  twenty  or  twenty-five. 
Many  also  insist  upon  re-vaccination  at  about  the  seventh  year.  It  is  a 
safe  rule  when  smallpox  is  prevalent  to  vaccinate  every  person  who  has 
not  been  successfully  vaccinated  within  five  years. 

Choice  of  Lymph. — The  substitution  of  bovine  for  humanized  virus 
is  now  well-nigh  universal.  It  has  precluded  the  possibilicy  of  trans- 
mitting syphilis  and  greatly  lessened  the  chances  of  other  forms  of  in- 
fection. A  still  further  advance  was  made  by  the  introduction  of 
"glycerinated"  lymph.  As  now  prepared,  the  lymph  is  taken  from  the 
calves  under  the  most  rigid  aseptic  precautions  and  emulsified  with 
glycerin.  The  few  saprophytic  bacteria  present  soon  die,  so  that  when 
properly  prepared  the  glycerinated  virus  is  practically  sterile.  It  should 
not  be  distributed  until  it  has  been  carefully  tested  for  pathogenic  organ- 
isms of  all  kinds,  particiilarly  the  tetanus  bacillus.  It  is  preserved  and 
distributed  in  capillary  tubes  hermetically  sealed;  these  are  much  safer 
than  quills  or  ivory  points,  which  may  easily  become  contaminated  by 
handling.  After  the  lymph  has  been  taken,  the  calves  are  killed  in  order 
to  make  certain  that  they  were  free  from  disease.  The  practical  advan- 
tages of  glycerinated  lymph  are  so  great  that  it  has  been  officially 
adopted  by  the  Governments  of  the  United  States,  Great  Britain,  Ger- 
many, and  many  other  countries. 


998 


THE  SPECIFIC  INFECTIOUS  DISEASES 


Xognchi  has  succeeded  in  cultivating-  vaccine  virus  in  vitro.  It  can 
readily  be  produced  in  indefinite  quantities;  so  that  we  may  soon  hope 
to  be  supplied  with  virus  in  pure  culture,  free  from  all  possibility  of 
bacterial  contamination  from  animal  sources.  Experience  with  its  use 
indicates  that  it  is  quite  as  effective  as  the  ordinary  bovine  virus. 


PRUSSIA. 

WJTH  COMPULSORY  VACCINATION, AND 

COMPULSORY  RE-VACCINATlOfi 

AT  THE  AGE  OF  12. 


After  the  Law  of  1874 
was  passed. 


Il-.lll.- 


HOLLAKD. 


18G8-1874 


jearl;  Deaths 
from  Bmall- 

poi  in  every 

100,000 
tnh&hitaDts. 


Aoniial  Deaths 

from  emaU-pox 

in  cTery  100,000 

inhahitanta. 


After  ihe  law  of  1878 


1860-1872 

Average 

yearlj  Deaths 

from  amalU 

pox  in  CTery 

100,000 
Inhabitants, 


ll 


L±aA 


lA. 


Annxial  Deaths 

from  small-pox 

In  every  100,000 

Inhabitants. 


ATTSTRIA. 


1808-1874 

Average 

yearly  Deaths 

from  small* 

pox  In  every 

100,000' 
lohabltants. 


Atmual  Deaths 

from  small-pox 

In  every  100,000 

Inhabitants^ 


-ja> 


_iii> 


.100 


_  90 


_  SOS 


70  a 

s 

o 

I 

60  fe 


_  50O 


-40 


_20 


_  10 


Fig.  164. Table    Showing    the    Protecitve    Power    of    Vaccination.     (Carsten.) 


Time  for  Vaccinating. — In  selecting  a  time  for  vaccination,  the 
child's  ase  and  general  health  must  be  taken  into  consideration.  It  is 
pretty  "«-ell  established  that  the  constitutional  disturbance  is  much  less 
in  infancy  than  in  later  childhood;  and  there  is  besides  in  infancy  less 
chance  of  accidental  infection  of  the  vaccine  wound.     Between  the  ages 


VACCINIA  999 

of  two  and  six  months  seems  the  best  general  time  for  vaceinatiou.  In 
delicate  infants  or  in  those  whose  nutrition  is  a  matter  of  great  difficulty., 
Those  who  are  syphilitic,  those  suffering  from  eczema  or  any  other  form 
of  actiA'e  skin  disease,  vaccination  should  be  deferred  until  the  child  is 
in  good  condition,  unless  he  is  likely  to  be  exposed  to  smallpox. 

Methods  of  Vaccinating. — In  our  experience  it  is  preferable  to  vac- 
cinate in  a  single  place  rather  than  to  make  two  or  three  inoculations. 
Either  the  leg  or  the  arm  may  be  chosen ;  in  young  infants  it  is  usually 
easier  to  protect  the  vaccine  sore  upon  the  leg  than  upon  the  arm ;  in  chil- 
dren old  enough  to  run  about,  the  arm  is  to  be  preferred,  as  being  more 
easily  kept  at  rest.  The  point  selected  for  inoculation  should  be  either  the 
outer  aspect  of  the  left  calf,  about  the  junction  of  the  middle  with  the 
upper  third  of  the  leg.  or,  if  the  arm  is  chosen,  the  insertion  of  the  left 
deltoid.  Vaccination  should  be  regarded  as  a  minor  surgical  operation 
and  the  hands  of  the  physician,  as  well  as  the  arm  of  the  patient,  should 
l)e  washed  with  soap  and  water,  dried,  and  the  skin  then  washed  with 
alcohol. 

The  New  York  Health  Department  supplies  with  each  tube  of  lymph. 
a  sterilized  needle  and  a  rubber  bulb.  A  single  scratch  not  more  than 
one-fourth  of  an  inch  long  is  made  with  the  needle  just  deep  enough  to 
draw  blood;  or  a  minute  scarification  may  be  made  not  over  one-eighth 
of  an  inch  in  diameter.  The  ends  of  the  capillary  tube  are  broken  off. 
and  the  lymph  blown  out  of  the  tube  upon  the  scratched  surface  and 
rubbed  in  for  a  full  minute.  The  wound  should  not  be  covered  until 
dry;  a  sterilized  bandage  should  then  be  applied.  The  limb  should  not 
be  washed  for  twenty-four  hours. 

The  Normal  Course  of  "Vaccinia. — The  course  of  a  proper  vaccina- 
tion-pock is  quite  uniform,  and  one  which  does  rot  follow  this  course 
should  not  be  considered  protective.  The  wound  heals  and  nothing  is 
noticed  until  the  third  or  fourth  day,  when  a  red  papule  makes  its  ap- 
pearance. Usually  in  twenty-four  hours  more  a  small  vesicle  appears 
which  enlarges  until  the  sixth  or  seventh  day,  reaching  its  full  develop- 
ment about  the  ninth  day.  Its  shape  an'd  size  depend  somewhat  upon 
the  extent  of  the  scarification  (Figs.  165-169).  The  vesicle  is  usually 
from  one-fourth  to  one-half  inch  in  diameter ;  it  is  of  a  pearly-gray  color 
and  has  a  depressed  center.  During  the  next  two  days  an  areola  forms 
about  the  vesicle  extending  from  it  a  variable  distance,  usually  for  one  or 
two  inches  into  the  healthy  skin.  Its  size  depends  upon  the  intensity  of 
the  infection.  This  areola  is  normally  of  a  bright-red  color  and  accom- 
panied by  some  induration.  It  is  generally  at  its  height  about  the  ninth 
day.  The  vesicle  usually  dries  down  to  a  firm,  dark  crust  which  remains 
from  one  to  three  weeks  and  falls  off,  leaving  a  bluish  scar  which  fades  to 
white,  becoming  somewhat  honey-combed.     When  the  process  is  at  its 


Fig.  165.— Fifth  day. 


Fig.  166. — Seventh  day. 


Fig.  167.— Ninth  day. 


Fig.  168.— Eleventh  day. 


Fig.  169.— Tenth  day. 


Figs.  165-169. — Vaccine  Vesicles.     (Two-thirds  natural  size.) 
Figs.  165,  166,  167,  and  168  show  typical  appearance  of  vesicle  at  the  different  stages 

when  a  very  small  scarification  is  made. 
Fig.  169  shows  the  effect  of  a  larger  scarification  with  a  more  intense  areola.     The  amount 
of  inflammation  is  excessive  but  not  unusual. 

1000 


VACCINIA 


1001 


height  some  constitutional  disturbance  is  usually  present;  there  may  be 
loss  of  appetite,  fretfulness,  and  general  indisposition,  and  the  tempera- 
ture is  usually  elevated  from  one  to  three  degrees.  The  lymph  nodes  in 
the  groin  or  axilla  may  be  tender  and  swollen.  These  symptoms  gener- 
ally last  for  three  or  four  days. 

If  in  a  young  infant  the  first  inoculation  is  unsuccessful,  at  least 
three  trials  should  be  made  with  good  virus,  and  in  the  event  of  further 
failure,  after  a  year  vaccination  should  be  repeated.  A  failure  to  inocu- 
late does  not  mean  insusceptibility  to  smallpox,  as  is  often  popularly  be- 
lieved, but  most  frequently  arises  from  the  fact  that  the  virus  is  inert. 
We  have  known  one  case  in  which  the  seventh,  and  another  in  which  the 
thirteenth,  inoculation  was 
successful  after  previous 
failures;  occasionally  there 
are  seen  children  who  can 
not  be  inoculated  at  all. 

Constitutional  symp- 
toms, as  previously  stated, 
may  be  absent  in  very  young 
infants;  but  in  others  there 
is  quite  constantly  present  a 
fever  which  runs  a  fairly 
regular  course.  It  usually 
begins  on  the  fourth  or  fiftli 
day,  is  remittent  in  type, 
and  rises  gradually,  reach- 
ing its  highest  point  with 
the  full  development  of  the 

vesicle.  At  this  time  even  without  complications  it  may  touch  104°  or 
105°  F.  The  duration  of  the  fever  in  cases  running  the  usual  course  is 
four  or  five  days.  Accompanying  the  fever  there  may  be  anorexia,  rest- 
lessness, loss  of  sleep,  slight  indigestion,  and  other  symptoms  of  a  general 
indisposition. 

Both  the  local  and  the  general  symptoms  are  sometimes  more  severe. 
This  may  depend  upon  the  susceptibility  of  the  child,  even  though  the 
lymph  is  pure  and  the  vaccination  properly  done.  The  original  vesicle 
may  be  much  larger  than  usual,  and  small  secondary  vesicles  may  form 
in  the  neighborhood.  In  very  rare  instances  a  generalized  eruption  of 
true  vaccine  vesicles  occurs  with  fever  and  other  general  symptoms  of  cor- 
responding severity  (Fig.  170).  Single  vesicles  may  be  produced  on  dis- 
tant parts  of  the  body  as  a  result  of  auto-inoculation,  usually  by  scratch- 
ing. When  eczema  of  the  face  is  present,  inoculation  is  not  infrequently 
carried  thither.     Most  of  the  very  sore  arms  and  legs,  however,  are  due 


Fig.   170. 


Generalized   Vaccinia. 
years  old. 


Boy  eight 


1002  THE  SPECIFIC  INFECTIOUS  DISEASES 

to  infection  from  pyogenic  bacteria  accidentally  introduced  at  the  time 
of  vaccination  but  more  often  subsequently.  In  the  milder  cases  the 
swelling  and. other  evidences  of  local  inflammation  are  more  marked  than 
in  a  normal  vaccination;  a  drop  or  two  of  pus  forms  beneath  the  crust, 
and  when  the  latter  comes  away  an  excavation,  is  left  which  Jieals  in  two 
or  three  weeks.  Or,  the  inflammation  may  extend  more  deeply  into  the 
connective  tissue,  to  be  followed  by  more  extensive  suppuration  or  slough- 
ing, leaving  an  ugly  ulcer  an  inch  or  more  in  diameter  which  slowly  fills 
by  granulation  in  from  five  to  eight  weeks.  Sometimes  the  period  of 
incubation  is  unduly  prolonged,  so  that  the  vesicle  does  not  form  until 
the  twelfth  or  fourteenth  day,  although  its  subsequent  course  may  be 
quite  normal.  In  other  cases  the  incubation  is  very  much  shorter  than 
usual,  and  the  vesicle  may  appear  as  early  as  the  fourth  or  even  the 
third  day. 

Much  has  been  written  about  the  so-called  "raspberry  excrescence" 
which  not  very  infrequently  takes  the  place  of  a  proper  vesicle.  It  is  of 
a  dark-red  color,  elevated,  smooth  or  slightly  granular,  not  sensitive, 
having  no  areola  and  no  constitutional  symptoms.  It  generally  per- 
sists for  two  or  three  weeks,  and  slowly  disappears,  leaving  no  scar.  It  is 
usually  the  result  of  virus  of  feeble  activity,  and  if  it  gives  any  protection 
it  is  very  slight.  Such  cases  should  always  be  re-vaccinated,  and  in  our 
experience  re-vaccination  is  usually  successful. 

Complications  and  Sequelae. — Post-vaccine  eruptions  are  many  and 
of  great  variety.  The  most  frequent  is  a  general  roseola,  usually  occur- 
ring at  the  height  of  the  local  process.  Other  eruptions  seen  are  urti- 
caria, and,  rarely,  purpura.  Complications  are  chiefly  from  accidental 
infection.  Syphilis  and  tuberculosis  are  excluded  by  the  modern  method 
of  procuring  the  lymph.  Tetanus  in  rare  instances  has  followed  vacci- 
nation. It  may  result  either  from  introduction  of  the  bacilli  with  the 
vaccine  lymph  but  more  often  from  subsequent  accidental  infection  of 
the  wound  or  sore.  Cases  of  the  first  mentioned  variety  are  extremely 
rare.  By  proper  legal  restrictions  regarding  the  production  of  vaccine 
virus  they  should  be  entirely  eliminated.  Its  production  should  never  be 
permitted  in  a  district  in  which  tetanus  is  endemic ;  and  each  quantity  of 
lymph  sent  out  should  be  tested  for  tetanus.  In  the  great  majority  of 
the  reported  cases  in  which  tetanus  has  followed  vaccination  the  evidence 
is  strong  that  infection  occurred  subsequent  to  vaccination,  owing  to  want 
of  proper  care  or  insufficient  protection  of  the  vaccinated  part.  It  should 
not  be  forgotten  that  vaccination  produces  an  open  wound,  which  may 
become  infected  like  any  other  wound.  The  most  common  form  of  local 
infection  is  cellulitis,  which  may  terminate  in  suppuration  or  sloughing 
at  the  site  of  vaccination,  and  sometimes  may  cause  suppuration  of  the 
neighboring  lymjDh  nodes.     Erysipelas  may  develop  at  any  time  before 


PERTUSSIS  1003 

the  wound  is  entirely  healed;  it  is  usually  due  to  neglect  of  proper  pre- 
cautions in  the  care  of  the  vaccine  sore. 

The  mortality  of  vaccination  is  stated  hy  Yoigt,  from  careful  statistics 
drawn  from  German  sources,  to  have  been  35  in  2,275,000  cases,  including 
both  primary  and  secondary  vaccinations.  Of  the  deaths,  19  were  due  to 
erysipelas,  8  to  gangrene,  2  to  cellulitis,  3  to  "blood  poisoning,"  and  3  to 
other  causes.  Nearly  all  the  deaths  from  vaccination  are  from  causes 
which  are  preventable. 

Treatment. — The  whole  purpose  of  treatment  is  to  prevent  infection. 
The  first  essentials  are  a  clean  limb,  pure  virus,  and  a  sterile  needle ;  the 
next,  to  allow  thorough  drying  of  the  wound  before  the  clothing  touches 
it.  After  this  no  treatment  is  necessary  until  the  vesicle  forms.  Then  the 
important  thing  is  to  prevent  scratching  and  the  irritation  by  the  cloth- 
ing. All  vaccine  shields  are  objectionable.  For  an  infant  nothing  is 
better  than  the  sterilized  gauze  bandage,  which  can  be  kept  in  place  by 
sewing  to  the  stocking  or  to  the  sleeve  of  the  shirt.  Any  constriction  of 
the  limb  is  injurious.  For  older  children  the  simplest  dressing  is  a  pad  of 
sterile  gauze  fastened  to  the  limb  by  two  pieces  of  adhesive  plaster. 
Should  the  vesicle  rupture  and  discharge  serum,  it  should  be  kept  clean 
and  dry  by  dusting  daily  with  boric  acid.  When  the  local  symptoms  are 
at  all  severe  the  limb  should  be  kept  at  rest.  An  infected  vaccination 
wound,  like  any  other  infected  wound,  requires  careful  surgical  treat- 
ment ;  disastrous  results  often  follow  the  use  of  poultices  and  other  appli- 
cations much  in  vogue  in  domestic  practice. 


CHAPTER  VI 

PERTUSSIS 
iWhooping-Cough) 

Peetussis  is  a  contagious  disease  which  prevails  epidemically  and, 
in  all  large  cities,  endemically.  Although  it  may  affect  persons  of  any 
age,  it  is  generally  seen  in  young  children.  While  in  later  childhood 
pertussis  may  be  ranked  as  one  of  the  milder  infectious  diseases,  in 
infancy  it  is  one  of  the  most  fatal.  Its  principal  complications  are 
bronchopneumonia  and  convulsions.  Pertussis  is  characterized  by  catar- 
rhal and  nervous  symptoms.  The  catarrh  affects  the  mucous  membrane 
of  the  respiratory  tract,  and  is  probably  due  to  a  specific  form  of  infec- 
tion. It  is  accompanied  by  a  hyperesthetic  condition  of  this  mucous 
membrane.     The  most  prominent  nervous  manifestation  is  a  peculiar 


1004  THE  SPECIFIC  INFECTIOUS  DISEASES 

spasmodic  cough  which  occurs  in  paroxysms,  and  from  which  the  disease 
takes  its  name.  The  cough  is  no  doubt  of  reflex  origin,  from  an  irrita- 
tion which  has  been  located  by  different  writers  in  various  parts  of  the 
resp.Tatory  tract.  In  addition  to  these  conditions,  there  is  present  in 
pertussis  a  marked  irritability  of  the  nervous  system,  which  in  infancy 
often  shows  itself  by  convulsions.  Whooping-cough  is  a  disease  whose 
importance  is  too  often  passed  over  lightly.  In  ISTew  York  State  it 
causes  more  deaths  than  scarlet  fever  and  nearly  as  many  as  does  typhoid 
fever. 

Etiolo^. — Present  evidence  points  to  the  Bordet-Gengou  bacillus 
as  the  specific  organism  of  pertussis.  It  is  a  small  G-ram-negative  bacillus 
which  in  many  points  resembles  the  influenza  bacillus.  It  is  difficult  to 
obtain  the  organism  from  the  respiratory  secretion  unless  the  plug  of 
mucus  brought  up  after  the  paroxysm  of  coughing  is  secured,  as  it 
develops  chiefly  in  the  lower  respiratory  tract.  It  is  found  only  in  the 
early  stage  of  the  disease,  rarely  later  than  a  week  after  the  whoop 
begins.  Smears  are  unreliable  for  diagnosis;  only  cultures  are  to  be 
depended  upon.  In  practically  all  cases  there  is  mixed  infection,  cer- 
tainly after  the  first  week  or  two.  There  may  be  associated  the  pneumo- 
coccus,  the  B.  influenzae,  the  staphylococcus,  or  streptococcus.  There  are 
still  lacking  some  elements  of  proof  that  the  Bordet-Gengou  bacillus  is 
the  cause  of  pertussis.  Although  it  has  been  found  in  the  great  majority 
of  cases  examined  by  competent  observers  early  in  the  disease,  yet  its 
absence  in  some  typical  cases  cannot  be  explained.  The  results  of  com- 
plement fixation  tests  have  not  been  uniform,  but  these  may  be  due  to 
differences  in  the  strains  of  the  organism.  Finally  there  is  evidence  that 
other  forms  of  infection  of  the  respiratory  tract  may  produce  a  group 
of  symptoms  which  are  clinically  indistinguishable  from  true  pertussis; 
i.  e.,  a  contagious  catarrh  and  a  paroxysmal  cough  with  a  duration  of 
four  to  eight  weeks.  This  we  have  repeatedly  seen  associated  with  the 
presence  of  the  B.  influenzae. 

Proximity  to  a  patient  seems  all  that  is  required  to  communicate  the 
disease  and  even  close  proximity  is  not  necessary.  Czerny  places  the 
infective  distance  at  about  five  feet  from  the  patient.  The  disease  seems 
to  be  spread  chiefly  by  droplets  diffused  by  coughing  and  sneezing. 

Predisposition. — Fully  one-half  the  cases  of  pertussis  occur  during 
the  first  two  years  of  life.  The  following  are  the  statistics  of  Szabo 
(Buda-Pesth),  showing  the  ages  at  which  the  disease  was  met  with  in 
4,591  cases,  comprising  the  records  of  one  clinic  for  thirty-four  years: 

Under  one  year 1,028  cases   Three  to  four  years 904  cases 

One  to  two  years 1,008     "       Four  to  seven  years 803     " 

Two  to  three  years 659     "       Over  seven  years 189     " 


PERTUSSIS  1005 

The  susceptibility  of  young  infants  to  pertussis  is  very  great.  To 
them  unquestionably  the  disease  may  be  carried  by  a  third  person. 
Many  cases  are  on  record  in  which  pertussis  has  occurred  during  the 
first  month,  and  one  has  come  to  our  notice  where  a  child  twelve  days 
old  was  attacked,  whose  mother  was  suffering  from  the  disease.  The 
disease  is  nearly  twice  as  frequent  in  the  winter  and  spring  as  in  the 
summer  and  autumn.  Epidemics  of  pertussis  often  occur  at  the  same 
time  with  or  follow  those  of  measles. 

The  susceptibility  to  pertussis  is  very  great,  and  is  equalled  only  by 
that  to  measles.  Biedert  reports  that  of  401  children  exposed  during 
an  epidemic  in  a  certain  village,  366,  or  ninety-one  per  cent,  took  the 
disease. 

As  a  rule  one  attack  protects  the  individual  during  his  life.  The 
great  majority  of  the  reported  instances  of  second  attacks  are  certainly 
to  be  explained  by  mistakes  in  diagnosis.  These  may  be  almost  unavoid- 
able; for  it  is  at  times  almost  impossible  to  distinguish  true  pertussis 
from  the  paroxysmal  cough  which  occurs  in  some  cases  of  influenza. 

Infective  Period. — Pertussis  may  be  communicated  from  the  very  be- 
ginning of  the  catarrhal  stage ;  it  is  more  contagious  at  this  period  than 
later.  There  seems  little  doubt  that  it  is  contagious  throughout  the 
spasmodic  stage,  but  the  infectivity  of  the  disease  after  the  first  few 
weeks  is  slight.  The  recurrence  of  the  whoop  with  a  fresh  cold,  after  it 
has  once  ceased,  cannot  be  considered  a  relapse  nor  regarded  as  con- 
tagious. Quarantine  is  generally  required  for  two  months.  The  usual 
source  of  the  contagion  is  the  patient,  rarely  the  room  or  the  clothing. 

Incubation. — The  very  gradual  onset  of  pertussis  renders  it  impos- 
sible in  the  majority  of  cases  to  fix  the  exact  date,  and  hence  to  estab- 
lish the  definite  duration  of  the  period  of  incubation.  In  cases  where 
this  could  best  be  determined  it  has  usually  been  from  seven  to  fourteen 
days,  or  about  the  same  as  in  measles.  If,  after  an  exposure,  sixteen 
days  pass  without  the  development  of  a  cough,  the  probabilities  are  very 
strong  that  the  disease  has  not  been  contracted. 

Lesions. — The  only  constant  lesion  of  pertussis  consists  in  a  catarrhal 
inflammation  of  varying  intensity,  which  affects  the  mucous  membrane 
of  the  larynx,  trachea,  and  bronchi,  and  sometimes  that  of  the  nose  and 
pharynx.  Mallory  claims  that  the  presence  of  the  bacilli  between  the 
ciliae  of  the  epithelial  cells  of  the  trachea  and  bronchi  is  the  specific 
lesion.  Others  have  found  a  similar  condition  in  influenza.  If  the  child 
dies  during  a  paroxysm,  either  with  or  without  convulsions,  the  brain  is 
found  intensely  congested  and  may  be  the  seat  of  punctate  hemorrhages, 
or  even  larger  extravasations.  The  lungs  always  show  emphysema  if 
the  attack  has  been  severe  or  protracted.     The  other  pulmonary  lesions 


1006  THE  SPECIFIC  INFECTIOUS  DISEASES 

are  due  to  complications,  the  most  frequent  of  which  is  bronchopneu- 
monia.    Catarrhal  enteritis  and  colitis  are  not  infrequent. 

Symptoms. — The  symptoms  of  pertussis  are  usually  divided  into 
three  stages — the  catarrhal,  the  spasmodic,  and  the  stage  of  decline. 

The  catarrhal  stage  continues  on  the  average  for  about  ten  days, 
although  cases  show  considerable  variation  on  this  point.  -  Some  chil- 
dren whoop  almost  from  the  very  beginning  of  the  disease,  while  others 
may  cough  for  three  or  four  weeks  before  a  typical  whoop  is  noticed. 
The  symptoms  in  the  beginning  are  indistinguishable  from  those  of  an 
ordinary  attack  of  subacute  tracheobronchitis,  and  unless  there  has  been 
an  exposure  to  pertussis  no  suspicion  is  excited.  After  five  or  six  days, 
however,  the  cough,  instead  of  abating  as  in  an  ordinary  cold,  gradually 
increases  in  severity  and  occurs  in  paroxysms.  At  first  these  are  mild, 
and  there  are  only  two  or  three  a  day,  but  they  gradually  increase  in  fre- 
quency and  severity  until  the  typical  whoop  is  heard  which  marks  the 
beginning  of  the  spasmodic  stage.  During  the  first  stage  there  may 
be  symptoms  of  a  mild  grade  of  catarrhal  inflammation  of  the  nose, 
pharynx  and  larynx,  and  often  there  is  a  slight  elevation  of  temperature. 

The  Spasmodic  Stage. — In  a  typical  paroxysm  of  average  severity  the 
child,  who  can  usually  foretell  it,  will  often  run  for  support  to  the  lap 
of  the  mother  or  the  nurse,  or  seize  a  chair  with  both  hands.  There 
now  occurs  a  series  of  explosive  coughs,  from  ten  to  fifteen  in  number, 
coming  in  such  rapid  succession  that  the  child  can  not  get  his  breath 
between  them;  the  face  becomes  a  deep-red  or  purple  color,  sometimes 
almost  black;  the  veins  of  the  face  and  scalp  stand  out  prominently; 
the  eyes  are  suffused,  and  seem  almost  to  start  from  their  sockets ;  there 
follows  a  long-drawn  inspiration  through  the  narrowed  glottis,  produc- 
ing the  crowing  sound  known  as  the  whoop ;  and  then  another  succession 
of  rapid  coughs  follows  and  another  whoop.  In  a  single  severe  paroxysm, 
which  lasts  several  minutes,  the  child  may  whoop  half  a  dozen  times; 
with  the  final  paroxysm  a  mass  of  tenacious  mucus  is  usually  brought 
up.  In  a  young  child  vomiting  is  almost  certain  to  follow,  if  food 
has  been  recently  taken.  Epistaxis  sometimes  occurs  with  nearly 
every  severe  paroxysm,  but  in  most  cases  the  bleeding  is  slight.  After 
a  severe  attack  the  child  is  at  times  so  exhausted  as  to  be  hardly  able  to 
stand.  There  is  profuse  perspiration ;  his  mind  is  confused,  and  he  may 
be  completely  dazed.  In  infants  the  attack  may  result  in  a  degree  of 
asphyxia  requiring  artificial  respiration.  Those  old  enough  to  describe 
their  sensations  tell  of  a  sense  of  impending  suffocation,  the  suffering 
from  which  is  almost  indescribable. 

The  number  of  severe  paroxysms  or  "kinks"  in  twenty-four  hours 
varies,  according  to  the  severity  of  the  case,  from  half  a  dozen  to  forty 


PERTUSSIS  1007 

or  fifty.  There  are  always  many  more  of  a  milder  form.  Paroxysms 
are  often  excited  by  eating  or  drinking  anything  cold,  by  a  draught  of 
air,  or  by  imitation;  they  are  usually  more  frequent  during  the  night 
than  the  day,  and  in  a  close  room  than  in  the  open  air. 

In  less  severe  cases  no  paroxysms  of  the  grade  above  described  may 
occur,  and  no  typical  whoop  may  be  heard  throughout  the  attack;  but 
the  paroxysmal  nature  of  the  cough  which  continues  until  the  plug  of 
mucus  is  expelled,  the  watery  eyes,  and  the  vomiting  which  follows  a 
paroxysm,  stamp  the  disease  as  pertussis.  In  young  infants  the  whoop 
is  frequently  not  marked.  The  child  sometimes  coughs  until  he  is  as- 
phyxiated, and  yet  no  whoop  occurs.  The  paroxysms  are  also  modified 
by  intercurrent  disease,  especially  by  attacks  of  pneumonia  or  severe 
bronchitis.  At  such  times  they  usually  become  less  frequent  and  less 
typical,  and  may  be  absent  for  several  days,  returning  as  the  complica- 
tion subsides. 

The  seat  of  the  irritation  which  produces  the  cough  has  been  vari- 
ously located  by  different  observers.  Some  have  thought  it  to  be  in  the 
nose,  others  in  the  trachea,  the  bronchi,  or  the  larynx.  It  is  very  prob- 
able that  it  may  not  always  be  in  the  same  place  and  that  the  infectious 
catarrh,  which  is  really  the  most  important  element  in  the  disease,  may 
vary  in  its  intensity  and  location  in  different  cases.  The  weight  of  evi- 
dence seems  to  be  that  in  the  great  majority  of  cases  the  source  of  irrita- 
tion is  in  the  larynx  or  trachea.  From  laryngoscopic  examinations  made 
during  the  disease.  Von  Herff  found  the  mucous  membrane  of  the  larynx 
to  be  swollen  and  congested,  aud  occasionally  the  seat  of  small  hemor- 
rhages or  superficial  ulcers.  He  states  that  the  frequency  and  severity 
of  the  paroxysms  corresponded  with  the  degree  of  laryngitis,  and  he 
found  that  a  paroxysm  could  always  be  excited  by  irritating  the  mucous 
membrane  between  the  arytenoid  cartilages.  During  a  paroxysm  he 
observed  that  there  was  a  collection  of  mucus  on  the  posterior  laryngeal 
wall,  the  removal  of  which  had  the  effect  of  shortening  the  paroxysm. 

Eossbach  made  laryngoscopic  examinations,  with  negative  results  so 
far  as  the  larynx  was  concerned,  but  he  states  that  a  plug  of  mucus  could 
always  be  seen  in  the  lower  trachea  for  one  or  two  minutes  before  the 
paroxysm  occurred.  There  is  little  doubt  that  this  collection  of  mucus 
is  the  exciting  cause  of  the  paroxysm,  as  it  is  a  familiar  clinical  fact  that 
the  paroxysm  continues  until  this  is  dislodged. 

The  average  duration  of  the  spasmodic  stage  is  about  one  month. 
It  increases  in  intensity  for  the  first  two  weeks,  remains  stationary  for 
about  a  week,  and  then  gradually  diminishes  in  severity.  The  course  and 
duration  of  this  stage  are,  however,  subject  to  wide  variations.  In  mild 
cases  it  may  last  only  a  week;  in  severe  cases,  especially  in  the  winter 


1008  THE  SPECIFIC  INFECTIOUS  DISEASES 

season,  it  may  continue  for  three  months,  at  times  almost  subsiding,  but 
lighting  up  again  with  all  its  previous  severity  with  every  fresh  catarrhal 
attack.  After  it  has  entirely  ceased  the  whoop  may  return  with  an 
attack  of  bronchitis,  and  continue  for  a  month  or  more.  This  is  not  to^ 
be  regarded  as  a  true  relapse  of  pertussis.  The  habit  of  the  paroxysmal 
cough  once  established,  it  tends  to  recur  with  every  slight  bronchitis, 
often  for  months  afterward. 

The  Stage  of  Decline.— GTadnallj  the  severity  of  the  paroxysms 
abates,  the  whoop  ceases,  and  the  cough  resembles  more  and  more  that 
of  ordinary  bronchitis.  This  stage  usually  continues  about  three  weeks, 
but  may  be  prolonged  indefinitely  in  the  winter  months. 

Complications..— 7Temo?T/ia^e6>. — The  hemorrhages  of  pertussis  are 
mechanical,  and  depend  upon  the  intense  venous  congestion  which  ac- 
companies the  paroxysm.  Epistaxis  is  the  most  frequent  variety,  and 
occurs  in  a  considerable  proportion  of  the  severe  cases,  in  a  few  with 
almost  every  severe  paroxysm,  but  it  is  rarely  severe  enough  to  require 
local  treatment.  Hemorrhages  from  the  mouth  may  have  their  origin 
either  in  the  pharynx  or  the  bronchi,  the  blood  being  brought  up  by 
the  cough;  such  hemorrhages  are  usually  small.  Conjunctival  hemor- 
rhages are  less  frequent,  and  are  usually  slight,  although  we  have  seen 
the  entire  conjunctiva  covered.  In  a  case  under  our  observation  there 
was  bleeding  from  both  ears  with  every  severe  paroxysm  for  more  than 
a  week.  This  child  had  previously  suffered  from  scarlatinal  otitis,  with 
perforation  of  the  drum  membrane.  Small  extravasations  into  the  cellu- 
lar tissue  beneath  the  eyes  are  occasionally  seen,  giving  an  appearance 
somewhat  like  an  ordinary  "black  eye."  Intracranial  hemorrhages  are 
not  frequent,  but  many  examples  have  been  recorded,  and  they  may 
be  severe  enough  to  produce  death.  They  are  usually  meningeal,  very 
rarely  cerebral ;  according  to  their  extent  and  location  they  may  produce 
hemiplegia,  monoplegia,  aphasia,  facial  paralysis,  or  disturbances  of 
sight,  hearing,  or  sensation;  in  addition,  there  may  be  convulsions  or 
rigidity,  but  rarely  complete  coma.  The  extravasations  are  sometimes 
small  and  the  symptoms  which  they  produce  may  disappear  at  the  end 
of  a  few  weeks.  More  extensive  hemorrhages  cause  serious  results.  In 
almost  every  instance  these  hemorrhages  have  occurred  as  a  direct  result 
of  the  severe  paroxysms.  Purpura  hemorrhagica  is  occasionally  seen 
as  a  sequel  of  pertussis. 

Respiratory  System. — The  most  serious  complications  of  pertussis  are 
connected  with  the  lungs.  By  far  the  largest  proportion  of  deaths  is 
due  to  pulmonary  complications,  usually  bronchopneumonia.  This  is 
more  frequent  in  winter  and  spring  than  in  the  summer  months,  and  is 
especially  to  be  dreaded  during  infancy.     In  later  childhood  lobar  pneu- 


PERTUSSIS  1009 

monia  is  occasionally  seen.  Pneumonia  rarely  begins  before  the  second 
week  of  the  disease,  and  most  frequently  develops  at  the  height  or  toward 
the  close  of  the  spasmodic  stage.  The  physical  signs  present  no  peculiar- 
ities; the  cough  changes  somewhat  in  character  during  the  pneumonia, 
and  the  whoop  may  not  be  heard.  The  prognosis  of  the  pneumonia  is 
bad,  because  of  the  debilitated  condition  of  the  children  at  the  time  of 
its  occurrence.  A  great  danger  is  from  the  supervention  of  convulsions, 
this  being  a  frequent  mode  of  termination.  As  there  is  always  consider- 
able emphysema,  the  rapidity  of  breathing  is  frequently  out  of  proportion 
to  the  temperature,  which  often  is  only  moderately  elevated.  If  the  child 
escapes  the  dangers  of  the  acute  stage,  death  may  still  occur  from  ex- 
haustion, owing  to  the  protracted  course  which  the  disease  frequently 
runs. 

Bronchitis  of  the  large  tubes  is  present  in  almost  all  the  severe  cases, 
and  is  not  of  itself  serious.  Bronchitis  of  the  small  tubes  has  the  same 
dangers  and  the  same  complications  as  bronchopneumonia. 

Vesicular  emphysema  is  invariably  present  in  every  case  of  pertussis 
which  comes  to  autopsy.  A  certain  amount  of  it  certainly  occurs  in 
every  severe  case.  It  is  produced  by  the  forcible  cough  of  the  paroxysm. 
In  very  severe  cases  interstitial  emphysema  is  also  found.  Eupture  of 
the  air-blebs  which  form  on  the  surface  of  the  lung  may  lead  to  em- 
physema of  the  cellular  tissue  of  the  mediastinum,  and  the  air  may  find 
its  way  along  the  great  vessels  into  the  neck,  and  finally  into  the  subcu- 
taneous cellular  tissue  of  the  entire  body.  Cases  of  general  subcutaneous 
emphysema  have  been  reported  by  Croker  and  by  Hodge,  both  of  which 
ended  fatally,  one  in  three  and  one  in  eight  days  from  the  beginning  of 
the  emphysema.  In  the  great  majority  of  the  cases  vesicular  emphysema 
is  not  permanent. 

Digestive  System. — During  the  summer,  infants  with  pertussis  are 
almost  certain  to  suffer  from  diarrhea;  it  may  be  only  an  occasional 
symptom,  or  the  attack  may  be  severe  and  prolonged,  resulting  in  the 
development  of  ileocolitis.  The  intestinal  complications  may  be  almost 
as  serious  in  summer  as  are  those  of  the  respiratory  tract  in  winter. 
Vomiting  is  even  more  frequent  than  diarrhea,  and  while  it  may  be  dis- 
tressing at  any  age,  it  is  especially  so  in  infancy.  So  frequently  does  the 
taking  of  food  excite  vomiting,  that  the  nutrition  of  these  patients  often 
becomes  a  matter  of  the  greatest  difficulty,  and  in  fact  the  most  serious 
problem  in  the  management  of  a  case.  Malnutrition  and  even  marasmus 
may  follow,  or  the  general  resistance  of  the  child  may  become  so  reduced 
by  lack  of  food  that  he  falls  a  ready  prey  to  pneumonia. 

Nervous  System. — There  may  be  convulsions,  coma,  paralysis, 
aphasia,  disturbances  of  sight  or  hearing,  and  in  rare  cases  even  th^ 


1010  THE  SPECIFIC  INFECTIOUS  DISEASES 

mental  condition  may  be  affected.  The  most  serious  of  these  complica- 
tions are  convulsions.  They  are  much  more  freqvient  in  infancy  than 
later,  and  particularly  in  those  who  are  rachitic,  in  whom  they  are  often 
fatal.  Convulsions  are  of  course  more  common  in  severe  attacks,  but  they 
may  occur  suddenly  when  there  has  previously  been^^no  cause  for 
anxiety.  They  are  especially  to  be  dreaded  if  pneumonia  is  present. 
The  attack  of  convulsions  may  be  the  culmination  of  the  extreme  degree 
of  nervous  irritability  which  accompanies  the  paroxysm,  it  may  be  due 
to  asphyxia,  or  to  an  intracranial  lesion;  if  the  latter,  there  is  usually 
meningeal  hemorrhage.  This  is  to  be  suspected  if  there  are  continued 
convulsions  for  several  hours,  with  general  rigidity  or  hemiplegia. 

Disturbances  of  sight  are  not  infrequent  in  severe  cases;  usually 
these  are  transient,  but  there  may  be  blindness  lasting  two  or  three  days 
or  even  weeks.  The  transient  symptoms  depend  most  likely  upon  cir- 
culatory changes  that  occur  in  the  brain  during  the  paroxysm,  while 
those  which  last  for  two  or  three  weeks  are  probably  due  to  meningeal 
hemorrhage.  Disturbances  of  hearing  are  rare.  The  different  forms 
of  paralysis  occurring  with  pertussis  may  likewise  be  transient  or  per- 
manent. They  are  to  be  explained  in  the  same  way  as  the  disturbances 
of  the  special  senses.     The  most  common  form  is  hemiplegia. 

Albuminuria  is  not  infrequent,  being  found  in  sixty-eight  of  eighty- 
six  examinations  by  Knight.  The  quantity  of  albumin  is  rarely  large, 
and  it  may  be  accompanied  by  a  few  hyaline  casts.  Both  are  probably 
the  result  of  circulatory  disturbances  in  the  kidney.  Other  complica- 
tions of  pertussis  are  hernia,  prolapsus  ani,  and  ulcer  of  the  frenum 
linguae. 

Diagnosis. — The  only  constant  features  of  pertussis  are  the  course  of 
the  disease  and  its  communicability.  In  many  cases  the  typical  whoop 
is  never  heard.  There  are  no  symptoms  by  which  a  positive  diagnosis 
can  be  made  in  the  catarrhal  stage;  but  a  cough  not  accompanied  by 
fever  or  physical  signs,  which  steadily  increases  in  severity  foi;  two  weeks, 
in  spite  of  treatment,  and  which  occurs  chiefly  at  night,  is  always  suspi- 
cious. When,  in  addition,  the  cough  begins  to  come  in  paroxysms,  ac- 
companied by  suffusion  of  the  face  and  occasionally  by  vomiting,  there 
can  be  little  doubt  even  though  no  whoop  is  heard.  If  the  disease  is 
prevalent  the  diagnosis  is  practically  certain.  Mild  cases  which  do  not 
go  even  as  far  as  the  symptoms  mentioned  are  most  puzzling.  But  if 
there  is  a  history  of  exposure,  if  the  cough  continues  from  four  to  six 
weeks,  little  influenced  by  treatment,  and  if  other  typical  cases  follow,  the 
disease  must  be  pertussis.  Without  evidence  of  communicability,  how- 
ever, one  may  be  in  doubt  even  after  the  disease  is  over.  In  certain  cases 
of  influenza  there  may  be  a  paroxysmal  cough  which  by  its  symptoms 


PERTUSSIS  1011 

and  course  can  not  be  distinguished  from  pertussis,  but  which  may  be 
recognized  by  an  examination  of  the  blood  and  sputum  (vide  Influenza). 

In  early  infancy  any  cough  may  have  more  or  less  of  a  spasmodic 
character,  and  a  fairly  typical  whoop  is  often  heard  in  the  course  of  an 
ordinary  bronchitis.  We  have  several  times  seen  abortive  or  very  short 
attacks  in  one  member  of  a  family  of  children,  the  others  having  the  dis- 
ease in  a  typical  form.  Occurring  by  themselves  such  cases  can  not  be 
recognized. 

Irritation  of  the  pneumogastric  or  recurrent  laryngeal  nerve  from 
tuberculous  tracheal  or  bronchial  lymph  nodes,  or  from  a  foreign  body 
in  the  air  passages,  may  give  rise  to  a  spasmodic  cough,  which  in  certain 
cases  may  be  indistinguishable  from  pertussis.  The  prolonged  duration 
of  the  symptoms  is  sometimes  the  only  diagnostic  point ;  but  the  par- 
oxysms are  usually  not  so  severe  as  in  true  pertussis,  and  the  course  is 
generally  less  typical. 

The  blood  examination  is  of  much  assistance  in  diagnosis.  The 
leucocytosis  accompanying  pertussis  far  exceeds  that  of  any  other  afebrile 
disease  of  the  respiratory  tract.  It  appears  in  the  early  part  of  the  con- 
vulsive stage,  and  disappears  slowly  with  improvement.  The  total 
count  is  usually  between  15,000  and  30,000,  although  it  may  reach 
50,000.  There  is  a  great  increase  in  the  lymphocytes  at  the  expense  of 
the  polymorphonuclear  neutrophiles.  The  lymphocytes  may  form  60 
to  80  per  cent  of  the  total  leucocytes.  The  leucocytosis  is  little  influenced 
by  complications,  and  even  during  bronchopneumonia  the  lymphocytes 
may  continue  to  be  in  excess. 

Prognosis. — The  most  important  factor  in  the  prognosis  of  the  dis- 
ease is  the  age  of  the  patient.  After  the  fourth  year  it  is  indeed  rare 
that  either  a  fatal  result  or  serious  complications  are  seen;  but  during 
infancy,  and  particularly  during  the  first  year,  there  are  few  diseases 
more  to  be  dreaded.  This  is  especially  true  on  account  of  the  connection 
of  whooping-cough  with  the  three  most  fatal  conditions  of  infancy 
— bronchopneumonia,  diarrheal  diseases,  and  convulsions.  Fully  two- 
thirds  of  the  deaths  from  whooping-cough  occur  during  the  first  year  of 
life.  The  prognosis  is  very  much  worse  in  infants  under  three  months 
than  in  those  who  are  older  and  consequently  have  more  resistance.  It 
is  better  in  the  summer  than  in  the  winter,  because  bronchopneumonia 
is  then  less  frequent.  It  is  particularly  bad  in  delicate  infants,  in  those 
who  are  rachitic,  in  those  who  are  prone  to  attacks  of  bronchitis,  in 
those  who  have  suffered  previously  from  pneumonia,  and  in  those  with 
a  strong  tendency  to  tuberculosis. 

The  exact  mortality  of  whooping-cough  it  is  difficult  to  state  in  fig- 
ures.    During  the  first  year  of  life  it  is  probably  not  far  from  twenty-five 


1012  THE  SPECIFIC  INFECTIOUS  DISEASES 

per  cent^  although  it  diminishes  rapidly  after  this  time.  In  foundling 
asylums  and  hospitals  for  infants  it  is  to  be  ranked  among  the  most 
fatal  diseases^  and  in  some  epidemics  the  mortality  in  such  institutions 
is  as  high  as  fifty  per  cent. 

Fully  two-thirds  of  the  deaths  during  whooping-cough  are  from 
bronchopneumonia;  the  next  most  frequent  cause  is  diarrheal  diseases. 
Convulsions  may  be  the  mode  of  death  in  either  of  the  above  conditions, 
or  may  occur  apart  from  them.  During  the  first  year,  death  often  results 
from  marasmus,  the  child  having  been  reduced  by  the  prolonged  disease. 
Occasionally  death  is  due  to  asphyxia  following  a  severe  paroxysm,  to 
intracranial  hemorrhage,  or  to  general  emphysema. 

As  a  predisposing  cause  of  generalized  tuberculosis,  pertussis  is  sec- 
ond only  to  measles.  In  both  diseases  tuberculosis  develops  in  much  the 
same  way  and  from  practically  the  same  causes. 

Prophylaxis. — Pertussis  is  a  contagious  disease,  and  a  child  sufiEering 
from  it  should  be  isolated  from  other  children  whenever  this  is  possible. 
Children  with  pertussis  should  never  be  allowed  to  attend  school,  and 
needless  exposure  should  always  be  avoided. 

Young  infants,  delicate  children,  and  those  with  a  predisposition  to 
tuberculosis,  should  be  most  carefully  protected  against  exposure,  since 
it  is  in  them  chiefly  that  the  disease  is  likely  to  be  serious.  As  it  is 
from  the  patient  that  the  disease  is  nearly  always  contracted,  there 
does  not  exist  the  same  necessity  for  the  careful  disinfection  of  apart- 
ments as  after  other  contagious  diseases.  In  institutions,  however, 
this  should  always  be  practiced,  and  in  private  houses  if  the  room  is 
subsequently  to  be  occupied  by  an  infant.  The  prophylactic  use  of 
vaccines  is  referred  to  under  Treatment. 

It  is  as  undesirable  as  it  is  impossible  to  confine  a  child  with  per- 
tussis to  a  single  room  during  the  attack;  all  those  persons  for  whom 
exposure  would  be  dangerous  should  therefore  be  sent  away  from  the 
house.  Quarantine  should  continue  for  at  least  six  weeks,  or  until  the 
spasmodic  stage  is  over. 

Treatment. — We  have  as  yet  no  specific  remedy  for  pertussis.  The 
important  thing  in  most  cases  is  the  hygiene  or  general  management  of 
the  case;  fully  half  of  the  cases  seen  in  practice  require  nothing  more. 
Much  harm  is  done  by  indiscriminate  drug  giving. 

General  Measures. — Fresh  air  is  important  throughout  the  attack. 
It  is  almost  invariable  that  the  paroxysms  are  fewer  while  patients  are 
out  of  doors,  and  more  frequent  when  they  are  in  close  rooms.  Older 
children  with  pertussis  may  go  out  even  in  winter  except  on  stormy,  raw, 
or  windy  days.  With  infants  and  delicate  children,  however,  the  outdoor 
treatment  in  cold  weather  so  enthusiastically  advocated  by  some  writers 
should  be  used  with  the  greatest  caution.     It  should  not  be  permitted 


PERTUSSIS  1013 

if  the  patient  has  even  the  slightest  amount  of  bronchitis.  Our  experi- 
ence is  that  during  the  winter  in  a  climate  like  that  of  New  York  or 
New  England,  the  class  of  patients  just  referred  to  are  better  ofE  indoors, 
taking  their  airing  in  their  rooms.  In  warm  weather  or  in  a  mild 
climate  all  children  should  be  kept  in  the  open  air  as  much  as  possible. 

A  change  of  climate  is  desirable  when  the  cough  is  unduly  prolonged, 
also  for  delicate  children  in  winter.  A  warm  place  at  the  seashore  is 
one  which  is  most  likely  to  be  beneficial.  The  improvement  following  a 
sea  voyage  is  often  very  marked,  surpassing  even  a  residence  at  the  sea- 
shore. 

The  rooms  occupied  by  children  suffering  from  pertussis  should  be 
frequently  changed,  thoroughly  aired  and  cleaned.  A  change  of  roopas, 
clothing,  bedding,  etc.,  sometimes  exerts  a  marked  influence  on  the  course 
of  very  prolonged  attacks,  the  inference  being  that  continued  re-mfection 
takes  place.  Such  a  change  should  be  made  twice  a  week,  and  it  is  of 
special  importance  in  hospitals,  where  many  children  quarantined  in  a 
single  ward  seem  to  cough  interminably. 

Careful  feeding  and  attention  to  the  bowels  are  matters  of  the 
greatest  importance;  with  infants  particularly,  chronic  indigestion  and 
abdominal  distention  have  a  very  marked  efEect  in  increasing  the  fre- 
quency of  the  paroxysms.  The  abdominal  support  furnished  by  a  snugly 
fitting  band,  adds  materially  to  the  comfort  of  the  patient  in  a  severe 
attack.  Feeding  is  difficult  since  vomiting  occurs  so  easily.  In  most 
cases  it  is  necessary  to  repeat  the  meal  in  a  short  time,  if  the  first  one 
has  been  vomited.  Children  over  two  years  old  should  in  all  such  cases 
be  kept  largely  upon  a  fiuid  diet ;  the  meals  should  be  smaller  and  more 
frequent  than  in  health.  For  infants,  milk  should  be  modified  according 
to  the  child's  digestive  symptoms.  Any  medication  which  causes  dis- 
turbance of  the  stomach  should  be  omitted. 

Local  applications  to  the  rhinopharynx  or  to  the  larynx  by  means  of 
a  spray  or  sM-ab  have  been  advocated  by  many.  "We  have  never  seen  the 
beneficial  results  claimed,  and  believe  them  to  be  exaggerated.  The 
application  of  cocain  to  the  larynx  should  under  no  circumstances  be  em- 
ployed in  young  children. 

Inhalations  are  of  much  more  value.  They  are  useful  to  modify  the 
catarrh  by  allaying  irritation,  facilitating  the  expulsion  of  the  mucus, 
and  possibly  as  antiseptics.  Those  most  employed  are  creosote  and  cres- 
olene.  In  our  experience  creosote  is  the  best.  These  substances  may  be 
used  upon  cotton  in  a  respirator,  or  vaporized  over  an  alcohol  lamp.  The 
possibility  of  absorption  should  not  be  forgotten,  and  the  urine  should  be 
watched.  When  the  paroxysms  are  frequent  and  of  great  severity,  chloro- 
form may  be  used  to  ward  off  convulsions  or  prevent  dangerous  asphyxia. 
In  such  conditions  O'Dwyer  used  intubation  with  striking  benefit.     The 


1014  THE   SPECIFIC    INFECTIOUS    DISEASES 

tube  entirely  overcomes  the  glottic  spasm  which  is  the  chief  cause  of 
suffering  and  danger. 

Internal  Medication. — Of  the  innumerable  drugs  which  have  been 
recommended  for  this  disease,  there  are  two  which  possess  undoubted 
advantages  over  all  others,  viz.,  belladonna  and  antipyrin.  In  giving 
belladonna  it  is  important  to  begin  with  a  small  dose  and  cautiously  in- 
crease both  its  frequency  and  size.  To  an  infant  two  years  old,  one- 
fourth  of  a  minim  of  the  fluid  extract  may  be  given  every  four  hours  as 
an  initial  dose,  gradually  increasing  to  every  two  hours;  if  atropin  is 
used,  gr.  1-800  may  be  given  in  the  same  way.  Although  belladonna 
usually  has  a  decided  influence  in  reducing  both  the  frequency  and  the 
severity  of  the  paroxysms,  it  causes  many  unpleasant  symptoms,  and  its 
effects  must  be  closely  watched. 

Antipyrin  has  been  in  our  experience  more  generally  useful  than 
any  other  single  drug.  It  may  be  given  with  safety,  even  to  young  in- 
fants, in  considerably  larger  doses  than  are  ordinarily  employed.  For  a 
child  six  months  old  the  initial  dose  may  be  one  grain  every  three  hours ; 
later  this  may  be  given  every  two  hours.  For  a  child  two  years  old  the 
initial  dose  may  be  two  grains  repeated  every  four  to  six  hours,  gradually 
increasing  up  to  two  grains  every  two  hours.  Should  pneumonia  develop, 
the  antipyrin  should  be  discontinued.  A  combination  of  the  bromid  of 
sodium  with  antipyrin  is  often  better  than  the  latter  given  alone. 

Nearly  all  drugs  which  allay  nervous  irritability  have  a  certain 
amount  of  effect  in  controlling  the  paroxysms  of  pertussis;  codein, 
chloral,  and  trional  are  useful  where  the  night  attacks  are  so  severe  as  to 
prevent  sleep.  We  do  not  believe  that  any  form  of  internal  medication 
or  local  treatment  shortens  pertussis;  but,  inasmuch  as  the  disease  is 
self -limited,  great  benefit  to  the  patient  results  from  the  reduction  of  the 
number  and  the  diminution  of  the  severity  of  the  paroxysms. 

Vaccines  have  been  much  employed  in  the  treatment  of  pertussis  dur- 
ing recent  years  with  exceedingly  variable  results.  Vaccines  made  from 
stock  cultures  of  the  Bordet-Gengou  bacillus  have  been  most  widely 
used.  Several  facts  militate  against  success  by  this  treatment :  first, 
our  uncertainty  regarding  the  bacterial  cause.  While  the  Bordet-Gen- 
gou bacillus  has  been  altogether  most  frequently  found,  a  paroxysmal 
cough  which  clinically  is  indistinguishable  from  pertussis  may  be  asso- 
ciated with  the  different  forms  of  so-called  hemoglobinophilic  bacteria. 
In  the  second  place  there  are  apparently  several  distinct  strains  of  the 
Bordet  bacillus.  The  evidence  as  to  curative  value  of  vaccines  is  as  yet 
inconclusive.  There  is  somewhat  more  evidence  that  they  are  useful  as 
a  means  of  prophylaxis;  but  this  point  is  by  no  means  established.  How- 
ever, inasmuch  as  they  are  harmless  the  use  of  vaccines  is  advisable  as 
a  preventive  measure  in  the  case  of  young  infants  exposed.     The  question 


MUMPS  1015 

of  therapeutic  dosage  is  still  unsettled;  from  25  to  100  millions,  accord- 
ing to  the  age  of  the  child,  repeated  every  two  to  four  days  is  at  present 
to  be  advised.  For  prophylaxis  full  doses  are  also  needed ;  they  should  be 
repeated  for  three  or  four  doses  at  intervals  of  five  or  six  days. 

In  establishing  the  value  of  any  method  of  treatment,  it  should  be  re- 
membered that  the  number  of  cases  in  which  the  duration  of  the  disease 
is  short  is  quite  large,  and  also  that  almost  any  method  of  treatment  if 
employed  after  the  attack  has  reached  its  height  will  be  thought  beneficial, 
as  the  natural  tendency  is  then  to  improve.  The  value  of  any  particular 
line  of  treatment  is  to  be  judged  in  a  given  case  only  by  its  effect  in 
reducing  the  number  and  severity  of  the  paroxysms.  This  ought  to  be 
evident  in  the  case  of  drugs  or  vaccines  within  a  few  days,  and  can  only 
be  determined  by  keeping  a  careful  record  of  the  number  of  severe 
paroxysms  day  and  night. 

In  a  mild  case,  when  the  number  of  paroxysms  does  not  exceed  eight 
or  ten  during  the  day,  when  there  is  no  vomiting  and  the  general  health 
ir  not  affected,  it  is  not  usually  advisable  to  continue  the  administra- 
tion of  any  drug  throughout  the  disease.  A  single  dose  of  antipyrin 
or  codein  at  night  may  be  all  that  is  necessary.  All  cases  in  infants 
must  be  watched  with  great  care  and  the  parents  warned  of  the  possible 
dangers  M^hich  may  supervene  suddeiily,  even  in  the  course  of  mild 
attacks.  For  severe  cases  antipyrin  should  be  given  to  diminish  the 
frequency  and  the  severity  of  the  paroxysms,  and  inhalations  of  creosote 
used  if  much  catarrh  is  present.  All  the  fresh  air  possible  should  be 
allowed,  but  without  exercise.  For  older  children  the  same  plan  of  treat- 
ment may  be  followed,  or  quinin  or  belladonna  may  be  substituted  for  the 
antipyrin. 

As  these  drugs  are  given  solely  for  the  purpose  of  diminishing  the 
frequency  and  severity  of  the  paroxysms,  their  continuous  use  should 
be  deferred  until  the  symptoms  are  sufficiently  severe  to  greatly  disturb 
the  child,  the  benefit  at  this  period  being  more  striking  than  if  they  are 
begun  early  and  used  continuously. 


CHAPTER  yil 

MUMPS 
{Epidemic  Parotitis) 

Mumps  is  a  contagious  disease  characterized  by  swelling  of  the  par- 
otid, and  sometimes  of  the  other  salivary  glands,  with  constitutional 
symptoms  which  are  usually  mild.     Both  severe  complications  and  a 


1016  THE    SPECIFIC    INFECTIOUS   DISEASES 

fatal  termination  are  extremely  infrequent.     The  disease  is  not  a  very 
common  one,  and  general  epidemics  are  not  common. 

Pathology  and  Lesions. — The  contagious  character,  regular  incuba- 
tion period  and  typical  course,  stamp  the  disease  as  a  general  one  due  to  a 
specific  organism,  but  this  has  not  been  definitely  determined.  Unques- 
tionably the  virus  is  present  in  the  saliva  of  affected  persons  and  in  all 
probability  the  poison  is  eliminated  by  Steno's  duct.  By  inoculating  the 
saliva  from  patients  vs^ith  mumps  into  the  parotid  gland  of  cats,  WoU- 
stein  has  reproduced  a  similar  disease  in  these  animals  with  typical 
symptoms  and  transferred  this  again  to  other  animals  with  the  produc- 
tion of  the  same  symptoms.  It  has  long  been  a  popular  tradition  that 
domestic  cats  were  occasionally  the  subjects  of  mumps. 

The  precise  nature  of  the  changes  in  the  gland  is  still  a  matter  of 
dispute,  as  opportunities  for  pathological  examination  are  very  rare. 
From  existing  evidence  it  would  appear  that  the  gland  substance  is  first 
involved,  and  afterward  the  surrounding  connective  tissue.  The  gland 
is  the  seat  of  an  intense  hyperemia  and  edema;  the  walls  of  the  salivary 
ducts  are  swollen,  and  the  ducts  are  obstructed.  While  the  primary  dis- 
ease does  not  tend  to  excite  suppuration,  pyogenic  germs  may  occasionally 
gain  entrance  and  an  abscess  form;  but  this  is  to  be  regarded  as  a  rare 
accidental  infection. 

In  the  great  proportion  of  cases  the  parotids  alone  are  affected,  al- 
though the  same  changes  are  occasionally  found  in  the  other  salivary 
glands.  There  are  no  other  essential  lesions  of  the  disease,  those  which 
are  found  depending  upon  complications. 

Etiology. — Mumps  is  spread  by  contagion,  close  contact  being  usually 
required  to  communicate  the  disease,  although  it  is  known  to  have  been 
carried  by  a  "third  person  and  even  by  clothing.  The  susceptibility  of 
children  to  the  poison  of  mumps  is  much  less  than  is  the  case  with  the 
other  contagious  diseases,  so  that  only  a  small  number  of  those  who  are 
exposed  take  the  disease.  The  greatest  predisposition  is  between  the 
fourth  and  fourteenth  years.  Infants  are  rarely  affected,  although  a 
case  in  a  child  three  weeks  old  is  vouched  for  by  so  good  an  observer  as 
Demme. 

Mumps  is  contagious  from  the  beginning  of  the  symptoms.  Two 
cases  have  come  under  our  notice  in  which  the  disease  was  communicated 
before  any  swelling  was  seen.  It  is  impossible  to  fix  with  certainty  the 
duration  of  the  infective  period.  The  disease  is  undoubtedly  communi- 
cable for  a  few  days  after  the  swellirig  has  subsided;  and  for  safety  a 
case  should  be  isolated  for  three  weeks  from  the  beginning  of  symptoms, 
or  one  week  after  the  swelling  has  disappeared. 

Incubation. — In  forty-eight  collected  cases  in  which  the  incuba- 
tion was  definitely  determined,  it  varied  between  three  and  twenty-five 


MUMPS  1017. 

days.  It  was  less  than  fourteen  clays  in  only  four  cases^,  and  in  twenty-six 
of  the  forty-eight  cases  it  was  between  seventeen  and  twenty  days.  In 
three  cases  of  our  own  in  which  it  could  be  definitely  fixed,  the  incubation 
was  nineteen  days  in  one  case  and  twenty  days  in  two  cases.  The  average 
period  of  incubation,  then,  may  be  stated  to  be  from  seventeen  to  twenty 
days. 

Symptoms. — In  the  milder  eases  the  local  symptoms  are  the  first  to 
attract  attention;  in  those  which  are  more  severe  there  are  frequently 
prodromal  symptoms  of  from  twelve  to  forty-eight  hours'  duration — 
anorexia,  headache,  vomiting,  pains  in  the  back  and  limbs,  and  fever. 
Soltmann  has  reported  a  case  ushered  in  by  convulsions.  The  initial 
temperature  in  a  mild  attack  is  100°  to  101°  F. ;  in  a  severe  one,  from 
102°  to  104°  F. 

Of  the  local  symptoms,  the  pain  usually  precedes  the  swelling;  it  is 
increased  by  movement  of  the  jaws,  by  pressure,  and  sometimes  by  the 
presence  of  acid  substances  in  the  mouth.  It  is  usually  referred  to  the 
posterior  part  of  the  jaw  just  below  the  ear.  The  swelling  may  begin 
simultaneously  in  both  parotids,  but  more  frequently  one  side  is  involved 
a  day  or  two  in  advance  of  the  other.  It  usually  reaches  its  maximum  on 
the  third  day,  remains  stationary  for  two  or  three  days,  and  then  sub- 
sides gradually.  The  degree  of  swelling  varies  with  the  severity  of  the 
attack.  When  it  is  marked,  the  patient  may  be  so  changed  in  appear- 
ance as  scarcely  to  be  recognizable.  The  swelling  fills  the  lateral  region 
of  the  neck,  between  the  jaw  and  the  sternomastoid  muscle  and  extends 
forward  upon  the  face  to  the  zygomatic  arch,  so  that  the  center  of 
the  tumor  is  usually  the  lobe  of  the  ear.  The  other  salivary  glands 
may  swell  simultaneously  with  the  parotids,  or  several  days  later,  even 
after  the  parotid  tumor  has  disappeared.  Occasionally  swelling  of  the, 
submaxillary  or  the  sublingual  glands  occurs  before  that  of  the  parotid, 
and  in  rare  instances  these  may  be  the  only  glands  affected. 

As  a  rule,  the  parotid  of  each  side  is  involved.  Of  282  cases  both 
sides  were  affected  in  215.  When  one  side  alone  is  involved,  it  is  the 
left  a  little  more  frequently  than  the  right.  The  interval  between  the 
swelling  of  the  two  sides  may  be  a  week,  or  even  five  or  six  weeks,  but 
usually  it  is  only  two  or  three  days. 

The  salivary  secretion  is  usually  very  much  diminished,  and  the  dry 
mouth  causes  great  discomfort.  Exceptionally,  distressing  salivation 
occurs,  the  secretion  amounting  to  six  or  eight  ounces  daily. 

Although  as  a  rule  the  patient  is  not  seriously  ill,  mumps  may  in 
rare  cases  produce  most  alarming  and  even  dangerous  symptoms.  The 
temperature  may  for  several  days  reach  104°  F.  or  more,  deglutition  may 
be  extremely  difficult,  pressure  on  the  jugular  veins  may  lead  to  venous 
hyperemia  of  the  brain,  causing  headache  and  sometimes  delirium;  there 


1018  THE    SPECIFIC    INFECTIOUS   DISEASES 

is  sometimes  great  prostration  and  tlie  symptoms  of  the  typhoid  condi- 
tion. These  severe  attacks  are  nearly  always  in  patients  over  twelve 
years  old.  ^ 

The  constitutional  symptoms  of  mumps  usually  last  from  three  to 
five  days;  the  swelling  continues  on  an  average  about  a  week.  If  the 
case  has  been  a  severe  one,  slight  swelling  may  continue  for  two  weeks 
or  even  longer.  Eelapses,  in  which  the  opposite  side  from  the  one  first 
affected  is  involved,  are  quite  frequent,  occurring  in  about  ten  per  cent 
of  the  cases. 

The  blood  findings  in  mumps  are  quite  characteristic.  The  total 
leucocytes  vary  considerably ;  they  may  be  normal  or  there  may  be  a  leu- 
eopenia  throughout  the  disease.  There  is  a  constant  reduction  in  the 
polymorphonuclears  and  an  actual  and  relative  increase  in  the  lympho- 
cytes. 

Complications  and  Sequelae. — In  childhood  the  complications  are  few 
and  usually  unimiDortant ;  but  in  adolescence  they  are  occasionally  seri- 
ous. Orchitis  is  exceedingly  rare  in  childhood;  of  230  cases  observed 
by  Rilliet  and  Barthez,  this  was  seen  in  but  ten,  and  only  three  of  these 
cases  were  in  children  under  fifteen  years,  and  no  case  in  one  under 
twelve  years  old.  ^^^len  orchitis  occurs  it  is  generally  toward  the  end 
of  the  second  or  the  beginning  of  the  third  week;  it  is  usually  marked 
by  an  accession  of  fever,  sometimes  by  a  chill;  if  severe,  nervous  symp- 
toms may  be  present.  The  body  of  the  testicle  and  not  the  epididymis 
is  generally  affected.  The  acute  symptoms  continue  for  three  or  four 
days,  and  the  entire  duration  of  the  attack  is  about  a  week ;  although  the 
testicle  is  often  enlarged  for  some  time  afterward,  and  atrophy  of  the 
organ  may  follow.  When  orchitis  is  double,  sterility  may  be  the  con- 
sequence. 

In  females,  congestion  and  swelling  of  the  breasts,  ovaries,  or  labia 
majora  may  occur;  and,  although  these  complications  are  all  very  rare, 
most  of  them  have  been  observed  even  in  young  children.  The  inter- 
relation between  the  parotids  and  the  sexual  glands  has  not  yet  received 
a  satisfactory  ex2:)lanation. 

Xephritis  has  in  a  few  instances  followed  mumps,  sometimes  coming 
on  as  late  as  four  or  five  weeks  after  the  attack.  Single  cases  have  been 
reported  by  Croner,  Isham,  Henoch,  and  others.  Xervous  sequelae  are 
more  frequent,  but  even  these  are  rare.  We  have  seen  multiple  neuritis 
in  a  boy  of  twelve  which  developed  two  weeks  after  a  severe  attack  of 
mumps.  The  paralysis  was  general,  lasted  for  six  weeks,  and  was  fol- 
lowed by  complete  recovery.  Jaffrey  has  reported  a  similar  case.  Facial 
paralysis  three  weeks  after  mumps  has  been  reported  by  Hillier,  appar- 
ently due  to  an  extension  of  inflammation  from  the  gland  to  the  seventh 
nerve.     Meningitis  may  occur  as  a  complication  of  mumps.     We  have 


MUMPS  1019 

seen  one  such  case  accompanied  by  high  fever,  delirium,  opisthotonus, 
and  a  turbid  cerebrospinal  fluid  containing  a  great  many  polymorphonu- 
clear cells.  It  was,  however,  sterile.  The  child  recovered  after  five 
days'  illness. 

Pearce  has  collected  an  interesting  series  of  forty  cases  of  deafness 
following  mumps,  in  which  there  was  no  sign  of  otitis,  the  symptoms 
coming  on  suddenly  with  vertigo,  a  staggering  gait,  and  often  with 
vomiting.  In  most  of  the  cases  the  deafness  was  unilateral  and  the  loss 
of  hearing  was  permanent.  The  cause  assigned  was  disease  of  the  au- 
ditory nerve,  the  seat  of  the  trouble  being  in  the  labyrinth.  Toynbee 
has  reported  ah  instance  of  hemorrhage  into  the  labyrinth.  Otitis  media 
is  rarely  seen. 

Suppuration  of  the  parotid  gland  occurs  in  about  one  per  cent  of  the 
cases,  and  is  probably  due  to  accidental  infection.  Gangrene  and  slough- 
ing of  the  parotid  were  observed  twice  by  Demme  in  117  cases;  both  of 
these  proved  fatal.  Pneumonia,  meningitis,  endocarditis,  and  pericar- 
ditis have  been  observed  as  complications  of  mumps,  although  all  are 
extremely  rare. 

Prognosis. — In  the  great  proportion  of  cases  mumps  is  a  mild  dis- 
ease, and  terminates  in  complete  recovery  in  a  few  days.  In  young 
children  complications  are  infrequent,  and  those  which  occur  are  rarely 
severe. 

Diagnosis. — Mumps  is  most  likely  to  he  confounded  with  acute  swell- 
ing of  the  cervical  lymph  nodes.  In  a  parotid  swelling,  the  lobe  of  the 
ear  is  near  the  center  of  the  tumor,  which  extends  backward  to  the 
sternomastoid  muscle  and  forward  upon  the  face  as  far  as  the  zygomatic 
arch,  embracing  the  angle  and  ramus  of  the  jaw. 

A  swollen  lymph  node  is  usually  entirely  below  the  ear  and  behind 
the  jaw,  not  extending  upon  the  face.  The  tumor  is  generally  smaller 
and  more  circumscribed  if  only  a  single  node  is  involved,  and  it  comes 
on  much  more  slowly  than  does  mumps.  When  only  the  submaxillary 
or  sublingual  glands  are  affected,  the  diagnosis  from  swollen  lymph  nodes 
is  sometimes  impossible  except  by  the  course  of  the  disease.  Mumps  is 
characterized  by  the  rapidity  with  which  the  swelling  occurs,  and  by  its 
relatively  short  duration. 

Treatment. — The  disease  is  self-limited  and  the  individual  symptoms 
rarely  distressing,  so  that  in  most  cases  very  little  treatment  is  required. 
If  constitutional  symptoms  are  present  the  patient  should  be  kept  in 
bed,  and  if  there  are  none  he  should  be  confined  to  the  house.  The  gland 
should  be  protected  by  flannel  or  absorbent  cotton,  and  if  the  pain  is 
severe  heat  should  be  applied.  The  diet  should  be  liquid,  on  account  of 
the  pain  produced  by  mastication.  The  mouth  should  be  kept  clean  by 
the  use  of  some  antiseptic  mouth-wash.    The  general  symptoms  and  com- 


1020  THE    SPECIFIC    INFECTIOUS    DISEASES 

plications  are  to  be  treated  according  to  the  indications  presented.  Cases 
of  mumps  occurring  in  schools  or  institutions  should  be  quarantined  for 
three  weeks,  and  in  private  practice  where  there  are  susceptible  persons. 
Fumigation  and  disinfection  after  an  attack  are  unnecessary. 


CHAPTER  YIII 
DIPHTHERIA 

Diphtheria  is  an  acute^,  specific,  communicable  disease  due  to  the 
bacillus  of  Klebs  and  Loeffler.  It  is  usually  characterized  by  the  forma- 
tion of  a  false  membrane  upon  certain  mucous  membranes,  especially 
those  of  the  tonsils,  pharynx,  nose,  or  larynx.  Like  other  pathogenic 
organisms,  however,  this  germ  acts  with  varying  intensity,  and  may 
cause  inflammation  of  all  degrees  of  severity,  from  a  mild  catarrhal 
angina  to  the  most  serious  membranous  inflammation;  but  to  all  alike 
the  term  diphtheria  should  be  applied.  In  its  mild  form  it  may  be 
almost  without  constitutional  symptoms;  but  in  its  severe  form  it  is 
attended  by  great  general  prostration,  cardiac  depression,  and  anemia; 
it  is  frequently  complicated  by  pneumonia  and  nephritis,  and  it  may  be 
followed  by  localized  or  general  paralysis ;  it  then  constitutes  one  of  the 
diseases  most  to  be  dreaded  in  childhood. 

Etiology. — The  Bacillus  DipMheriae. — This  was  first  described  by 
Klebs  in  1883,  and  during  the  following  year  it  was  isolated  by  Loeffler 
and  shown  to  be  pathogenic.  It  is  a  Gram-positive  bacillus  and  varies 
considerably  in  size  and  shape  even  in  the  same  culture.  In  a  specimen 
it  occurs  singly  or  in  pairs,  sometimes  in  chains  of  three  or  four ;  the 
bacilli  may  lie  parallel,  but  frequently  two  form  an  acute  or  an  obtuse 
angle.  They  are  straight  or  slightly  curved,  and  sometimes  branching; 
they  may  be  swollen  or  club-shaped  at  their  ends. 

Distribution  and  Mode  of  Communication. — In  most  large  cities 
diphtheria  prevails  endemically,  with  periods  in  which  outbreaks  of  con- 
siderable severity  are  observed.  In  the  country  it  prevails  chiefly  as  an 
epidemic.  The  disease  is  often  introduced  into  remote  districts  in  some 
inexplicable  manner,  and  before  its  nature  is  recognized  a  large  number 
of  persons  may  be  exposed,  and  an  epidemic  results. 

Diphtheria  does  not  arise  de  novo.  Every  case  has  its  origin  in  a 
previous  case  either  directly  or  remotely.  The  bacilli  may  enter  the 
body  through  the  inspired  air;  they  may  be  taken  into  the  mouth  with 
toys  or  other  articles  upon  which  they  have  lodged,  or  by  kissing,  and 


DIPHTHERIA  1021 

sometimes  by  accidental  inoculation.  As  a  rule,  the  bacilli  first  gain  a 
foothold  upon  the  mucous  membrane  of  the  tonsils,  nose,  or  larynx. 

Direct  infection  is  the  cause  in  the  great  majority  of  the  cases.  There 
is  no  proof  that  the  bacilli  are  contained  in  the  breath  of  a  person  suf- 
fering from  the  disease.  They  are  present  in  great  numbers  in  the  saliva 
and  mucus  from  the  mouth  and  nose,  often  being  distributed  by  sneezing, 
coughing,  or  even  by  talking.  They  are  contained  in  pieces  of  membrane 
which  are  discharged ;  they  are  not  present  in  the  feces.  In  rare  instances 
they  have  been  found  in  the  urine  but  in  such  small  numbers  as  to  make 
it  very  improbable  that  this  is  an  important  source  of  infection.  The 
most  contagious  cases  are  those  of  pharyngeal  diphtheria  on  account  of 
the  amount  of  discharge  which  accompanies  them.  The  least  contagious 
are  those  in  which  the  membrane  is  limited  to  the  larynx  and  lower  air 
passages. 

Direct  infection  may  occur  from  persons  convalescent  from  diph- 
theria, whose  throats  still  contain  virulent  bacilli,  or  from  persons  suf- 
fering from  a  mild  form  of  the  disease,  which  is  not  recognized  as  diph- 
theria. In  the  latter  way  it  is  often  spread  in  schools.  It  has  been 
repeatedly  shown  that  a  person  may  harbor  virulent  bacilli  in  his  nose  or 
throat,  and  may  even  communicate  the-  disease  to  others,  without  himself 
suffering  from  diphtheria  at  any  time.  Such  persons  are  known  as  "car- 
riers" and  are  responsible  for  spreading  the  disease  to  many  persons. 

The  length  of  time  during  which  a  patient  with  diphtheria  may  con- 
vey the  disease  to  others  is  somewhat  uncertain.  Transmission  is  possi- 
ble so  long  as  virulent  bacilli  remain  in  the  throat;  these  are  frequently 
found  two  weeks  after  the  membrane  has  disappeared  and  the  patient  is 
regarded  as  entirely  well,  and  in  a  few  cases  they  are  found  for  many 
months  after  recovery. 

Indirect  infection  is  uncommon.  It  may  occur  from  dishes,  feeding- 
bottles,  or  drinking-cups,  from  swabs  and  brushes  used  for  local  applica- 
tions to  the  throat;  from  spoons  and  tongue-depressors,  and  from  surgical 
instruments  with  which  tracheotomy  or  intubation  has  been  done.  It  is 
undoubtedly  very  unusual  for  infection  to  occur  from  the  bed  or  cloth- 
ing of  a  patient,  from  carpets,  toys,  books,  etc.  Diphtheria  may  be  car- 
ried by  a  third  person  but  rarely,  except  by  one  who  has  been  in  close 
contact  with  the  patient — either  the  physician  or  nurse^and  has  not 
taken  sufficient  precautions.  The  frequency  of  diphtheria  in  physicians' 
families  bears  witness  to  the  danger  of  infection  in  this  manner. 

Bacilli  may  retain  their  virulence  for  an  indefinite  period.  Both 
Park  and  Loeflfier  have  found  cultures  in  blood-serum  to  be  virulent  after 
seven  months ;  Eoux  and  Yersin,  bacilli  in  dried  membrane  to  be  virulent 
after  twenty  weeks,  and  Abel,  upon  a  child's  toy  after  five  months. 

Domestic  animals  may  in  rare  instances  be  carriers  of  infection,  and, 
34 


1022  THE  SPECIFIC   INFECTIOUS   DISEASES 

in  the  case  of  pigeons  at  least,  they  may  themselves  suffer  from  the 
disease.  Diphtheria  has  been  repeatedly  spread  by  milk,  but  very  rarely 
through  the  contamination  of  a  water  supply. 

Predisposing  Causes. — Local  conditions  in  the  throat  influence  largely 
the  occurrence  of  diphtheria.  An  important  predisposing  cause  is  the 
existence  of  a  chronic  catarrhal  inflammation  of  the  mucous  membranes 
of  the  nose  and  throat,  frequently  found  in  children  suffering  from  ade- 
noid growths  of  the  pharynx  or  from  enlarged  tonsils.  These  adenoid 
growths,  the  tonsillar  crypts,  and  the  cavities  of  carious  teeth  may  harbor 
the  bacilli  for  a  considerable  time  both  before  and  after  an  attack.  The 
condition  of  the  mucous  membranes  of  the  nose  and  pharynx  in  other 
acute  infectious  diseases  furnishes  a  marked  predisposition  to  diphtheria. 
This  is  most  striking  in  the  case  of  measles  and  scarlet  fever.  While 
diphtheria  is  seen  throughout  the  year,  it  is  more  frequent  during  the 
cold  than  the  warm  months. 

Imrnuniiy. — The  most  important  factor  which  determines  if  a  per- 
son who  has  been  exposed  is  to  contract  the  disease  is  the  presence  or 
absence  of  immunity.  Schick  has  shown  by  means  of  his  test  (described 
later)  that  many  persons  who  have  never  had  diphtheria  or  received 
antitoxin,  already  have  antitoxin,  or  a  substance  similar  to  it,  in  their 
blood.  Those  who  possess  this  natural  antitoxin  are  immune  to  the  dis- 
ease, and  even  though  they  may  harbor  virulent  diphtheria  bacilli  in  the 
throat  or  nose,  they  never  show  any  clinical  evidences  of  the  disease.  This 
natural  antitoxin  is  possessed  by  most  newly-born  infants,  only  about 
7  per  cent  being  without  it.  Infants  gradually  lose  their  immunity; 
at  the  end  of  the  first  year  about  40  per  cent,  and  by  the  second  or  third 
year  fully  60  per  cent,  have  lost  it  altogether  and  are  consequently  sus- 
ceptible to  the  disease.  After  four  years  the  incidence  of  natural  anti- 
toxin slowly  increases  so  that  at  the  age  of  ten  or  twelve  years,  only  about 
25  per  cent  of  children  are  without  protection.  These  figures,  obtained 
by  combining  those  of  Schick  and  Park,  are  in  accordance  with  clinical 
experience.  Very  few  newly-born  infants  acquire  diphtheria,  but  the 
number  of  susceptible  children  steadily  increases  with  age  until  about 
the  third  year,  when  it  declines.  Children  from  two  to  six  years  of  age 
make  up  the  majority  of  patients  in  diphtheria  hospitals.  Those  persons 
who  after  the  first  year  possess  an  immunity  probably  always  retain  it; 
while  those  who  at  ten  years  of  age  do  not  possess  an  immunity  probably 
will  never  acquire  it.    There  is  no  difference  in  the  sexes  in  this  respect. 

The  immunity  conferred  by  one  attack  of  diphtheria  is  not  of  long 
duration,  amounting  probably  to  a  few  weeks  or  months  only ;  the  passive 
immunity  conferred  by  antitoxin  is  still  shorter,  lasting  but  a  few  days 
or  weeks.  Even  in  patients,  therefore,  to  whom  antitoxin  has  been  given, 
a  second  attack  may  occur  after  a  brief  interval. 


DIPHTHEEIA 


1023 


The  incTibation  of  diphtheria  is  short.  In  most  of  the  cases  in  which 
it  could  be  definitely  traced  it  has  been  between  two  and  five  days.  The 
virulence  of  the  bacillus  varies  much  in  different  cases  and  in  different 
seasons,  and  while  it  is  frequently  true  that  persons  infected  from  a  mild 
type  of  the  disease  have  a  mild  attack,  and  those  infected  from  a  malig- 
nant case  a  severe  attack,  there  is  no  certainty  that  such  will  be  the 
sequence.  Park  states  that,  out  of  many  hundreds  tested  in  the  labora- 
tory of  the  New  York  Health  Department,  by  far  the  most  virulent 
bacillus  was  obtained  from  the  throat  of  a  boy  who  had  what  was  clinic- 
ally a  very  mild  form  of  tonsillar  diphtheria. 

Lesions. — The  essential  lesions  of  diphtheria  consist  not  in  the  pro- 
duction of  a  membrane,  but,  as  long  ago  pointed  out  by  Oertel,  in  cer- 
tain acute  degenerative  changes  in  the  cells  of  the  body  caused  by  the 
diphtheria  toxins.  These  changes  are  seen  particularly  in  the  epithelial 
cells  of  the  afEected  mucous  membranes,  the  heart  muscle,  the  kidney, 
the  liver,  the  central  and  peripheral  nervous  system,  the  spleen,  and  the 
lymph  nodes.  There  are  other  lesions  which  are  the  result  of  the  action 
of  other  organisms,  especially  the  streptococcus  pyogenes  and  the  pneu- 
mococcus,  either  alone,  together,  or  in  conjunction  with  the  diphtheria 
bacillus.  The  most  important  lesions  due  to  these  organisms  are  broncho- 
pneumonia and  nephritis ;  but  there  may  be  found  in  the  blood,  and  in 
many  of  the  organs  of  the  body,  the  evidences  of  the  invasion  of  these 
bacteria,  i.  e.,  a  streptococcus  septicemia,  less  frequently  a  general  pneu- 
mococcus  infection. 

Distribution  of  the  Diphtheria  Bacillus  in  the  Body. — Unlike  many 
other  pathogenic  organisms,  the  diphtheria  bacillus  is  not  in  most  cases 
widely  distributed  throughout  the  body.  It  is  found  in  great  numbers 
on  the  surface  of  the  affected  mucous  membranes  and  in  the  false  mem- 
brane itself,  particularly  in  its  superficial  portion,  but  it  does  not  invade 
deeply  the  subjacent  structures. 

The  frequency  with  which  the  diphtheria  bacillus  and  other  organ- 
isms are  found  in  the  blood  and  viscera  in  severe  cases  is  shown  in  a 
series  of  209  autopsies  studied  by  Councilman,  Mallory,  and  Pearce,  of 
Boston,  in  1901.  The  following  table  shows  the  percentage  of  cases  in 
which  the  different  bacteria  were  found  by  culture: 


Heart's  blood. 


Liver. 


Spleen. 


Kidneys. 


Diphtheria  bacillus .  .  . 

Streptococcus 

Staphylococcus  aureus 
Pneumococcus 


6  per  cent. 
20 
2. ,5     " 
1.5     " 


20  per  cent. 
30 

4 

2.5     " 


12  per  cent. 
27 

3 

1.5     " 


19  per  cent. 

28 
8 
5 


In  this  series,  153  were  cases  of  pure  diphtheria ;  56  were  complicated 
by  measles  or  scarlet  fever  or  both,    The  streptococcus  was  much  oftener 


1024  THE   SPECIFIC   INFECTIOUS   DISEASES 

found  in  tlie  viscera  in  the  complicated  cases ;  otherwise  there  was  little 
difference  in  the  two  groups  of  cases. 

The  Diphtheria  Toxins. — The  wide-spread  effects  seen  in  diphtheria 
are  due  to  the  action  of  certain  substances  called  toxins  which  the  diph- 
theria bacillus  produces  during  its  growth  on  mucous  membranes.  They 
are  very  diffusible,  readily  entering  the  lymphatic  circulation  and  the 
blood,  and  through  these  channels  may  affect  the  entire  body.  In 
susceptible  animals  there  may  be  produced  by  the  injection  of  these 
toxins  all  the  characteristic  lesions  of  diphtheria  except  the  membrane, 
as  Avell  as  the  essential  symptoms  of  the  disease,  even  including  paralysis. 
For  the  production  of  the  membrane  living  bacilli  arc  required. 

Catarrhal  Diphtheria. — The  routine  practice  of  making  cultures  from 
diseased  throats  has  established  the  fact  that  catarrhal  inflammation  may 
often  be  the  only  result  of  diphtheritic  infection.  Although  to  the  naked 
eye  there  were  only  the  ordinary  changes  of  a  simple  inflammation,  Oertel 
found  the  characteristic  degenerative  changes  in  the  epithelial  cells,  vary- 
ing in  degree  with  the  severity  of  the  process. 

The  Diphtheritic  Membrane. — The  membrane  in  diphtheria  is  most 
frequently  seen  upon  the  mucous  membrane  of  the  tonsils,  soft  palate, 
uvula,  pharynx,  nose,  larynx,  trachea,  and  bronchi ;  less  frequently  upon 
the  mouth,  lips,  esophagus,  conjunctivae,  middle  ear,  stomach,  and  genital 
organs.  It  may  also  affect  fresh  wounds,  notably  a  tracheotomy  wound, 
or  any  abraded  cutaneous  surface.  The  gross  appearance  of  the  mem- 
brane varies  greatly.  It  is  most  frequently  yellowish-white  or  gray, 
but  it  may  be  pearly-white,  green,  and  sometimes  almost  black.  It  is 
composed  of  fibrin,  cells,  granular  matter,  and  bacteria.  Its  consistency 
varies  with  the  relative  proportions  of  the  different  elements.  When 
made  up  chiefly  of  fibrin  it  is  firm  and  retains  its  form,  often  being 
discharged  as  a  complete  cast  of  the  nose,  larynx,  or  trachea.  When  the 
amount  of  fibrin  is  small  the  membrane  is  soft,  friable,  and  sometimes 
granular.  It  is  more  closely  adherent  upon  the  mucous  membranes  cov- 
ered with  squamous  epithelium,  as  in  the  pharynx  and  upper  air  passages, 
than  upon  those  covered  with  columnar  and  ciliated  epithelium,  as  in  the 
lower  air  passages. 

The  microscopical  examination  shows  the  fibrin  to  be  sometimes 
granular,  but  usually  in  the  form  of  a  network,  inclosing  in  its  meshes 
small  round  cells  and  epithelial  cells  in  various  stages  of  degeneration. 
On  the  surface  and  in  the  superficial  layer  there  is  usually  found  quite  a 
variety  of  bacteria  including  diphtheria  bacilli.  Beneath  this  is  a  cellu- 
lar layer  containing  little  or  no  fibrin,  in  which  also  the  diphtheria 
bacilli  are  usually  found.  In  the  deepest  parts  of  the  false  membrane 
and  in  the  niucous  membrane  itself  the  bacilli  are  few  in  number  or 
absent. 


DIPHTHERIA  1025 

Changes  which  are  similar  in  all  the  afEected  mucous  membranes,  are 
found  in  the  epithelial  cells  which  undergo  marked  degeneration  with 
fragmentation  of  their  nuclei;  the  mucosa  is  infiltrated  with  leucocytes. 
The  infiltration  with  small  round  cells  is  variable  in  degree  in  the  differ- 
ent mucous  membranes;  in  some  it  extends  deeply  into  the  submucous 
and  even  the  rhuscular  layers,  while  in  others  it  is  very  superficial. 
Marked  evidences  of  degeneration  are  seen  also  in  the  cells  infiltratiaig 
the  deeper  layers.  In  places  the  epithelium  is  detached,  in  others  the 
line  between  the  false  membrane  and  the  granular  mucous  membrane 
is  scarcely  distinguishable. 

The  Seat  and  the  Distribution  of  the  Mem'bt'ane.— This  varies  some- 
what with  the  age  of  the  patient,  the  season,  and  the  peculiarity  of  tlie 
epidemic. 

Our  own  records  show  that  the  larynx  is  involved  in  about  twenty-five 
per  cent  of  the  cases  in  children  under  three  years.  In  general  the  state- 
ment may  be  made  that  the  younger  the  child  the  greater  the  liability  of 
the  disease  to  attack  the  larynx.  The  larynx  and  lower  air  passages  are 
rather  more  frequently  attacked  in  winter  than  in  summer. 

The  tonsils  are  the  most  frequent  and  usually  the  earliest  seat  of  the 
diphtheritic  membrane;  it  may  form  here  a  tough,  leathery  patch,  par- 
tially or  completely  covering  and  very  adherent  to  them;  or  the  disease 
may  affect  only  the  tonsillar  crypts,  so  that  the  gross  lesion  may  resem- 
ble that  of  ordinary  follicular  tonsillitis.  There  is  in  most  cases  only 
moderate  swelling,  l)ut  it  may  be  so  great  that  the  tonsils  are  in  contact. 
The  surrounding  cellular  tissue  is  infiltrated  with  infiammatory  products. 

The  membrane  covering  the  pharynx  and  uvula  is  also  usually  very 
adherent.  The  uvula  is  swollen  and  edematous.  Membrane  may  be  seen 
only  upon  the  fauces  and  uvula,  or  the  posterior  and  lateral  pharyngeal 
walls  may  be  covered  down  to  the  level  of  the  cricoid  cartilage,  but  gen- 
erally not  below  this  point.  If  the  posterior  pharyngeal  wall  is  covered, 
the  membrane  is  apt  to  extend  into  the  rhinopharynx,  and  even  the  pos- 
terior nares. 

The  nose  may  be  involved  secondarily  to  the  rhinopharynx,  or  the 
infection  may  be  through  the  anterior  nares ;  if  the  latter,  it  is  not  infre- 
quently the  only  part  involved.  The  membrane  in  the  pure  nasal  cases 
is  usually  thick  and  tough  and  often  separates  en  masse. 

The  observations  of  Councilman,  Mallory,  and  Pearce  have  shown 
that  it  is  very  common  for  the  accessory  sinuses  of  the  nose,  especially 
the  antrum  of  Highmore,  to  be  involved  in  fatal  cases.  It  seems  highly 
probable  that  infection  of  these  parts  explains  the  remarkable  persistence 
0-.  diphtheria  bacilli  in  the  nose  which  is  occasionally  seen. 

The  epiglottis  is  swollen  to  three  or  four  times  its  normal  thickness 
and  the  aryteno-epiglottic  folds  are  edematous.     The  anterior  surface 


1026  THE  SPECIFIC  INFECTIOUS  DISEASES 

of  the  epiglottis  is  rarely  covered  b_y  membrane;  but  its  lateral  borders 
and  posterior  surface,  and  the  aryteno-epiglottic  folds  are  involved  in 
most  of  the  severe  pharyngeal  cases. 

The  lesions  of  the  larynx,  trachea,  and  bronchi  are  similar  to  the 
above,  although  much  more  superficial.  The  interior  of  the  larynx  may 
be  completely  covered,  the  membrane  coating  the  true  and  false  vocal 
cords  and  lining  the  ventricles  of  the  larynx.  The  membrane  in  the 
larynx  is  not  usually  very  adherent,  and  it  frequently  separates  and  is 
coughed  up  in  large  pieces  or  even  as  a  cast.  That  covering  the  epiglot- 
tis and  the  aryteno-epiglottic  folds  is  very  adherent,  like  that  in  the 
pharynx. 

In  a  considerable  number  of  cases  the  membrane  stops  abruptly  at 
the  lower  border  of  the  larynx.  In  the  trachea  it  is  generally  loosely 
attached,  and  often  it  is  found  at  autopsy  entirely  separated  from  the 
mucous  membrane.  It  is  almost  invariably  associated  with  membrane  in 
the  larynx.  As  a  rule,  the  bronchi  of  both  sides  are  affected,  and  to  the 
same  degree. 

The  extent  of  the  membrane  varies  greatly  in  different  cases.  It 
may  stop  at  the  bifurcation  of  the  trachea  or  at  the  bifurcation  of  the 
primary  bronchi;  but  if  it  goes  beyond  this  point  it  is  likely  to  extend 
to  the  minutest  subdivisions.  Exceptionally  a  very  tough  filjrinous  mem- 
l)rane  forms  in  the  trachea  and  bronchi,  of  sufficient  thickness  and  con- 
sistency to  be  expelled  as  a  cast,  reproducing  almost  the  entire  bronchial 
tree. 

The  buccal  cavity  is  very  seldom  covered  by  the  membrane ;  but  in 
the  worst  cases  of  pharyngeal  disease  it  may  line  the  cheeks,  cover  the 
lips,  gums,  and  more  or  less  of  the  hard  palate,  but  rarely  the  tongue. 
It  usually  occurs  in  patches  rather  than  as  a  continuous  membrane.  In 
one  case  we  saw  the  membrane  on  the  lower  lip,  extending  on  to  the  face, 
though  the  buccal  cavity  was  free.  It  is  not  common  for  the  diphtheritic 
membrane  to  spread  doAvn  the  digestive  tract.  In  127  autopsies  studied 
l)y  Councilman,  Mallory,  and  Pearce,  in  which  the  extent  of  the  niem- 
l)rane  was  carefully  noted,  it  was  found  twelve  times  in  the  esophagus, 
five  times  in  the  stomach,  and  once  in  the  duodenum.  The  accompany- 
ing changes  consist  in  infiltration,  hemorrhage,  and  cell  degeneration. 
In  the  intestines  there  is  often  found  a  hyperplasia  of  the  lymphoid  ele- 
ments— solitary  follicles  and  Peyei-'s  patches — with  changes  similar  to 
those  in  the  lymph  nodes  elsewhere  in  the  body,  but  nothing  else  that  is 
characteristic. 

The  writers  just  referred  to  found  otitis,  usually  double,  in  sixty 
per  cent  of  144  autopsies ;  although  in  less  than  one-third  of  the  number 
was  the  complication  recognized  during  life.  Mastoid  disease  is  infre- 
quent.    Otitis  is  usually  the  result  of  direct  extension  from  the  pharynx. 


DIPHTHERIA  1027 

It  may  be  due  to  the  diphtheria  bacillus,  to  the  streptococcus,  or  to  both 
combined.  Conjunctival  diphtheria  is  rare  and  probably  due  to  acci- 
dental infection  rather  than  to  extension  through  the  lachrymal  duct. 
Before  the  advent  of  antitoxin,  it  almost  invariably  resulted  in  destruc- 
tion of  the  eye;  but  many  cases  successfully  treated  have  been  reported. 
Diphtheria  may  attack  any  mucocutaneous  surface,  especially  the  anus, 
prepuce,  or  female  genitals;  any  abraded  cutaneous  surface,  or  recent 
wound,  most  frequently  the  tracheotomy  wound  of  the  neck.  The  diph- 
theria bacilli  have  in  rare  instances  been  found  in  pure  culture  in  super- 
ficial abscesses. 

Visceral  Lesions. — The  visceral  lesions  of  diphtheria  are  due  partly 
to  the  action  of  the  diphtheria  toxins  and  partly  to  the  invasion  of  the 
body  with  other  organisms,  especially  the  streptococcus.  It  is  to  experi- 
mental diphtheria  that  we  owe  our  most  accurate  knowledge  of  the  for- 
mer changes,  for  in  human  diphtheria  the  large  proportion  of  all  the 
fatal  cases  show  infection  with  other  organisms. 

The  visceral  lesions  of  diphtheria  consist  in  wide-spread  areas  of  cell 
degeneration  similar  to  those  which  have  already  been  described  as  occur- 
ring in  the  epithelial  cells  of  the  affected  mucous  membranes,  together 
with  hemorrhages  due  to  changes  in  the  blood-vessels  and  possibly  in 
the  blood  itself. 

The  lymph  nodes  of  the  cervical  region  are  the  most  constantly  and 
the  most  seriously  affected.  Similar  but  less  marked  changes  are  seen 
in  the  tracheobronchial  and  the  mesenteric  groups,  and  in  the  lymph 
nodules  of  the  mucous  membrane  of  the  stomach  and  intestine.  There 
are  degenerative  changes  in  the  cells  of  the  nodes  most  affected,  with 
marked  infiltration  with  leucocytes  and  frequently  small  hemorrhages. 
The  cellular  tissue  in  the  neighborhood  of  the  cervical  nodes  is  often 
extensively  infiltrated  with  cells.  The  process  in  the  lymph  nodes  usu- 
ally terminates  in  resolution,  rarely  in  suppuration. 

The  spleen  is  swollen,  sometimes  very  much  so,  and  deeply  congested. 
Hemorrhages  are  often  seen  beneath  the  capsule ;  the  spleen  pulp  is  soft, 
the  follicles  are  large,  and  cell  degeneration  is  quite  constantly  observed 
similar  to  that  which  takes  place  in  the  lymph  nodes. 

There  are  frequently  small  hemorrhages  beneath  the  capsule  of  the 
liver,  and  sometimes  these  are  seen  througbout  the  organ.  There  are 
found  scattered  through  the  liver,  areas  of  necrotic  hepatic  cells;  some 
of  these  areas  are  infiltrated  with  leucocytes. 

The  kidneys  are  involved  in  almost  all  fatal  cases  except  when  death 
occurs  early  from  laryngeal  stenosis,  also  in  nearly  every  severe  case 
which  terminates  in  recovery.  Acute  degeneration  of  the  epithelium 
of  the  tubes  and  the  tufts  is  seen  in  less  severe  cases  and  those  of  shorter 
duration,  and  is  the  direct  result  of  the  action  of  the  toxins.     In  the 


1028  THE  SPECIFIC  INFECTIOUS  DISEASES 

more  severe  and  protracted  cases  there  is  acute  diffuse  nephritis  of  vari- 
able type  and  intensity. 

In  children  dying  suddenly  in  the  early  stage  of  the  disease,  cardiac 
'thrombi  are  occasionally  found.  They  may  form  rapidly  only  a  short 
time  before  death,  or  slowly  during  several  days  when  the  circulation 
is  very  feeble.  Portions  of  these  thrombi  may  be  carried  into  the  pul- 
monary or  systemic  circulation,  causing  embolism  in  any  of  the  arteries 
of  the  extremities,  the  lungs,  or  other  viscera.  Even  in  the  early  fatal 
cases  the  heart  muscle  may  be  seriously  affected ;  in  the  later  ones  this 
is  almost  constant.  The  changes  consist  in  a  toxic  myocarditis,  the  left 
ventricle  being  most  involved.     (See  Myocarditis.) 

Degeneration  of  the  arteries,  especially  of  the  endothelial  layer,  is 
occasionally  seen,  and  there  may  be  infiltration  of  the  adventitia. 

Lesions  of  the  brain  are  rare ;  both  hemorrhage  and  embolism  may 
be  met  with.  In  the  spinal  cord  and  membranes  multiple  hemorrhages 
occasionally  occur.  The  chief  lesion,  however,  consists  in  degenerative 
changes  which  are  found  to  some  degree  in  nearly  all  the  more  severe 
cases  which  have  been  examined.  These  affect  the  ganglion  cells  of  the 
anterior  horns,  the  anterior  and  posterior  nerve-roots,  and  sometimes  the 
pyramidal  tracts  and  columns  of  Goll.  Some  writers  are  of  the  opinion 
that  the  cord  lesions  are  primary  and  the  degeneration  of  the  spinal 
nerves  secondary.  However,  the  general  opinion  prevails  that  certainly 
the  less  severe  cases  of  diphtheritic  paralysis  are  due  to  peripheral  rather 
than  to  central  lesions.  Degenerative  changes  have  been  found  also  in  the 
pneumogastric,  spinal  accessory,  hypoglossal,  motor-oculi,  and  in  the 
cardiac  nerves.  These  nerve  degenerations  produced  by  the  diphtheria 
toxin  constitute  one  of  the  most  striking  lesions  of  diphtheria.  (See 
Multiple  jSTeuritis. ) 

In  infants  and  young  children  bronchopneumonia  is  found  at  au- 
topsy in  fully  three-fourths  of  the  cases.  It  is  well-nigh  constant  in  cases 
of  diphtheritic  bronchitis  of  the  finer  tubes,  and  is  usually  present  where 
the  membrane  has  extended  to  the  bifurcation  of  the  trachea.  The  largest 
factor  in  the  production  of  pneumonia  is  the  aspiration  of  diphtheria 
bacilli  and  streptococci  from  the  upper  air  passages. 

With  laryngeal  stenosis,  some  emphysema  is  invariably  present,  and 
usually  it  is  of  the  vesicular  variety.  Eupture  of  some  of  the  larger 
blebs  may  lead  to  the  escape  of  air  into  the  cellular  tissue  of  the  medi- 
astinum or  of  the  neck,  which  may  result  in  the  production  of  a  general 
emphysema  of  the  subcutaneous  cellular  tissue. 

Blood. — There  is  found  in  all  severe  cases  of  diphtheria  a  reduction  in 
the  number  of  red  cells  to  the  extent  of  500,000  to  2,000,000.  There  is  a 
nearly  proportionate  reduction  in  the  hemoglobin,  this  amounting  to 
from  10  to  30  per  cent.     While  the  hemoglobin  falls  coincidently  with 


DIPHTHERIA  1029 

the  number  of  red  cells,  it  is  regained  much  more  slowly,  Leucocy- 
tosis  is  generally  present,  and  usually  proportionate  to  the  severity  of 
the  attack,  but  is  occasionally  wanting  in  the  most  severe  as  well  as  in 
some  of  the  very  mildest  cases.  The  increase  in  the  leucocytes  is  in  the 
polymorphonuclear  forms.  Engel  has  noted  the  frequent  presence  of 
myelocytes,  especially  in  fatal  cases,  the  proportion  of  these  in  some  in- 
stances reaching  sixteen  per  cent  of  the  white  cells. 

Symptoms. — The  clinical  picture  of  diphtheria  is  one  which  presents 
wide  variations,  depending  upon  the  principal  location  of  the  disease,  its 
severity,  and  its  complications.  For  practical  purposes  the  following 
seems  the  simplest  grouping  that  can  be  made : 

1.  The  mild  cases,  in  which  there  is  either  no  membrane,  or  the 
amount  of  membrane  is  small  and  limited  to  the  tonsils  or  to  the  nose, 
with  few  or  none  of  the  constitutional  symptoms  which  follow  absorp- 
tion of  the  diphtheria  poison.  These  cases  partake  essentially  of  the 
character  of  a  local  disease. 

2.  The  severe  cases  in  which  there  are  marked  evidences  of  constitu- 
tional poisoning  from  the  diphtheria  toxin.  This  form  is  usually  accom- 
panied by  an  extensive  formation  of  membrane  in  the  pharynx  and 
sometimes  in  the  nose. 

3.  The  laryngeal  cases  in  which  the  larynx  may  be  primarily  or 
alone  affected  or  in  which  it  is  involved  secondarily  to  the  severe  pharyn- 
geal form. 

4.  The  malignant  cases.  In  these  cases  the  symptoms  of  inflam- 
mation are  especially  prominent,  not^  only  in  the  pharynx  but  sometimes 
in  the  lymph  nodes  and  cellular  tissue  of  the  neck,  which  may  be  fol- 
lowed by  suppuration  or  sloughing.  This  form  is  frequently  complicated 
by  bronchopneumonia  even  without  laryngeal  disease,  and  sometimes  by 
severe  nephritis. 

Cases  ivithout  Membrane. — During  an  epidemic  of  diphtheria  in  a 
family  or  an  institution,  cases  are  frequently  seen  which  present  the 
clinical  evidences  of  only  a  catarrhal  inflammation  of  the  nose  or  pharynx, 
and  yet  cultures  show  the  presence  of  the  diphtheria  bacillus.  Such  cases 
may  be  examples  of  simple  catarrhal  inflammation  with  the  accidental 
presence  of  the  diphtheria  bacillus;  or  the  inflammation  may  be  caused 
by  infection  with  the  diphtheria  bacillus,  but  not  of  sufficient  intensity 
to  lead  to  the  production  of  a  membrane.  The  latter  is  the  view  of 
pathologists,  and  the  one  to  which  clinicians  must,  it  seems,  inevitably 
come. 

Catarrhal  diphtheria  may  be  either  pharyngeal  or  nasal.  In  the 
pharyngeal  cases  there  are  present  the  usual  appearances  belonging  to 
a  catarrhal  inflammation  of  moderate  severity,  often  accompanied  by 
swelling  and  tenderness  of  the  cervical  lymph  glands. 


1030  THE  SPECIFIC  INFECTIOUS  DISEASES 

The  nasal  cases^  in  our  experience,  have  been  most  frequent  in  in- 
fants or  very  young  children.  Constitutional  symptoms  may  be  wanting 
or  so  slight  as  to  be  overlooked.  The  only  striking  thing  is  a  persistent 
nasal  discharge  which  may  be  serous  and  frothy,  purulent  or  bloody.  It 
is  usually  copious,  often  excoriating  the  upper  lip  and  sometimes  con- 
tinuing for  three  or  four  weeks  before  any  otlier  symptoms  are  observed. 
We  have  several  times  known  it  to  be  mistaken  for  a  syphilitic  coryza. 
Such  cases  can  be  recognized  vsdth  certainty  only  by  cultures.  Clinical 
evidence  of  their  true  character  is  sometimes  afforded  by  the  appearance 
of  visible  membrane  in  the  nose  or  pharynx,  by  the  development  of  croup, 
or  by  the  fact  that  they  cause  diphtheria  in  other  children.  The  bacilli 
are  non- virulent  in  quite  a  large  proportion  of  these  cases,  but  in  others 
they  are  of  extreme  virulence. 

Catarrhal  diphtheria  is  not  in  itself  serious,  but  it  may  be  followed, 
particularly  in  young  children,  by  laryngeal  diphtheria,  or  pharyngeal 
diphtheria  may  develop  in  its  usual  form. 

Cases  until  a  Small  Amount  of  Membrane. — Tonsillar  Diplitlieria. — 
The  exudation  is  usually  limited  to  the  tonsils  and  may  partake  of  the 
character  of  either  follicular  or  croupous  tonsillitis ;  sometimes  there  is  a 
slight  extension  to  the  faucial  pillars  or  to  the  pharynx.  These  cases 
are  quite  common,  and  are  more  frequent  in  older  children  and  adults 
than  in  infants  and  young  children. 

The  onset  is  accompanied  by  a  little  soreness  of  the  throat ;  the  initial 
temperature  is  from  101°  to  103°  F. ;  but  the  symptoms  are  often  not 
severe  enough  to  keep  the  patient  in  bed.  If  seen  early,  the  throat  shows 
slight  redness,  followed  by  a  gray  film,  and  later  by  a  gray  or  white 
deposit  upon  the  tonsils.  This  may  start  as  a  small  patch  which  enlarges, 
or  as  small,  isolated  spots  which  coalesce  or  remain  separate.  The  mem- 
brane is  quite  adherent,  and  can  not  easily  be  removed  with  a  swab; 
usually  it  is  sharply  defined.  In  many  cases  the  patch  is  not  larger  than 
the  finger  nail.  The  inflammatory  changes  in  the  pharynx  are  slight ;  a 
faint  red  areola  is  present  at  the  border  of  the  patch.  The  lymph  glands 
behind  the  jaw  may  be  slightly  swollen.  There  is  no  nasal  discharge  and 
very  little  increase  in  the  saliva  or  mucus  from  the  pharynx.  Some  con- 
stitutional symptoms  are  present,  but  they  are  not  severe.  The  tempera- 
ture commonly  continues  above  the  normal  while  the  membrane  lasts,  its 
usual  range  being  from  100°  to  102°  F.  The  membrane  remains  from 
three  to  seven  days — a  shorter  time  if  antitoxin  is  used.  It  is  very  often 
a  matter  of  surprise  that  so  small  an  exudate  is  so  persistent.  The  urine 
is  generally  normal.  The  parents  are  loath  to  believe  that  strict  quar- 
antine is  necessary  in  so  mild  an  illness ;  and  when  the  membrane  is  only 
upon  the  tonsils,  even  after  the  disease  has  run  its  course,  the  physician 
may  be  led  to  doubt  the  diagnosis  of  diphtheria. 


DIPHTHERIA  1031 

In  many  cases  one  with  experience  can  usually  make  an  accurate  diag- 
nosis from  the  clinical  symptoms  alone;  but  there  are  many  others  in 
which  the  diagnosis  from  ordinary  tonsillitis  is  impossible,  except  by  cul- 
tures. When  diphtheria  bacilli  are  found  in  these  mild  cases  the  question 
often  arises  whether  they  may  not  be  the  non-virulent  form.  Park  tested 
forty  such  cases,  and  found  the  bacilli  to  be  virulent  in  thirty-five  and 
non-virulent  in  five.  In  twenty  of  the  forty  cases  the  clinical  diagnosis 
was  follicular  tonsillitis. 

Severe  Cases. — The  clinical  picture  of  diphtheria  is  so  modified  by 
the  use  of  antitoxin  that  those  who  see  it  given  regularly  and  early  can 
have  but  little  conception  of  the  horrors  of  this  disease  when  not  thus 
influenced.  The  onset  in  severe  cases  may  be  gradual,  even  insidious. 
There  is  then  a  slight  indisposition  for  a  day  or  two,  and  perhaps  some 
soreness  of  the  throat ;  the  temperature  may  be  but  little  elevated,  some- 
times less  than  100°  F.  The  symptoms  may  steadily  increase  in  in- 
tensity for  four  or  five  days,  until  the  maximum  is  reached.  At  other 
times  the  disease  begins  abruptly  with  vomiting,  headache,  chilly  sensa- 
tions, and  a  temperature  of  103°  or  104°  F.  Occasionally,  the  first  thing 
to  attract  attention  is  the  swelling  of  the  cervical  lymph  nodes,  which 
may  be  so  great  that  mumps  is  suspected.  The  abrupt  onset  is  more  often 
seen  in  young  children  than  in  those  who  are  older. 

The  membrane  upon  the  tonsils  resembles  that  of  the  mild  form  pre- 
viously described,  but,  instead  of  remaining  limited  to  them,  it  gradually 
spreads  to  the  fauces,  the  lateral  wall  of  the  pharynx,  the  uvula,  the 
rhinopharynx,  and  the  posterior  nares.  In  some  cases  it  may  cover  all 
the  parts  mentioned  in  twenty-four  hours  from  its  first  appearance;  in 
others  this  may  require  several  days.  When  the  nose  is  first  affected 
there  is  an  abundant  discharge  of  serum  and  mucus,  occasionally  tinged 
Avith  blood,  which  may  continue  some  days  before  any  membrane  is  vis- 
ible. 

When  a  severe  case  is  fully  developed  there  is  a  very  abundant  dis- 
charge of  mucus  from  the  mouth  and  nose.  The  tonsils,  the  entire  fau- 
cial  ring,  and  the  pharynx  are  covered  with  membrane  which  is  at  first 
gray  and  gradually  becomes  darker,  often  being  of  a  dirty  olive-green 
color.  There  is  obstrtiction  to  nasal  respiration  from  the  swelling  of  the 
palate,  the  tonsils,  and  the  tissues  of  the  rhinopharynx;  the  mouth  is 
half  open,  the  breathing  noisy,  the  tongue  dry,  and  the  lips  are  fissured 
and  bleed  readily.  Occasionally  large  nasal  hemorrhages  occur  which 
may  necessitate  plugging  the  nares.  Both  nostrils  are  generally  blocked 
by  the  swelling  and  the  false  membrane;  the  discharge  excoriates  the 
upper  lip,  and  frequently  has  a  fetid  odor.  During  the  second  week 
there  may  be  regurgitation  of  fluids  through  the  nose,  owing  to  paralysis 
of  the  palate.    The  lymph  glands  at  the  angle  of  the  jaw  swell  rapidly; 


1032  .  THE  SPECIFIC  INFECTIOUS  DISEASES         , 

in  severe  cases  they  are  very  prominent,  and  there  may  also  he  extensive 
infiltration  of  the  cell^^lar  tissue  ahoiit  them. 

The  con-stitutional  symptoms  nsiially  increase  steadily  with  the  ex- 
tension of  the  membrane.  In  the  most  severe  cases  the  system  is  over- 
whelmed with  the  poison,  and  all  the  evidences  of  intense  toxemia  are 
present  by  the  third  day  of  the  disease.  This  is  shown  by  great  muscular 
weakness  and  prostration,  by  a  feeble,  rapid  pulse,  and  a  mental  state 
of  complete  apathy  or  stupor,  sometimes  alternating  with  great  restless- 
ness. The  pulse  becomes  rapid,  weak,  and  compressible,  sometimes  irreg- 
ular ;  the  heart  sounds  are  faint  and  there  is  a  great  and  steadily  increas- 
ing anemia!  The  course  of  the  temperature  is  irregular,  and  may  bear  no 
constant  relation  to  the  severity  of  the  other  symptoms.  Its  usual  range 
is  from  101°  to  103°  F.,  but  in  some  of  the  worst  cases  it  may  never  go 
above  101°  F.  It  fluctuates  irregularly  with  the  development  of  com- 
plications, and  sometimes  without  apparent  cause.  By  the  second  or 
third  day  the  urine  regularly  shows  the  presence  of  albumin,  and  by  the 
end  of  the  first  week  the  quantity  is  often  large.  Granular  and  hyaline 
casts,  and  occasionally  blood  in  small  quantities,  are  also  found.  The 
amount  of  urine  secreted  is  not  noticeably  diminished,  and  dropsy  is 
rare.  jSTervous  symptoms  are  seen  in  all  the  very  severe  cases.  There 
may  be  dulness  and  apathy,  but  more  frequently,  owing  to  the  discomfort 
arising  from  local  symptoms,  there  is  extreme  restlessness  and  excitement, 
sometimes  followed  by  delirium. 

'  At  any  time  during  the  first  week,  but  not  often  after  that  time, 
symptoms  may  arise  indicating  that  the  disease  has  extended  to  the 
larynx.  The  first  signs  of  laryngeal  invasion  usually  appear  from  the 
second  to  the  fifth  day  of  the  disease.  These  are  at  first  hoarseness,  a 
croupy  cough,  and  slight  dyspnea.  In  the  severe  cases  these  symptoms 
steadily  increase  until  all  the  signs  of  laryngeal  stenosis  are  present. 

The  local  process  in  the  pharynx  seems  to  be  a  self-limited  one,  even 
when  no  antitoxin  is  used.  It  usually  reaches  its  height  by  the  fifth  or 
sixth  day,  and  after  that  the  appearances  do  not  change  materially  for 
two  or  three  days.  From  the  seventh  to  the  tenth  day,  in  favorable 
cases,  the  diphtheritic  membrane  begins  to  loosen  and  separate  from  its 
attachment.  It  hangs  loosely  from  the  palate  or  uvula,  and  can  often  be 
pulled  away  in  large  masses.  The  detachment  is  frequently  rapid,  and 
in  two  or  three  days  from  the  time  when  the  first  improvement  is  seen, 
the  tonsils  and  pharynx  may  be  almost  free  from  membrane.  The  mu- 
cous surface  left  behind  is  of  a  bright-red  color  and  bleeds  easily.  The 
separation  of  the  membrane  in  the  nose  and  rhinopharynx  takes  place 
more  slowly.  From  the  former  it  may  disintegrate  gradually  or  come 
away  en  masse.  With  the  disappearance  of  the  membrane  the  local  sjonp- 
toms  abate  rapidly — the  discharge   ceases,   the   swelling  of  the  lymph 


DIPHTHERIA  1033 

glands  subsides,  deglutition  becomes  easy  and  natural,  and  nasal  breath- 
ing is  re-established.  When  antitoxin  is  given  the  local  process  passes 
through  similar  stages,  but  much  more  rapidly. 

Simultaneously  with  these  changes  in  the  throat  the  constitutional 
symptoms  improve,  but  much  more  slowly.  Convalescence  is  often  pro- 
tracted. The  anemia  and  muscular  weakness,  and  most  of  all  the  feeble 
heart  action  may  persist  for  weeks.  Symptoms  due  to  myocarditis  may 
appear  in  the  second  or  third  week  or  even  later.     (See  Myocarditis.) 

Instead  of  the  usual  course  just  described,  the  diphtheritic  mem- 
brane may  persist  for  two  or  three  weeks.  In  rare  cases  relapses  occur, 
the  membrane  forming  again  after  it  has  entirely  or  partially  disappeared. 

The  early  course  of  the  disease  in  the  fatal  cases  often  does  not  dif- 
fer from  that  of  the  severe  cases  which  end  in  recovery,  except  in  the 
malignant  form,  which  kills  in  twentj'^-four  or  forty-eight  hours,  and 
which  is  rare.  In  very  young  children  death  is  most  frequently  due 
to  bronchopneumonia,  usually  accompanying  diphtheria  of  the  larynx 
and  bronchi.  It  may  also  be  due  to  progressive  asthenia,  the  result  of 
diphtheritic  toxemia,  or  to  heart  failure. 

Laryngeal  Di'phfheria. — In  cases  of  primary  laryngeal  diphtheria 
there  are  wanting  most  of  the  characteristic  clinical  features  which  dis- 
tinguish diphtheria  of  the  pharynx.^  There  are  two  reasons  for  this: 
one  is  the  relatively  rapid  course  of  the  disease,  often  producing  death 
from  local  causes  before  the  constitutional  symptoms  resulting  from  the 
absorption  of  the  toxin  have  developed ;  the  second  reason  is,  that  absorp- 
tion of  the  poison  by  the  laryngeal  mucous  membrane  is  very  feeble  as 
compared  with  that  which  takes  place  from  the  pharynx.  Hence  it 
follows  that  glandular  enlargements,  albuminuria  and  asthenic  symp- 
toms are  generally  wanting ;  also,  that  in  the  cases  which  come  to  autopsy 
early,  the  parenchymatous  degenerations  of  the  heart,  kidney,  and  other 
organs  are  seldom  fotmd,  but  instead  only  such  lesions  as  are  connected 
with  the  laryngeal  disease!.  The  feeble  contagion  is  due  to  the  fact  that 
the  course  is  much  shorter,  and  that  the  discharge  from  the  nose  and 
mouth  is  slight,  or  absent  altogether. 

In  its  onset,  diphtheria  of  the  lar^'nx  is  indistinguishable  from 
catarrhal  inflammation.  It  is  usually  somewhat  less  abrupt,  and  ap- 
parently not  quite  so  severe  for  the  first  twelve  hours  or  even  for  a  longer 
time.  There  are  present  the  same  hoarse  cough  and  A^oice,  with  slight 
stridor,  gradually  increasing.  The  constitutional  symptoms  are  usually 
not  quite  so  marked,  the  temperature  ranging  from  99°  to  101°  F.  The 
pulse  is  accelerated,  but  not  weak  or  intermittent.  It  is  the  progress  of 
the  disease  which  indicates  its  character,  usually  during  the  first  twenty- 
four  hours.  A  child  beginning  in  the  morning  with  such  symptoms  as 
have  been  described,  may  by  evening  show  a  decided  change  for  the 


1034  THE  SPECIFIC  INFECTIOUS  DISEASES 

worse,  or  the  symptoms  may  increase  with  ^eat  rapidity  during  the 
night.  At  first  the  voice  is  hoarse;  later  it  is  entirely  lost.  Dyspnea 
in  the  beginning  is  scarcely  noticeable,  bnt  steadily  increases  liour  by 
hour.  Sometimes,  from  the  first  sign  of  hoarseness  to  such  extreme 
dyspnea  as  to  necessitate  intubation  may  be  but  a  few  hoiirs.  During 
the  second  twenty-four  hours  all  the  symptoms  are  usually  well  developed. 
The  respiration  is  often  somewhat  accelerated,  but  it  may  be  slower 
than  normal.  The  face  is  pale  and  anxious.  The  alae  nasi  dilate  with 
each  inspiration.  The  loud,  "sawing,"  stridulous  breathing  is  present, 
indicating  obstruction  both  to  inspiration  and  expiration.  As  the  dys- 
pnea increases,  all  the  accessory  muscles  of  respiration  are  brought 
into  action.  There  is  now  with  every  inspiration  deep  recession  of  the 
suprasternal  fossa,  the  supraclavicular  re.gions,  and  the  epigastrium.  The 
child  tosses  uneasily  from  side  to  side  in  his  crib,  at  times  struggling 
violently  to  get  more  air  into  the  kings.  The  pulse  grows  rapid  and 
weaker.  There  is  slight  blueness  of  the  finger  nails  and  the  lips;  the 
face  is  usually  pale;  but  later  this  too  may  be  cyanotic.  The  skin  is 
covered  with  clammy  perspiration.  On  auscultating  the  chest,  very  rude 
respiratory  sounds  are  heard,  but  no  vesicular  murmur.  As  the  symp- 
toms increase  in  severity  the  temperature  usually  rises  gradually,  in  some 
very  severe  cases  at  the  rate  of  a  degree  an  hour,  until  shortly  before 
death  it  reaches  10-1°  or  even  106°  F.  Late  in  the  cUsease  the  intellect 
becomes  dull,  the  violent  struggles  for  air  cease,  and  the  child  passes  into 
a  condition  of  semi-stupor  which  gradually  deepens  until  death  occurs, 
which  may  be  preceded  by  convulsions. 

Such  is  the  usual  course  of  the  disease  when  unrelieved  by  treatment. 
Its  progress  is  most  rapid  in  infants,  in  whom  death  usually  takes  place 
in  from  thirty-six  to  forty-eight  hours  from  the  first  symptoms.  In  older 
children  the  course  is  rather  slower,  and  the  attack  may  last  from  two- 
days  to  a  week,  death  occurring  more  frequently  from  bronchial  croup  or 
pneumonia.  They  are  indicated  by  continued  high  temperature,  rajDid 
respiration,  cyanosis,  and  increased  prostration. 

The  course  of  the  disease  is  not  always  so  regular.  Occasionally  for  a 
"week  or  more  the  symptoms  are  precisely  like  those  of  catarrhal  laryngitis 
of  moderate  severity — hoarseness,  laryngeal  cough,  little  or  no  fever,  and 
slight  or  occasional  dyspnea.  Then  there  may  be  the  sudden  develop- 
ment of  very  severe  symptoms,  and  death  in  a  few  hours.  Great  im- 
provement may  follow  the  dislodgement  of  the  membrane  by  vomiting  or 
coughing,  although  in  most  cases  it  forms  again. 

The  issue  of  every  case  of  diphtheritic  laryngitis  is  doubtful.  The 
prognosis  is  worse  in  infants  and  very  young  children  than  in  those  over 
three  years  of  age.  Before  the  days  of  antitoxin  the  mortality  of  cases 
not  operated  upon  was  from  eighty  to  ninety  per  cent.     Even  with  mod- 


DIPHTHERIA  1035 

eru  methods  of  treatment  the  outlook  in  infants  under  a  year  is  bad; 
fully  forty  per  cent  die. 

It  may  be  difficult  in  a  given  case  to  decide  whether,  the  dyspnea  is 
due  to  laryngeal  inflammation,  and  whether  this  inflammation  is  catar- 
rhal or  diphtheritic.  The  dyspnea  of  retropharyngeal  abscess,  of  for- 
eign bodies  in  the  larynx  or  trachea,  or  of  bronchopneumonia,  may  be 
mistaken  for  that  due  to  laryngitis.  But  in  none  of  these  conditions 
should  there  be  any  doubt  if  a  careful  examination  is  made  and  a  history 
obtained.  Retropharyngeal  abscess  may  be  recognized  by  digital  ex- 
amination of  the  pharynx ;  bronchopneumonia  by  the  signs  in  the  lungs, 
the  difference  in  the  character  of  the  dyspnea,  and  especially  by  the 
absence  of  the  noisy  stridor;  in  the  case  of  foreign  bodies,  whether  they 
enter  through  the  mouth  or  consist  of  ulcerating  caesous  glands  which 
have  ruptured  into  the  trachea,  the  dyspnea  comes  suddenly,  and  is  not 
accompanied  by  fever.  The  main  points  by  which  catarrhal  laryngitis 
is  distinguished  from  the  diphtheritic  form  have  been  considered  under 
the  former  disease.  In  brief,  diphtheritic  inflammation  may  be  assumed 
if  there  is  severe,  constant,  and  increasing  dyspnea  with  aphonia. 

Malignant  Diphtheria. — The  symptoms  are  usually  severe  from  the 
outset.  The  exudation  in  these  cases  may  be  of  a  yellow,  dirty-gray, 
or  olive  color,  sometimes  being  almost  black  from  the  presence  of  blood. 
The  membrane  is  usually  extensive,  covering  the  entire  pharynx,  often 
extending  to  the  nose  and  the  middle  ear,  and  occasionally  spreading  to 
the  buccal  cavity.  There  is  great  swelling  of  the  tonsils  and  uvula,  and 
it  is  often  impossible  to  obtain  a  view  of  the  pharynx.  Sometimes  the 
inflammation  is  of  a  necrotic  character,  and  there  may  be  extensive 
sloughing  of  the  tonsils,  the  uvula,  or  the  soft  palate.  The  nasal  dis- 
charge is  generally  abundant,  and  often  offensive.  There  is  marked 
swelling  of  the  cervical  lymph  glands,  and  frequently  extensive  infiltra- 
tion of  the  cellular  tissue  of  the  neck,  so  that  the  head  is  thro^vn  back 
to  relieve  the  pressure  upon  the  larynx  and  trachea.  The  swelling  some- 
times forms  a  distinct  collar,  reaching  from  ear  to  ear  and  filling  out 
the  whole  space  beneath  the  Jaw.  The  pressure  upon  the  Jugular  veins 
leads  to  congestion  and  swelling  of  the  face,  and  congestion  of  the  brain. 

The  temperature  is  usually  high ;  it  follows  no  regular  course,  but 
generally  fluctuates  widely  from  102°  to  106°  P.  In  some  cases,  how- 
ever, it  may  never  be  above  101°  F.  In  the  form  characterized  by  very 
high  temperature  there  is  sometimes  found  a  general  streptococcus  or 
pneumocoGcus  infection,  usually  the  former.  The  pulse  is  Aveak,  rapid, 
and  compressible.  The  peripheral  circulation  is  poor,  the  extremities  are 
often  cold,  there  is  extreme  muscular  prostration,  and  both  vomiting  and 
diarrhea  are  frequent.  There  may  be  excitement,  restlessness,  and  active 
delirium,  or  dulness,  apathy,  and  stupor.    Nephritis  is  very  frequent  and 


1036  THE  SPECIFIC  INFECTIOUS  DISEASES 

is  often  severe ;  the  urine  contains  a  large  amount  of  albumin  and  casts  of 
all  varieties^  but  rarely  blood.  In  a  large  proportion  of  the  children 
under  three  years  old  bronchopneumonia  develops.  Severe  symptoms  con- 
tinue for  from  two  days  to  a  week;  the  patient  may  die  from  the  sud- 
den invasion  of  the  larynx,  or  there  may  be  suppression  of  urine  and 
uremic  convulsions ;  but  more  frequently  the  cause  of  death  is  circulatory 
failure  or  bronchoj^neumonia.  Death  usually  occurs  while  the  local 
disease  is  at  its  height.  Occasionally  it  comes  later  from  myocarditis 
after  the  signs  of  local  improvement  have  begun.  Evidences  of  myocar- 
ditis are  present  post  mortem  in  nearly  every  case. 

Those  who  manage  to  escape  the  dangers  of  the  acute  period  have 
still  others  to  encounter.  Among  the  latter  may  be  mentioned,  ex- 
tensive sloughing  in  the  throat  or  of  the  cellular  tissue  of  the  neck, 
which  may  be  followed  by  severe  or  even  fatal  hemorrhage,  diffuse  sup- 
puration of  the  same  region,  late  nephritis,  pneumonia,  or  pleurisy,  and 
finally  paralysis  of  the  heart  or  respiration. 

Complications  and  Sequelae. — Most  of  the  complications  of  diph- 
theria have  already  been  mentioned  either  under  the  head  of  Lesions  or 
Symptoms.    It  only  remains  to  consider  their  clinical  association. 

Otitis  occurs  particularly  in  the  rhinopharyngeal  cases,  and  is  some- 
times due  to  the  diphtheria  bacillus  alone,  but  more  often  to  mixed  in- 
fection. The  type  of  inflammation  is  often  a  severe  one,  and  it  may  be 
accompanied  by  necrotic  changes  in  the  drum  membrane  which  resem- 
ble those  of  scarlet  fever. 

Bronchopneumonia  is  the  most  frequent  complication  in  young  chil- 
dren. It  occurs  especially  in  laryngeal  cases,  and  in  those  of  a  severe 
type  whether  the  larynx  is  involved  or  not.  Other  pulmonary  compli- 
cations are  infrequent.  Emphysema  is  a  complication  of  laryngeal  diph- 
theria ;  it  is  nearly  always  vesicular,  rarely  interstitial.  It  may  become 
general,  extending  into  the  cellular  tissue  of  the  neck  and  afterward  that 
of  the  entire  body. 

Pericarditis,  endocarditis,  and  meningitis  are  all  rare  and  are  seen 
chiefly  in  septic  cases ,  of  the  most  severe  type.  Myocarditis  is  much 
more  frequent,  and  is  present  to  a  greater  or  less  degree  in  nearly  all 
severe  cases.  It  usually  causes  no  distinctive  symptoms  but  can  be 
detected  by  physical  examination.  Heart  block  has  been  described  in  the 
course  of  and  following  diplitheria,  but  is  rarely  permanent.  It  is  to  be* 
referred  to  a  lesion  of  the  bundle  of  His. 

Thrombosis  and  embolism  are  among  the  less  frequent  complica- 
tions. If  cerebral,  they  may  cause  hemiplegia,  aphasia,  and  sometimes 
convulsions;  if  peripheral,  they  usually  affect  one  of  the  lower  extrem- 
ities, where  they  may  cause  sudden  pain,  numbness,  and  coldness  of  the 
limb,  followed  by  partial  paralysis,  edema,  and  sometimes  even  by  gan- 


DIPHTHERIA  1037 

grene.     Thrombosis  of  tlie  pulmonary  artery  or  of  the  heart  may  be  a 
cause  of  sudden  death. 

Hemorrhages  are  usually  nasal,  and  while  in  most  cases  they  are  not 
serious,  they  may  necessitate  plugging  of  the  posterior  nares.  Bleeding 
from  any  other  mucous  membrane  may  occur,  but  it  is  rare  except  from 
the  mouth.  Subcutaneous  hemorrhages  are  infrequent,  and  are  evi- 
dence of  a  very  high  degree  of  diphtheritic  toxemia.  They  usually 
occur  as  small  petechial  spots,  but  are  sometimes  extensive.  They  may 
be  seen  upon  almost  any  part  of  the  body,  most  frequently  upon  the 
abdomen  and  lower  extremities;  but  the  most  extensive  extravasation 
we  have  ever  seen  was  in  the  neck,  reaching  from  the  clavicle  almost 
to  the  ear  and  covering  nearly  one  lateral  half  of  the  neck. 

Albumin  is  present  in  the  urine  of  almost  every  case  of  moderate 
severity,  usually  depending  upon  acute  degeneration  of  the  kidneys. 
Acute  nephritis  is  most  frequently  seen  in  severe  cases.  It  then  usually 
develops  at  the  height  of  the  local  disease,  but  may  come  during  con- 
valescence.    Chronic  nephritis  very  infrequently  follows  diphtheria. 

Diarrhea  is  of  frequent  occurrence.  There  may  beno  intestinal  lesion 
or  ileocolitis  may  be  present,  which,  however,  seldom  goes  on  to  ulcera- 
tion. It  is  extremely  rare  that  the  membranous  form  of  ileocolitis  is 
seen,  and  then  it  is  associated  with  the  presence  of  other  organisms  than 
the  diphtheria  bacillus. 

Diphtheria  is  usually  followed  by  a  severe  and  often  persistent  ane- 
mia which  may  continue  for  weeks.  Pneumonia,  nephritis,  and  cardiac 
disease  may  first  show  themselves  during  convalescence,  and  so  be  ranked 
as  sequelae.  The  most  important  sequel  of  diphtheria,  however,  is  post- 
diphtheritic paralysis,  already  discussed  in  the  chapter  on  Multiple  Keu- 
ritis. 

Pneumogastnc  Paralysis. — Some  cases  of  diphtheria,  especially  those 
which  receive  no  antitoxin  or  when  the  antitoxin  is  administered  late  or 
in  too  small  amount,  present  a  group  of  symptoms  which  have  been 
referred  to  degeneration  of  the  pneumogastric  nerves.  The  evidence, 
however,  is  by  no  means  conclusive  that  this  is  the  true  explanation  of 
the  clinical  picture,  which  is  a  familiar  one. 

These  symptoms  may  come  on  at  any  time  in  the  course  of  the  disease, 
but  seldom  earlier  than  the  end  of  the  second  week.  By  this  time  the 
throat  has  usually  cleared  off  entirely,  and  the  patient  is  considered 
convalescent.  The  symptoms  relate  to  the  stomach,  the  heart,  and  the 
respiration.  Usually  the  first  thing  to  attract  notice  is  that  the  patient 
refuses  food  and  vomits  occasionally,  afterward  persistently,  without  ap- 
parent cause.  If  the  pulse  is  carefully  observed  it  is  found  to  be  much 
slower  than  previously,  being  only  80  or  90  when  it  was  formerly  120  or 
more.     It  is  also  weaker,  compressible,  and  often  somewhat  irregular. 


1038  THE  SPECIFIC  INFECTIOUS  DISEASES 

The  face  is  pale  or  slightly  cyanotic,  and  moderate  dyspnea  may  be 
noticed.  There  are  frequent  attacks  of  severe  abdominal  pain  which 
comes  in  paroxysms,  and  is  usually  referred  to  the  epigastrium.  These 
symptoms  in  most  cases  gradually  increase  in  severity  for  two  or  three 
days,  but  sometimes  develop  with  such  intensity  that  death  occurs  within 
twelve  or  twenty-four  hours.  The  later  symptoms  are  a  continuance  of 
the  abdominal  pain  and  vomiting;  there  is  a  feeling  of  great  precordial 
oppression  and  distress  accompanied  by  dyspnea;  the  respiration  is  shal- 
low and  often  rapid ;  the  face  is  either  pale  or  cyanotic ;  the  extremities, 
cold;  the  pulse,  slow,  irregular,  and  intermittent,  becoming  rapid  on 
the  slightest  exertion.  The  heart  sounds  are  weak,  the  muscular  quality 
is  absent,  and  the  rhythm  much  disturbed.  There  may  be  no  murmurs. 
There  is  great  restlessness,  but  the  mind  is  entirely  clear.  Death  usually 
results  from  heart  failure,  which  may  come  quite  suddenly,  often  from  so 
slight  exertion  as  turning  over  in  bed  or  attempting  to  take  food. 

Not  all  the  cases  are  so  severe.  In  the  milder  forms  there  is  some 
palpitation,  an  irregular  pulse,  slight  dyspnea,  and  occasional  syncopal 
attacks,  but  of  no  great  severity.  Such  symptoms  may  come  and  go 
for  several  days  and  then  disappear;  but  more  frequently  they  prove  to 
be  the  beginning  of  the  more  serious  form  of  the  complication.  The 
time  of  occurrence  of  these  symptoms  varies  considerably.  It  may  be 
as  late  as  the  third  or  fourth  week.  The  late  cases  are  generally  asso- 
ciated with  some  other  form  of  postdiphtheritic  paralysis. 

Sudden  heart  failure  may  be  seen  late  in  diphtheria  quite  apart  from 
the  symptoms  just  described.  It  may  occur  with  few  or  no  premonitory 
symptoms;  as  when  a  child  falls  dead  after  walking  across  a  room,  or 
suddenly  sitting  up  in  bed,  or  from  some  other  muscular  effort,  or  pos- 
sibly as  a  consequence  of  passion  or  excitement.  We  knew  of  one  little 
girl  who  was  considered  well  enough  to  go  coasting  and  who  died  sud- 
denly after  the  effort. 

The  explanation  of  heart  failure  during  or  after  diphtheria  is  there- 
fore not  always  the  same.  When  it  occurs  at  the  height  of  the  disease 
it  is  sometimes  due  to  cardiac  thrombosis,  probably  always  associated 
with  changes  in  the  muscular  walls.  Wlien  it  occurs  late  and  follows 
some  sudden  musi-ular  effort  or  excitement  Avithout  premonitory  symp- 
toms of  any  sort,  it  is  probably  the  result  of  changes  in  the  muscular 
walls — a  true  myocarditis. 

Diagnosis. — The  diagnosis  of  diphtheria  rests  upon  two  kinds  of 
evidence — clinical  and  bacteriological.  In  mild  cases  and  in  the  early 
stage  only  bacteriological  evidence  can  be  relied  upon.  However,  the 
clinical  manifestations  of  the  disease  are  important  and  should  not  be 
ignored.  It  is  in  most  cases  possible  to  say  from  clinical  symptoms  that  a 
case  is  one  of  diphtheria;  but  it  is  never  possible  to  say  from  symptoms 


DIPHTHERIA  1039 

alone  that  a  case  is  not  one  of  diphtheria.  Cultures,  therefore,  should, 
if  possible,  be  made  in  every  case.  They  are  necessary  in  the  mild  cases 
in  order  that  a  correct  diagnosis  may  be  made  and  proper  quarantine 
regulations  enforced. 

The  mere  presence  of  diphtheria  bacilli  in  the  throat  does  not  prove 
that  a  person  has  diphtheria  any  more  than  the  presence  of  the  pneumo- 
coccus  in  his  saliva  proves  that  he  has  pneumonia;  but  when  diphtheria 
bacilli  are  associated  with  clinical  evidences  of  inflammation  of  the 
throat  or  nose  the  diagnosis  may  be  regarded  as  established.  Again,  the 
case  may  be  one  of  diphtheria  and  the  bacilli  not  found  at  the  first 
examination,  although  found  subsequently.  In  using  antitoxin  one  must, 
in  perliaps  the  majority  of  cases,  be  guided  by  clinical  symptoms  alone, 
not  waiting  for  the  result  of  the  bacteriological  examination.  It  is  there- 
fore important  that  both  methods  of  diagnosis  shoiild  be  emp]o3'ed. 

1.  The  Clinical  Diagnosis. — ISTot  much  importance  can  be  attached 
to  the  mode  of  onset ;  for  diphtheria  may  begin  in  many  different  ways. 
The  presence  of  a  nasal  discharge,  especially  if  abundant,  ichorous 
and  tinged  with  blood,  the  early  development  of  the  symptoms  of  croup, 
and  the  rapid  enlargement  of  the  cervical  lymph  nodes,  all  point  strongly 
to  diphtheria.  Later  symptoms  which  are  especially  diagnostic  arc 
marked  anemia,  progressive  asthenia,  very  feeble  pulse  which  is  some- 
times slow,  sometimes  rapid,  sudden  attacks  of  syncope,  nasal  regurgita- 
tion from  paralysis  of  the  soft  palate,  contagion,  and,  finally,  the  develop- 
ment of  paralysis  of  the  muscles  of  the  throat,  eye,  or  extremities,  with 
paralysis  of  the  heart  or  respiration. 

The  membrane  of  diphtheria  generally  appears  first  upon  the  tonsils, 
usually  as  a  gray  film  which  gradually  becomes  more  dense  and  white, 
and  often  has  the  look  of  being  plastered  on.  The  color  of  older  mem- 
brane is  gray,  greenish-yellow,  brown,  sometimes  black.  Beginning  as 
a  small  patch,  it  soon  covers  the  tonsils.  It  frequently  affects  one  tonsil 
twenty-four  or  thirty-six  hours  before  the  other,  and  occasionally  it  is 
confined  to  one  side.  In  exceptional  cases  it  begins  in  the  crypts  of  the 
tonsil  a]ul  appears  as  isolated  dots,  which  may  coalesce  to  form  a  con- 
tinuous patch  like  that  already  described,  or  it  may  remain  isolated  like 
the  exudate  of  an  ordinary  follicular  tonsillitis.  More  important  is 
the  fact  that  the  membrane  spreads  from  the  original  seat,  and  also  the 
manner  of  its  spreading.  If  it  extends  beyond  the  tonsils  to  the  walls 
of  the  pharynx,  the  faucial  pillars,  and  the  uvula,  it  is  almost  surely 
diphtheria.  The  same  is  true  of  doubtful  patches  on  the  tonsils  or  fauces 
followed  by  symptoms  of  croup.  The  rapidity  of  the  spreading  varies 
much  in  the  different  cases,  but  the  gradual  extension,  as  shown  by  obser- 
vations made  at  intervals  of  six  or  eight  hours,  usually  settles  the  diag- 
nosis in  the  primary  cases.    However,  if  the  throat  symptoms  complicate 


1040  THE  SPECIFIC  INFECTIOUS  DISEASES 

measles  or  scarlet  fever  the  above  rules  do  not  apply.  Most  of  the  mem- 
branous inflammations  of  the  throat  seen  in  these  diseases  are  not  due  to 
diphtheria.  This  is  particularly  true  of  those  which  occur  at  the  height 
of  the  primary  disease.  Those  which  develop  at  a  later  period  are  often 
due  to  diphtheria. 

Primary  membranous  inflammation  of  the  larynx  may  always  be 
safely  regarded  as  diphtheria;  but  if  there  is  no  visible  membrane,  the 
diagnosis  is  rendered  positive  only  by  a  bacteriological  examination. 
This. may  be  true  of  many  nasal  cases  where  the  only  symptoms  are  a 
discharge  of  the  character  previously  described.  Such  cases  may  con- 
tinue for  weeks  with  no  symptoms  other  than  the  discharge,  especially 
in  infants. 

It  is  seldom  difficult  to  distinguish  diphtheria  from  other  diseases; 
but  the  exudation  upon  the  pharynx  or  tonsils  may  be  confounded 
with  thrush  or  ulceromembranous  angina.  The  appearance  of  the  ton- 
sils on  the  second  or  third  day  after  tonsillotomy  has  been  performed, 
may  easily  be  mistaken  for  diphtheria  by  one  who  is  unfamiliar  with  the 
appearance  of  the  postoperative  wound. 

Diphtheria  of  the  mouth  may  be  mistaken  for  herpetic  or  ulcerative 
stomatitis ;  but,  as  a  rule,  it  is  seen  only  in  the  worst  cases  of  pharyngeal 
diphtheria.  Diphtheria  of  the  mouth  alone  is  so  rare  that  it  may  be 
ignored. 

It  is  sometimes  difficult  to  distinguish  cases  of  scarlet  fever  in  which 
the  throat  symptoms  are  severe  and  appear  early,  from  cases  of  primary 
diphtheria.  In  many  of  these  cases  the  eruption  appears  late,  and  is 
not  characteristic.  Much  importance  is  to  be  attached,  as  pointing 
toward  scarlet  fever,  to  a  prevailing  epidemic,  a  history  of  exposure,  a 
sudden  onset  with  severe  symptoms,  vomiting,  prostration,  very  high 
temperature,  and  to  a  very  active  inflammation  in  the  pharynx.  In  all 
cases  with  a  sudden  onset,  in  which  from  the  throat  symptoms  one  is 
inclined  to  make  a  diagnosis  of  diphtheria,  the  possibility  of  scarlet  fever 
should  not  be  forgotten,  and  one  should  never  omit  to  examine  the  patient 
thoroughly  for  an  eruption. 

2.  The  Bacteriological  Diagnosis. — The  Technic. — In  many  cases 
an  immediate  diagnosis  may  be  reached  by  the  examination  of  a  cover- 
glass  smear  from  the  throat.  This  method,  although  often  valuable,  is 
not  adapted  for  general  use,  as  bacilli  directly  from  the  throat  are  much 
less  typical  than  those  from  cultures,  and  the  chances  of  contamination 
are  much  increased.  Furthermore,  the  mouth  often  contains  other  bacilli 
which  somewhat  resemble  the  diphtheria  bacillus. 

In  taking  a  culture  from  the  throat  nothing  but  the  membrane  should 
be  touched  and  this  should  be  rubbed  firmly  with  a"  swab,  which  is  then 
rubbed  over  the  surface  of  the  culture-medium.     In  laryngeal  eases  the 


DIPHTHERIA  1041 

culture  should  be  taken  from  the  posterior  "vyall  of  the  pharynx,  and  in 
nasal  cases  from  the  nostril. 

The  Reliance  to  he  Placed  upon  Bacteriological  Diagnosis. — The  diph- 
theria bacillus  will  almost  invariably  be  found,  if  there  is  visible  mem- 
brane in  the  pharynx,  if  no  antiseptics  have  been  applied  shortly  before 
using  the  swab,  and  if  the  culture  has  been  made  with  sufficient  care  to 
avoid  contamination. 

The  diphtheria  bacillus  sometimes  disappears  early;  hence  cultures 
made  while  the  membrane  is  loosening  may  be  negative.  If  the  meni-- 
brane  has  disappeared,  or  if  none  has  been  present,  it  is  not  infrequently 
necessary  to  obtain  material  from  the  tonsillar  crypts  in  order  to  dis- 
cover bacilli.  It  is  therefore  important  in  all  cases  to  consider  the  dura- 
tion of  the  disease  before  drawing  a  conclusion  from  a  negative  culture. 
In  cases  of  laryngeal  disease  without  pharyngeal  exudation,  an  early 
culture  is  negative  in  nearly  half  the  cases ;  although  a  little  later  bacilli 
may  be  coughed  up  and  found  in  the  pharynx  in  abundance.  A  single 
negative  culture  should  never  be  taken  as  conclusive. 

For  diagnostic  purposes,  all  bacilli  present  in  suspicious  throats,  hav- 
ing the  morphological  and  cultural  characteristics  of  diphtheria  bacilli, 
are  to  be  regarded  as  virulent. 

Non-virulent  Bacilli  Resembling  the  Diphtheria  Bacillus. — There 
may  be  found  in  throats  a  form  which  corresponds  in  every  other  charac- 
teristic with  the  diphtheria  bacillus,  but  which  lacks  virulence,  as  shown 
by  animal  tests.  Also,  another  form,  which,  though  in  many  particulars 
resembling  the  diphtheria  bacillus,  differs  from  it  in  being  shorter, 
plumper,  and  more  uniform  in  size,  and  in  producing  an  alkali  in  broth 
cultures ;  to  this  the  term  pseudo-diphtheria  bacillus  has  been  given.  It 
is  more  frequently  seen  than  the  form  just  described  and  like  it  is  non- 
virulent.  Both  these  forms  are  rare  in  throats  where  a  suspicion  of  diph- 
theria exists. 

The  Presence  of  Virulent  Bacilli  in  the  Throats  of  Healthy  Persons. 
— That  virulent  bacilli  may  be  harbored  for  an  indefinite  period  in  the 
throat  or  nose  of  a  healthy  person  is  proved  by  many  observations.  The 
New  York  Health  Department  made  observations  upon  forty-eight  chil- 
dren in  fourteen  families  in  which  one  or  more  cases  of  diphtheria  had 
occurred,  and  where  no  attempt  at  isolation  had  been  made.  In  one- 
half  these  cases  bacilli  were  found,  and  animal  tests  showed  them  to  be 
virulent  in  every  one  of  six  cases  tested,  although  four  of  the  children 
did  not  develop  diphtheria.  Of  the  entire  number,  forty  per  cent  subse- 
quently developed  diphtheria.  Our  own  experience  in  two  institutions 
where  diphtheria  has  been  endemic,  fully  confirms  the  observation  that 
bacilli  of  all  degrees  of  virulence  are  very  frequently  found  in  the  noses 
or  throats  of  exposed  children,   although  a   large  proportion  of  them 


1042  THE  SPECIFIC  INFECTIOUS  DISEASES 

never  develop  the  disease.  Outside  of  institutions  and  infected  tene- 
ment houses,  however,  such  a  condition  is  much  less  common.  Moss  and 
Guthrie  took  cultures  from  1,217  public  school  children  in  Baltimore. 
In  44  children  diphtheria  bacilli  were  found,  but  in  only  eight  were  they 
virulent. 

-  Prognosis. — Many  possibilities  exist,  and  even  the  mildest  case  must 
be  regarded  as  serious  and  carefully  watched,  since  one  can  never  know- 
when  unfavorable  symptoms  may  develop. 

The  factors  to  be  considered  in  the  prognosis  of  any  given  case  are : 
the  age  and  previous  condition  of  the  patient;  the  extent  of  the  mem- 
brane and  the  rapidity  with  which  it  is  spreading;  the  degree  of  diph- 
theritic toxemia  as  shown  by  the  condition  of  the  pulse  and  the  nervous 
symptoms;  whether  or  not  the  membrane  has  invaded  the  larynx;  and 
the  presence  or  absence  of  complications,  especially  nephritis  and  bron- 
chopneumonia;  but  of  more  importance  than  any  or  all  these  things  is 
whether  antitoxin  is  used  and  when  it  is  administered. 

The  following  figures  are  from  the  Eeport  of  the  Health  Depart- 
ment of  Chicago  of  cases  treated  for  a  series  of  years. 

Died.  Mortality. 

Injected  1st  day 355  1  0 .  27  per  cent. 

2d  day 1,018  17  1 .  67    "       " 

«         3d  day 1,509  57  3.77    "       " 

"         4th  day 720  82  11 .39    "       " 

later.. 469  119  25.37    «       " 


Totals 4,071   276   6.77    "       " 

In  all  these  cases  the  diagnosis  of  diphtheria  was  confirmed  by  cul- 
ttires. 

Diphtheria  mortality  is  highest  during  the  first  two  years  of  life, 
from  its  strong  tendency  to  invade  the  larynx  and  lower  air  passages, 
and  from  the  frequency  with  which  bronchopneumonia  occurs  as  a  com- 
plication. Those  whose  experience  with  this  disease  does  not  antedate 
the  introduction  of  antitoxin  can  scarcely  appreciate  the  results  previ- 
ously obtained.  Of  eighty-five  consecutive  cases  under  twenty-six  months 
of  age  observed  in  the  New  York  Infant  Asylum,  in  a  period  extending 
over  two  years,  the  mortality  was  sixty-eight  per  cent ;  in  over  two-thirds 
of  the  fatal  cases  the  disease  involved  the  larynx.  In  diphtheria  hos- 
pitals, where  most  of  the  mild  cases  included  in  the  above  statistics  would 
probably  not  have  been  admitted,  the  mortality  in  children  luider  two 
years  formerly  varied  from  sixty  to  eighty  per  cent;  in  private  practice 
it  ranged  for  this  age  from  thirty  to  sixty  per  cent. 

It  can  not  be  too  often  emphasized  that  the  danger  from  diphtheria 
is  not  over  when  the  throat  has  cleared.  The  most  frequent  causes  of 
death  after  this  time  are  bronchopneumonia  and  cardiac  paralysis. 


DIPHTHEEIA  1043 

Prophylaxis. — In  no  infectious  disease,  smallpox  alone  excepted,  can 
so  much  be  accomplished  in  the  way  of  prevention  as  in  diphtheria. 

Public  funerals  of  children  dying  from  diphtheria  should  invariably 
be  prohibited.  Schools  should  be  closed  whenever  the  disease  is  epi- 
demic. Children  from  families  where  diplitheria  exists  should  not  be 
allowed  to  attend  school,  nor  mingle  in  an^^  way  with  other  children, 
for  the  reasons  that  they  may,  while  healthy,  be  the  carriers  of  the  dis- 
ease; and,  what  is  even  more  important,  that  they  may  be  themselves 
suffering  from  diphtheria  in  an  early  stage  or  in  a  mild  form. 

In  every  large  city,  hospitals  for  diphtheria  patients  should  be  estab- 
lished, not  only  for  the  poor,  but  with  private  rooms  for  cases  develop- 
ing in  hotels  or  other  places  where  isolation  is  impossible.  Every  city 
should  be  provided  with  a  steam  disinfecting  plant,  where  carpets,  blan- 
kets, bedding,  etc.,  can  be  sent  from  the  sick-room  for  disinfection. 

Quarantine. — Not  only  every  undoubted  case  of  diphtheria,  but  every 
suspected  case,  should  be  immediately  isolated.  Quarantine  for  the  lat- 
ter should  continue  until  the  diagnosis  is  settled  either  by  a  bacterio- 
logical examination  or  by  the  course  of  the  disease.  Positive  and  sus- 
pected cases  should  not  be  isolated  together.  The  quarantine  in  every 
instance  must  be  complete.  If  possible,  cultures  should  be  taken  from 
the  throats  of  all  exposed  children.  Those  containing  diphtheria  bacilli 
should  be  quarantined  like  cases  of  diphtheria,  for  they  may  be  equally 
dangerous;  they  should  use  gargles  and  sprays,  and  the  nose  and  throat 
should  be  closely  watched. 

Bacteriology  has  furnished  some  very  definite  data  from  which  the 
necessary  duration  of  the  period  of  quarantine  may  be  determined.  In 
this  the  physician  is  to  be  guided  by  the  time  that  the  bacilli  remain  in 
the  throat,  for  the  patient  is  to  be  considered  as  dangerous  while  they 
persist.  This  point  was  investigated  by  the  New  York  Health  Depart- 
ment in  605  cases :  In  304  of  these  the  bacilli  had  disappeared  by  the 
third  day  after  the  membrane  was  gone;  and  in  301  they  persisted  for  a 
longer  time — in  176,  for  seven  days;  in  64,  for  twelve  days;  in  36,  for 
fifteen  days;  in  12,  for  twenty-one  days;  in  4,  for  twenty-eight  days;  in 
4,  for  thirty-five  days;  and  in  3,  for  sixty-three  days.  In  many  of  the 
cases  in  which  the  bacilli  persist  for  an  unusual  time  they  are  found 
deep  in  the  crypts  of  the  tonsils.  Others  are  cases  of  nasal  diphtheria; 
in  some  of  these  doubtless  the  antrum  has  been  invaded.  While  it  is 
unquestionably  true  that  in  a  certain  number  of  cases  these  persistent 
bacilli  are  non-virulent,  the  opposite  has  been  frequently  shown.  Of 
15  cases  in  which  the  virulence  was  tested,  virulent  bacilli  were  found 
in  9  at  periods  varying  from  eight  to  twenty-five  days  after  the  membrane 
was  gone. 

Treatm.ent  of  Stispected  Cases. — During  an  epidemic  of  diphtheria, 


1044  THE  SPECIFIC  INFECTIOUS  DISEASES  ^ 

especially  in  an  institution,  every  child  with  sore  throat  or  nasal  dis- 
charge should  be  looked  upon  with  suspicion,  and  isolated  pending  the 
result  of  a  bacteriological  examination,  even  though  no  membrane  is 
present.  If  there  are  patches  on  the  tonsils  or  any  other  visible  mem- 
brane, the  case  should  be  treated  as  true  diphtheria,  in  order  that  no  time 
may  be  lost.  If  the  bacteriological  examination  shows  the  disease  not 
to  be  true  diphtheria,  the  patient  may  be  released  from  quarantine  in 
two  or  three  days,  provided  the  throat  symptoms  disappear.  It  is,  of 
course,  important  that  the  conditions  laid  down  with  reference  to  bac- 
teriological diagnosis  shall  have  been  fulfilled.  Should  symptoms  con- 
tinue, however,  a  second  culture  should  be  taken. 

Immunization  of  Persons  Exposed. — When  a  case  of  diphtheria  oc- 
curs in  a  family  or  an  institution,  every  child  and  all  adults  should  have 
their  immunity  determined  by  the  Schick  test.  This  is  based  upon  the 
irritating  action  of  unneutralized  diphtheria  toxin  upon  tissues,  when  in- 
jected intracutaneously  even  in  the  minute  amoimt.  The  test  therefore 
determines  the  presence  or  absence  of  natural  antitoxin,  and  indicates 
whether  or  not  persons  are  susceptible  to  the  disease.^ 

The  New  York  Health  Department  supplies  an  outfit  for  making  this 
test. 

Those  persons  with  an  immunity  do  not  require  antitoxin.  Children 
who  give  a  positive  Schick  reaction  should  be  immunized.  Adults  who 
are  not  immune  should  be  carefully  observed.  If  they  are  to  come  in 
close  contact  with  diphtheria  patients  they  also  should  receive  an  immu- 
nizing dose  of  antitoxin.  When  it  is  impossible  to  apply  the  Schick  test, 
children  under  five  years  of  age  should  be  immunized  with  antitoxin  at 
once.  With  older  children  immunization  may  be  postponed,  provided 
only  that  they  can  be  observed  at  least  twice  a  day.  If  this  can  not  be 
thoroughly  done,  all  children  under  ten  years  of  age  should  receive  a 
prophylactic  injection  of  antitoxin.  Those  older  may  be  treated  as  adults 
are  treated  by  close  observation,  but  without  antitoxin  unless  sore  throat 
or  other  suspicious  symptoms  arise. 

*The  method  of  applying  the  Schick  test  is  as  follows:  With  a  fine  hypo- 
dermic needle  and  using  a  carefully  graduated  syringe  1/50  of  a  minimum  lethal 
dose  for  the  guinea-pig,  of  diphtheria  toxin  is  injected  intracutaneously  in  .1  or 
.2  c.  c.  of  salt  solution. 

If  natural  antitoxin  is  present  no  reaction  occurs  beyond  that  due  to  the  small 
puncture.  If  no  antitoxin  is  present  a  circumscribed  area  of  redness,  V^.  cm.  in 
diameter,  appears  in  twenty-four  to  forty-eight  hours.  This  persists  for  six  to  ten 
days  and  gradually  disappears,  leaving  a  brownish  pigmented  spot  that  scales 
superficially,  and  that  may  be  appreciable  for  months.  There  are  no  constitu- 
tional symptoms  and  no  pain.  The  test  is  sharp  and  accurate.  Occasionally 
a  pseudo-reaction  may  be  seen.  This  appears  earlier  and  disappears  in  48  hours. 
The  area  is  less  sharply  circumscribed  and  more  indurated. 


DIPHTHERIA  1045 

The  dose  for  immunization  is  from  500  to  1^000  units,  the  former 
being  that  required  for  an  infant,  and  the  latter  for  older  children. 
There  is  no  doubt  that  for  a  limited  time — from  two  to  three  weeks — 
almost  complete  protection  is  conferred. 

Diphtheria  so  often  complicates  scarlet  fever  and  measles,  particularly 
in  institutions  and  in  hospitals  for  contagious  diseases,  that  special 
consideration  should  be  given  to  such  patients.  The  Schick  test  should 
be  made  on  all,  and  those  patients  with  no  natural  immunity  should 
be  given  antitoxin.  If  the  test  can  not  be  made,  the  only  safe  rule  is  to 
immunize  every  child  admitted  to  a  scarlet  fever  or  measles  hospital,  and 
in  institution  epidemics  of  either  of  these  diseases  to  immunize  every 
child  attacked. 

A  nurse  who  is  not  immune  to  diphtheria  should  not  work  in  infec- 
tious hospitals  nor,  ordinarily,  care  for  diphtheria  patients  in  private 
practice.  If  it  is  necessary  for  her  to  take  care  of  a  diphtheria  patient 
she  should  receive  1,000  units  of  antitoxin.  These  general  rules  do  not 
apply  to  physicians  who  are  in  less  close  contact  with  patients.  They 
should  take  the  same  precautions  as  in  scarlet  fever. 

-  The  injection  of  a  mixture  of  toxin  and  antitoxin  in  which  the  toxin 
is  not  completely  neutralized  is  often  used  with  animals  to  cause  a 
production  of  antitoxin.  Theobald  Smith  suggested  such  a  mixture  for 
the  immunization  of  children  and  von  Behring  put  it  to  the  practical 
test.  Recent  observations  by  Park  and  Zingher  have  shown  that  this 
method  not  only  increases  greatly  the  amount  of  antitoxin  present  in 
the  blood  of  immune  persons,  but  causes  the  production  of  antitoxin  in 
a  large  proportion  of  those  who  are  susceptible  to  the  disease.  A  com- 
bination of  the  mixture  with  a  vaccine  of  killed  diphtheria,  bacilli  seems 
to  be  advantageous.  The  effect  is  not  evident  at  once,  but  after  several 
weeks  an  immunity  can  be  demonstrated  which  has  been  proven  to  last 
for  many  months ;  how  much  longer  it  is  as  yet  impossible  to  .  say. 
Forty  out  of  fifty  susceptible  persons  in  Park  and  Zingher's  series  de- 
veloped an  antitoxic  immunity.  It  is  evident  that  a  means  is  thus  offered 
of  producing  immunity  in  susceptible  persons,  which  may  be  of  great 
service,  not  only  for  the  individual,  but  one  which  can  be  employed  to 
prevent  outbreaks  of  diphtheria  in  institutions  in  which  children  remain 
for  a  length  of  time.  The  method  is  not,  however,  applicable  for  use 
(luring  epidemics. 

Treatment. — General  Measures. — The  directions  to  be  carried  out  in 
the  sick-room  have  been  outlined  in  the  introductory  pages  on  Infectious 
Diseases.  It  is  important  in  every  case  of  diphtheria  that  there  should 
be  plenty  of  fresh  air  in  the  room  throughout  the  attack.  Hospital 
patients  should  never  have  less  than  1,000  cubic  feet  of  air  space,  and 
if  possible  1^200  should  be  allowed.     Even  in  mild  attacks  the  patient 


1046  THE  SPECIFIC  INFECTIOUS  DISEASES 

should  be  kept  in  bed  throughout  the  entire  illness,  and  in  severe  attacks 
this  should  be  continued  for  some  time  during  convalescence. 

Nursing  infants  may  be  fed  on  breast-milk  obtained  by  a  breast- 
pump,  but  should  not  be  put  to  the  mother's  breast.  Those  who  are  not 
nursed  and  older  children  should  be  fed  very  much  as  in  other  cases  of 
severe  illness.  Milk  is  the  main  reliance;  it  should  usually  be  diluted. 
The  greatest  difficulty  in  feeding  is  seen  in  the  latter  part  of  the  disease,, 
when  the  patients  are  septic  and  have  a  strong  aversion  to  food,  when 
vomiting  is  easily  excited  and  when  swallowing  is  difficult  on  account  of 
the  swelling  and  pain.  It  is  then  that  gavage  is  most  valuable.  In 
older  children  the  tube  may  be  passed  through  the  nose. 

Stimulants. — In  most  cases  they  are  not  needed  until  the  third  or 
fourth  day,  and  in  many  they  may  not  be  required  at  all.  The  indica- 
tions for  stimulants  are  marked  prostration,  a  feeble  pulse,  and  a  weak 
first  sound  of  the  heart.  Of  alcohol,  half  an  ounce  of  whisky  or  brandy 
in  twenty-four  hours  is  enough  for  a  child  four  years  old.  This  should 
be  diluted  with  at  least  eight  parts  of  water.  In  very  severe  cases  two  or 
three  times  as  much  may  be  given;  but  more  than  this,  except  for  a 
short  period,  is  seldom  wise.  More  reliance  is  to  be  placed  upon  the 
other  circulatory  stimulants,  especially  caffein,  camphor,  and  digitalis, 
which  are  given  for  the  same  indications  as  in  other  acute  diseases.  In 
cases  of  threatened  cardiac  paralysis  occurring  late  in  the  disease  or  dur- 
ing conA^alescence,  morphin  should  be  used  hypodermically.  Full  doses 
must  be  given  and  repeated  every  two  to  four  hours,  so  that  the  child  may 
be  kept  under  its  influence. 

Except  for  stimulation  or  the  control  of  special  symptoms  such  as 
diarrhea,  all  internal  medication  should  be  omitted;  for  there  is  yet 
wanting  jDroof  that  driigs  influence  the  course  or  the  result  of  the 
disease. 

Local  Treatment. — Since  the  introduction  of  antitoxin  local  treat- 
ment has  become  a  matter  of  secondary  importance;  and  under  condi- 
tions when  it  can  be  carried  out  only  with  great  difficulty  and  the  use  of 
force  it  is  often  wise  not  to  attempt  it  regularly. 

The  purpose  of  local  treatment,  it  is  now  generally  agreed,  should  be 
cleanliness,  and  not  the  destruction  of  bacilli.  Cleanliness  of  the  nose, 
mouth,  and  pharynx  is  important,  inasmuch  as  one  of  the  chief  dangers 
of  the  disease  is  the  aspiration  of  bacteria  contained  in  the  abundant 
secretions  of  these  parts,  into  the  larynx  and  bronchi.  Our  aim  should 
therefore  be  to  keep  the  parts  as  clean  as  possible  without  too  severely 
taxing  the  strength  of  the  child. 

For  cleansing  the  nose  and  pharynx  only  syringing  can  be  depended 
upon.  Nasal  syringing  is  indicated  when  there  is  much  nasal  discharge, 
whether  membrane  is  visible  in  the  anterior  nares  or  not.     In  septic 


DIPHTHERIA  1047 

cases  with  a  profuse  fetid  discharge  it  may  be  necessary  to  syringe  the 
nose,  no  matter  how  strongly  the  child  resists.  Whether  it  shall  be 
done,  will  depend  npon  the  condition  of  the  patient's  strength  and  his 
pulse.  The  purpose  in  syringing  is  not  so  much  to  clear  the  nose,  from 
which  absorption  is  slow  and  imperfect,  as  to  flush  the  rhinopharynx, 
from  which  absorption  is  always  very  active.  Only  bland  solutions 
should  be  employed,  such  as  a  saline  solution,  one  per  cent,  or  a  boric- 
acid  solution,  one-  to  four-per-cent  strength.  For  some  cases,  a  piston 
syringe  may  be  used ;  but  for  most  a  fountain  syringe  possesses  man- 
ifest advantages,  and  it  is  more  convenient  for  hospital  purposes.  Irri- 
gation of  the  pharynx  is  best  done  with  the  fountain  syringe,  and  is 
of  especial  value  where  there  is  much  swelling  or  abundant  discharge. 
A.11  solutions  should  be  used  as  warm  as  can  be  borne,  and  in  sufficient 
quantity  to  irrigate  the  parts  thoroughly,  a  few  such  irrigations  being 
much  better  than  a  great  many  partial  ones.  By  a  skilful  nurse  syringing 
can  in  most  cases  be  done  with  comparatively  little  disturbance  to  the 
child. 

Slight  nasal  hemorrhages  may  necessitate  less  frequent  syringing, 
and  a  free  hemorrhage  may  require  it  to  be  discontinued.  Astringent 
solutions  of  alum  and  epinephrin  are  often  beneficial  in  such  cases,  but 
they  must  be  used  carefully.  In  children  who  are  old  enough  gargles 
should  be  used.  A  solution  of  boric  acid,  or  Dobell's  or  Seller's  solution 
much  diluted,  may  be  employed. 

In  cases  with  a  moderate  nasal  discharge  it  is  usually  sufficient  to 
syringe  three  or  four  times  a  day;  but  in  severe  septic  cases,  with  very 
abundant  discharge,  syringing  should  be  repeated  as  often  as  every  two 
hours  during  the  day  and  every  four  hours  at  night. 

External  applications  have  no  effect  upon  the  disease,  but  are  often 
useful  to  relieve  pain  and  tension  in  the  swollen  lymph-glands.  Poultices 
should  not  be  employed.  As  a  continuous  application,  only  cold  is  to  be 
advised,  generally  by  means  of  an  ice-bag  well  protected  to  prevent  wet- 
ting the  clothing. 

The  treatment  of  cardiac  and  other  forms  of  post-diphtheritic  paral- 
ysis has  been  considered  in  the  chapter  on  Multiple  Xeuritis. 

The  Serum  Treatment. — Antitoxin  is  produced  by  the  cells  of  the 
body  under  the  stimulus  of  the  diphtheria  toxin.  It  is  intimately  com- 
bined with  the  globulin  of  the  blood,  and  is  itself  possibly  a  globulin.  It 
directly  neutralizes  the  toxin  produced  by  the  diphtheria  bacillus,  and 
also  has  some  effect  upon  the  bacilli  themselves,  the  nature  of  which  is 
not  understood.  It  induces  a  condition  in  the  blood  which  inhibits  the 
growth  of  the  bacilli,  and  thus  arrests  the  membranous  inflammation 
which  they  excite. 

Properly  prepared,  it  will  keep  without  deterioration  for  from  tliree 


1048  THE  SPECIFIC  INFECTIOUS  DISEASES 

to  six  months;  but  after  one  year  it  loses  somewhat  its  antitoxic  prop- 
erties. It  should  be  kept  in  a  cool,  dark  place,  and  after  a  bottle  has 
been  opened  it  should  be  used  within  a  few  days.  Antitoxin  is  now 
prepared  in  a  dry  form,  which  is  to  be  preferred  only  when  it  must  be 
kept  for  a  very  long  time. 

The-  strength  of  the  serum  is  measured  in  antitoxin  units,  the  unit 
being  an  arbitrary  one,  viz.,  the  amount  of  antitoxin  which  will  protect 
a  guinea-pig  weighing  250  to  300  grams  against  one  hundred  times  the 
fatal  dose  of  diphtheria  toxin.  Behring's  serum  first  used  contained  but 
one  unit  in  each  c.  c.  At  present  there  can  be  obtained  sera  containing 
1,000  antitoxin  units  or  more  in  each  c.  c.  This  concentration  is  of 
immense  advantage  and  has  to  a  large  degree  done  away  with  the  un- 
pleasant symptoms. 

Method  of  Administration  and  Dosage. — The  skin  should  be  thor- 
oughly cleansed  with  alcohol ;  the  needle  should  invariably  be  boiled  and 
the  whole  syringe  either  boiled  or  rinsed  with  alcohol.  The  seat  of  injec- 
tion is  not  a  matter  of  great  importance;  our  own  preference  is  for  the 
cellular  tissue  of  the  abdomen  or  axilla  or  the  muscles  of  the  buttock. 
Absorption  from  the  cellular  tissue  is  slower  than  from  the  muscles. 
For  very  rapid  effect,  however,  intravenous  injections  should  be  em- 
ployed. After  the  injection  is  made  the  puncture  should  be  covered  by 
adhesive  plaster. 

The  union  of  the  toxin  with  the  cells  takes  place  rapidly.  To  prevent 
this  the  maximum  required  dose  should  be  given  early  in  a  single  injec- 
tion, rather  than  in  divided  doses.  While  the  deleterious  effect  of  the 
toxin  bound  to  the  cells  can  not  be  neutralized  except  to  a  slight  extent, 
the  blood  can  be  supplied  with  sufficient  antitoxin  to  neutralize  new  toxin 
as -fast  as  it  is  produced.  Convinced  now  of  the  essential  harmlessness 
of  the  serum,  the  tendency  everywhere  has  been  to  use  larger  and  larger 
doses.  For  a  child  over  two  years  old  an  initial  dose  for  a  severe  attack, 
including  all  laryngeal  cases,  should  not  be  less  than  7,000  or  8,000  units 
administered  intramuscularly  or  preferably  intravenously.  Children 
under  two  years  should  receive  from  5,000  to  6,000  units.  Cases  of 
exceptional  severity,  in  older  children,  should  receive  from  10,000  to 
15,000  units  intravenously.  Mild  cases  should  receive  from  3,000  to 
5,000  units,  a  repetition  of  the  dose  in  any  patient  being  usually  unneces- 
sary. 

In  cases  receiving  antitoxin  late,  even  though  the  symptoms  may 
not  seem  particularly  severe,  the  dose  should  be  increased  in  proportion 
to  the  length  of  the  illness,  and  given  intravenously.  Only  serum  from 
a  trustworthy  manufacturer  should  ever  be  used.  The  most  concentrated 
serum  which  can  be  obtained  should  be  selected. 

All  experience  shows  that  the  results  are  greatly  modified  by  the 


DIPHTHERIA  1049 

time  of  its  administration.  The  serum  can  not  undo  the  serious  damage 
already  done  to  the  cells  of  the  body,  and  this  at  the  time  of  injection 
may  be  so  great  that  death  will  result.  In  very  mild  cases,  with  older 
children,  one  may  wait  for  the  result  of  a  bacteriological  examination, 
but  never  in  a  severe  case  and  never  in  a  young  child.  In  the  group  of 
severe  cases  should  be  placed  every  one  which  at  the  first  visit  shows  a 
pharyngeal  exudate  covering  more  than  the  tonsils,  also  all  cases  with 
symptoms  of  laryngeal  invasion,  and  all  with  an  exudate  on  the  pharynx 
and  a  profuse  nasal  discharge.  If  in  a  doubtful  case  twelve  hours'  ob- 
servation shows  that  the  membrane  has  spread  from  its  original  seat,  no 
further  delay  is  admissible.  In  human  diphtheria  marked  benefit  usually 
follows  injections  made  as  late  as  the  third  day;  but  after  this  time  the 
value  of  the  serum  diminishes  very  rapidly,  and  although  striking  ex- 
amples of  benefit  are  sometimes  seen  after  later  injections,  they  can  not 
be  depended  upon.  In  very  severe  or  in  malignant  cases  so  much  harm 
may  be  done  during  the  first  twenty-four  hours  of  the  attack  that  the 
subsequent  use  of  antitoxin  is  without  avail. 

The  effect  upon  the  diphtheritic  membrane  is  usually  noticeable 
within  twenty-four  and  often  in  twelve  hours;  it  first  stops  spreading, 
and  soon  begins  to  soften  and  loosen.^  The  swelling  of  the  mucous  mem- 
brane subsides  and  the  local  disease  abates,  very  much  as  when  the  dis- 
ease runs  its  usual  course.  The  striking  thing  after  the  use  of  antitoxin 
is  the  rapidity  with  which  these  changes  take  place,  and  the  abrupt  tran- 
sition from  an  advancing  to  a  retrograde  process.  The  subsidence  of 
the  inflammatory  conditions  in  the  larynx  and  trachea  is  quite  as  marked 
as  in  the  pharynx.  The  symptoms  of  stenosis,  even  when  severe,  often 
diminish  in  a  few  hours,  making  operation  unnecessary  in  a  very  large 
number  of  cases  when  previously  it  seemed  inevitable.  The  membrane 
loosens  rapidly  in  the  larynx  and  trachea,  sometimes  necessitating  the 
frequent  removal  of  the  intubation  tube,  when  operation  has  been  per- 
formed. Improvement  is  also  shown  by  the  cessation  of  the  nasal  dis- 
charge, the  re-establishment  of  nasal  respiration,  and  the  diminution  in 
the  swelling  of  the  glands  of  the  neck. 

The  effect  upon  the  constitutional  symptoms  is  not  less  striking.  In 
favorable  cases  there  is  seen,  often  in  twelve  hours,  a  fall  in  tempera- 
ture and  Improvement  in  the  pulse  and  in  the  nervous  symptoms. 

The  Limitations  of  Antitoxin. — It  is  important  that  these  should 
always  be  kept  in  mind.  The  serum  must  be  gi\eu  early,  for  if  given 
late  it  can  not  undo  the  mischief  already  doue  by  the  diphtheria  toxin. 
Cases  of  great  severity  have  often  passed  the  period  when  recovery  was 
possible,  before  the  antitoxin  is  given.  This  period  may  in  some  cases  be 
four  days,  in  others  it  may  be  less  than  twenty-four  hours.  The  tissues 
most  susceptible  to  the  diphtheria  toxin  are  probably  those  of  the  nervous 


1050  THE  SPECIFIC  INFECTIOUS  DISEASES 

system,  the  heart,  and  the  kidneys;  and  the  consequences  of  its  action 
may  he  seen  in  the  production  of  nephritis,  in  heart  failure  at  the  height 
of  the  disease,  or  in  later  paralysis  of  the  heart,  respiration,  or  the  volun- 
tary muscles,  in  spite  of  the  fact  that  antitoxin  is  given  at  a  period  early 
enough  to  avert  death  from  local  disease  in  the  larynx  or  bronchi. 
Against  the  phlegmonous  inflammation  of  the  throat  or  the  cellular 
tissue  of  the  neck,  bronchopneumonia,  and  nephritis,  antitoxin  is  power- 
less; and  just  in  proportion  to  the  severity  of  these  inflammations  are 
negative  results  seen. 

Eruptions  and  Other  Unpleasant  Effects. — Some  transient,  local 
edema  usually  follows  the  injection  and  a  slight  rise  of  temperature '  is 
very  frequently  observed.  In  a  few  hours  there  may  be  seen  a  general 
erythema;  this,  however,  is  rare  and  usually  of  short  duration.  The 
most  important  eruptions  are  seen  between  the  eighth  and  fourteenth 
days.  They  follow  from  five  to  ten  per  cent  of  the  injections  made,  and 
appear  to  be  quite  independent  of  the  amount  of  serum  used.  The  exact 
cause  is  not  known.  The  most  common  eruption  is  urticaria.  This  is 
often  intense,  very  annoying,  and  may  nearly  cover  the  body.  It  may 
be  accompanied  by  a  slight  rise  of  temperature ;  it  usually  lasts  for  two 
or  three  days;  but  is  rarely  severe  for  more  than  twenty-four  hours. 
Various  forms  of  erythema  are  occasionally  met  with.  In  several  in- 
stances we  have  seen  hemorrhagic  eruptions,  generally  in  the  neighbor- 
hood of  the  large  joints,  and  always  in  children  suffering  from  extreme 
malnutrition.  In  a  few  cases  a  moderate  swelling  of  some  of  the  joints 
has  been  observed,  and  a  transient  albuminuria.  One  occasionally  meets 
with  patients  who  seem  unusually  susceptible  to  serum  injections,  and 
in  Avhom  even  small  immunizing  doses  cause  headache,  muscular  pains, 
and  general  malaise,  so  that  they  feel  quite  Avretched  for  several  days, 
'  All  of  the  above  symptoms  except  the  urticaria  are  rare,  and  should  not 
for  an  instant  deter  one  from  using  antitoxin  when  indicated.  They 
are  much  less  common  with  the  refined  and  concentrated  antitoxin  in 
use  at  the  present  time. 

Recti  and  Alleged  Dangers  from  Antitoxin  Injections. — In  a  few  in- 
stances sudden  death  has  followed  antitoxin  injections,  but  the  evidence 
that  antitoxin  was  the  cause  of  death  has  not  always  been  conclusive.  In 
some  of  these  patients  the  autopsy  has  revealed  a  status  lymphaticus 
not  before  suspected.  In  this  condition  the  shock  of  so  slight  a  thing  as 
a  needle  puncture  may  produce  death.  There  are  other  cases  which  do 
not  admit  of  this  explanation,  x'^lmost  all  have  occurred  in  patients 
during  adolescence  or  adult  life.  The  symptoms  usually  come  on  within 
a  few  seconds  or  minutes  after  the  injection  and  occur  quite  independ- 
ently of  the  dose  given.  Several  have  followed  small  immunizing  doses 
given  to  apparently  healthy  persons,  but  the  majority  have  been  suf- 


DIPHTHERIA  1051 

ferers  from  hay  fever  or  asthma,  usually  from  that  form  excited  by  con- 
tact with  horses.  In  some  recorded  cases  the  patients  had  received  anti- 
toxin before;  in  the  great  majority,  however,  the  sensitiveness  to  the  pro- 
tein of  horse  serum  had  been  acquired  in  some  other  way.  The  most 
striking  symptoms  are  a  rapidly  developing  dyspnea  with  cyanosis  and 
great  prostration.  In  the  most  severe  cases  death  may  follow  in  a  few 
minutes  from  respiratory  failure ;  in  those  less  severe,  a  gradual  recovery 
takes  place  with  no  permanent  after  effects. 

Such  experiences  are,  fortunately,  exceedingly  rare.  ISTo  fatalities  or 
even  severe  respiratory  symptoms  due  to  the  administration  of  antitoxin 
have  been  observed  since  its  introduction  in  the  Willard  Parker  Hospital 
in  New  York  where  many  thousands  of  injections  of  antitoxin  are  given 
each  year.  Certainly  in  children  with  diphtheria  one  should  not  hesitate 
one  moment  in  regard  to  its  use.  If  the  patient  gives  a  history  of  asthma, 
and  inquiry  should  always  be  made  regarding  this,  special  precautions 
should  be  employed  in  giving  antitoxin.  As  concentrated  a  preparation  as 
possible  should  be  used  and  injected  subcutaneously  a  drop  or  two  at  a 
time,  at  intervals  of  ten  or  fifteen  minutes.  If  there  is  no  reaction  after 
the  first  few  drops  the  rest  may  be  injected  at  once.  If  there  is  any  reac- 
tion it  will  not  be  severe  and  after  a  time  a  drop  or  two  more  may  be 
given.  Thus  the  whole  dose  may  be  given,  though  it  may  require  much 
time.  With  a  clear  history  of  asthma,  injections  for  immunization  may 
well  be  omitted  and  the  child  kept  under  close  observation.  If  symptoms 
develop  after  the  injection  of  serum,  atropin  should  be  given  in  full  doses ; 
epinephrin  and  morphin  are  also  useful.  In  some  instances  artificial 
respiration  has  apparently  been  beneficial. 

Results  with  Antitoxin  Treatment. — Since  1895  the  serum  has  been 
tested  on  such  an  extensive  scale  as  the  prevalence  of  diphtheria  all  over 
the  world  has  made  possible,  with  results  so  uniformly  good  that  it  seems 
quite  unnecessary  any  longer  to  cite  statistics  in  proof  of  the  value  of  this 
remedy. 

The  beneficial  effects  of  antitoxin  may  be  summed  up  in  the  follow- 
ing statements:  (1)  The  percentage  mortality  from  diphtheria  in  hos- 
pitals both  in  Europe  and  in  America  has  been  reduced  to  a  little  more 
than  one-third  the  previous  figures;  (2)  the  proportion  of  cases  now 
requiring  operation  for  laryngeal  stenosis  has  been  reduced  to  aboiit 
one-half;  (3)  the  mortality  after  tracheotomy  has  been  reduced  to  one- 
half,  and  that  after  intubation  to  about  one-third  the  former  figures; 
(4)  but  even  more  convincing  is  the  effect  of  the  serum  treatment  upon 
the  actual  diphtheria  mortality  of  cities  and  countries  where  it  has 
been  used. 

Convalescence. — After  a  severe  attack  of  diphtheria  convalescence  is 
always  slow  on  account  of  the  anemia  and  the  depressing  effects  of  the 


1052  THE  SPECIFIC  IXFECTIOUS  DISEASES 

disease.  Patients  should  invariably  be  kept  in  bed  for  at  least  a  week 
after  the  throat  has  cleared,  and  much  longer  if  any  tendency  to  cardiac 
weakness  is  seen.  The  pulse  should  be  carefully  watched,  and  irregular- 
ity, intermission,  dicrotism,  or  a  weak  first  sound  of  the  heart,  should 
make  one  apprehensive.'  An  abnormally  slow  pulse  is  generally  more 
serious  than  one  which  is  rapid.  In  such  circumstances  the  patient 
should  be  kept  recumbent  and  absolutely  quiet,  since  fatal  syncope  may 
be  the  result  of  a  violation  of  these  rules.  The  extreme  degree  of  anemia 
frequently  requires  that  iron  be  given  for  a  considerable  time  during 
convalescence. 

Great  difficulty  is  occasionally  experienced  in  getting  rid  of  the 
bacilli  in  the  throat.  The  tonsillar  crypts,  the  adenoid  tissue  of  the 
rhinophar^-nx,  and  the  nasal  sinuses  are  the  places  where  the  bacilli  are 
most  likely  to  remain.  Inasmuch  as  it  is  now  generally  made  a  condition 
of  release  from  quarantine  that  the  throat  shall  have  been  shown  by 
cultures  to  be  free  from  bacilli,  this  becomes  a  matter  of  much  im- 
portance. Xasal  syringing  with  a  very  weak  solution  (1-10,000)  of 
bichlorid  to  which  ten  per  cent  solution  of  glycerin  has  been  added  is 
sometimes  efficacious.  The  fluid  should  be  warm  and  the  syringing 
gently  done  twice  daily.  The  same  solution  may  be  used  as  a  gargle.  For 
children  under  four  years  old  a  simple  salt  solution,  or  a  dilute  Dobell's 
solution,  should  be  substituted  and  the  gargle  omitted.  In  some  ob- 
stinate cases  the  best  procedure  is  to  omit  all  local  treatment  and  get 
the  patient  into  the  open  air  of  the  country.  When  bacilli  are  very  per- 
sistentj  as  they  often  are  for  weeks,  their  virulence  should  be  tested.  In 
the  great  majority  of  such  cases  they  are  found  to  be  non-virulent  and 
further  quarantine  is  unnecessary.  When  virulent  bacilli  long  persist, 
the  question  of  the  removal  of  the  tonsils  should  be  considered.  It  is 
sometimes  successful  when  all  other  means  of  getting  rid  of  the  bacilli 
have  failed. 

Laryngeal  Diplitlieria. — Emetics,  inhalations  of  steam,  and  solvents 
for  the  membrane,  although  they  all  sometimes  give  relief,  are  not  to  be 
relied  upon. 

Opinions  will  always  differ  as  to  the  time  when  operative  inter- 
ference is  called  for.  One  should  never  wait  for  general  cyanosis,  for 
often  this  does  not  occur  until  just  before  death.  It  is  better  to  operate 
too  early  than  too  late.  If,  in  spite  of  other  measures,  the  dyspnea  in- 
creases steadily,  operation  should  not  be  deferred  longer.  Intubation  has 
almost  universally  superseded  tracheotomy  as  a  primary  operation  for 
the  relief  of  membranous  laryngitis.  Tracheotomy  is  still  needed  at 
times  for  the  cases,  few  in  number,  in  which  intubation  fails  to  give 
relief  on  account  of  the  position  of  the  membrane  or  for  some  other 
complication. 


INTUBATION  1053 


Intubation 


Intubation  is  the  introdiiction  of  a  tube  through  the  mouth  into  the 
larynx  for  the  relief  of  laryngeal  dyspnea.  For  the  operation,  as  now 
performed,  the  world  is  indebted  to  the  late  Dr.  Joseph  O'Dwyer,  of 
New  York. 

A  set  of  O'Dwyer's  instruments  consists  of  seven  tubes,  an  introduc- 
tor,  an  extractor,  a  mouth-gag,  and  a  gauge.  The  tubes  are  made  of 
hard  rubber  and  lined  with  gold-plated  metal.  So  carefully  did  O'Dwyer 
perfect  his  instruments  that  nothing  of  importance  has  been  added  by 
others.  It  is  interesting  to  note  that  nearly  all  the  modifications  which 
have  been  suggested  since  his  first  publication  had  already  been  tried 
by  him  and  discarded.  No  one  thing  is  more  essential  to  success  with 
intubation  than  properly  constructed  instruments.  The  operation  is 
not  difficult  if  one  has  had  practice  on  the  cadaver.  Without  this  it 
should  not  be  attempted.  The  tube  is  selected  according  to  the  age  of 
the  patient,  this  being  indicated  on  the  gauge.  A  very  large  child  Avill 
often  require  a  tube  of  larger  size  than  his  age  would  call  for. 

Introduction  of  the  Tube. — Either  one  of  two  positions  may  be 
employed,  the  choice  depending  upon  the  preference  of  the  operator. 
In  one  the  child  is  seated  vipon  the  lap  of  a  nurse  while  his  head  is 
steadied  by  a  second  assistant  standing  behind.  In  the  other  position  the 
child  lies  upon  his  back  upon  a  table,  his  head  being  steadied  by  an 
assistant.  In  both  positions  the  arms  should  be  pinioned  to  the  sides  by 
a  sheet.  In  the  recumbent  position  the  child  can  be  held  more  firmly; 
it  has  also  the  advantage  of  dispensing  with  one  assistant,  and  in  an 
emergency  with  both  of  them.  The  tube  is  attached  to  the  introductor, 
and  the  gag^is  inserted  at  the  left  angle  of  the  mouth  and  opened  as 
widely  as  possible.  The  attempts  at  introduction  must  be  made  quickly, 
for  during  them  respiration  is  practically  arrested.  Several  short  at-" 
tempts  are  always  better  than  a  single  prolonged  one.  Yery  little  force 
is  ordinarily  required  in  introducing  the  tube,  that  used  in  passing  a 
catheter  being  a  good  general  guide.  In  cases  of  subglottic  stenosis, 
however,  quite  a  little  force  may  be  necessary. 

The  index  finger  of  the  left  hand  is  used  as  a  guide  in  introduction. 
This  is  passed  well  back  into  the  pharynx,  then  brought  forward  until  a 
hard  nodule — the  upper  border  of  the  cricoid  cartilage — is  encountered. 
This  is  the  best  of  all  landmarks,  since  the  soft  parts  are  often  distorted 
by  swelling.  Directly  in  front  of  the  cricoid  cartilage  may  be  felt  the 
epiglottis  and  the  opening  of  the  larynx,  which  are  readily  recognized 
after  the  touch  has  become  somewhat  educated.  The  epiglottis  is  drawn 
forward  and  the  tube  is  passed  along  the  palmar  surface  of  the  left  index 
finger,  by  which  it  is  guided  into  the  larynx;  it  is  then  pushed  off  the 
35 


1054  THE  SPECIFIC  IKFECTIOUS  DISEASES      -" 

introductor  by  a  thumb-piece  attached  to  its  handle.  When  it  is  certain 
that  the  tube  is  in  position,  and  the  patient  breathes  properly,  the  loop 
of  silk  attached  to  the  head  of  the  tube  is  cut  off  and  pulled  through, 
the  removal  of  the  tube  being  prevented  by  placing  the  left  forefinger 
upon  its  head.  The  silk  is  not  usually  left  attached  unless  there  is  evi- 
dence of  loose  membrane  below  the  tube.  Tt  may  be  desirable  to  leave 
the  silk  attached  in  case  no  one  is  witliin  reach  who  is  able  to  remove 
the  tube  should  it  become  obstructed.  The  child's  arms  and  hands  should 
then  be  secured  to  prevent  him  from  seizing  it  himself.  When  not  re- 
moved, the  silk  is  fastened  to  the  cheek  by  a  piece  of  adhesive  plaster. 
The  tube  is  known  to  be  in  place,  first,  by  the  hissing  breathing  sounds, 
somewhat  similar  to  what  is  heard  when  the  trachea  is  opened;  secondly, 
by  a  severe  paroxysm  of  coughing,  which  is  usually  excited  by  a  tube  in 
the  larynx;  thirdly,  by  the  relief  of  the  dyspnea.  If  this  relief  is  not 
very  apparent  the  physician  may  still  be  in  doubt  as  to  whether  the  tube 
is  in  the  larynx  or  the  esophagus.  If  in  the  former,  it  can  not  be  pushed 
down  by  the  finger  without  depressing  the  larynx  with  it ;  and  by  in- 
troducing the  finger  into  the  pharynx,  the  posterior  wall  of  the  larynx 
can  be  felt  between  tlie  finger  and  the  tube.  The  most  common  mistake 
made  is  to  pass  the  tube  into  the  esophagus.  This  sometimes  happens 
because  the  position  of  the  child's  head  is  improper — too  far  forward  or 
too  far  backward — but  more  often  because  the  operator  has  not  been  quite 
sure  of  his  landmarks.  If  this  has  occurred,  there  is  no  relief  to  the 
dyspnea,  no  hissing  sound,  and  the  tube  can  be  pushed  down  indefinitely. 
When  this  condition  is  recognized,  the  tube  is  withdrawn  by  the  loop  of 
silk  and  after  a  few  moments  a  second  attempt  made. 

False  ]3assages  in  the  larynx  are  most  frequently  made  by  emj)loying 
too  much  force  or  because  the  operator  has  worked  at  the  angle  of  the 
mouth  instead  of  keeping  in  the  median  line.  The  tube  usually  goes 
into  one  of  the  ventricles  of  the  larynx  and  may  be  pushed  quite  through 
tlie  larynx  into  the  cellular  tissue.  This  is  not  very  likely  to  happen, 
however,  unless  undue  force  has  been  used.  The  production  of  a  false 
passage  is  recognized  by  the  fact  that,  although  the  tip  of  the  tube  can 
be  felt  to  enter  the  larynx,  the  tube  does  not  descend,  but  projects  above 
the  epiglottis. 

False  membrane  which  has  become  loosened  is  sometimes  crowded 
down  by  the  tube  and  obstructs  the  larynx  just  below  it.  This  is  one  of 
the  most  serious  accidents  that  may  occur,  but  fortunately  it  is  not  a 
frequent  one.  It  is  more  likely  to  happen  when  the  disease  has  existed 
for  several  days  than  in  recent  cases.  The  tube  may  be  in  place  in  the 
larynx  as  shown  by  all  the  signs  above  mentioned,  except  relief  of  the 
dyspnea.  In  such  a  case  the  immediate  withdrawal  of  the  tube  is  neces- 
sajrv,  it  being  often  followed  by  the  discharge  of  masses  of  loose  mem- 


INTUBATION  1055 

brane.  This  is  aided  by  the  administration  of  half  a  teaspoonful  of  pure 
whisky  or  brandy  to  excite  a  strong  cough.  Artificial  respiration  may  be 
required,  and  if  there  is  no  relief  by  any  of  these  means  tracheotomy  is 
indicated.  Asphyxia  is  sometimes  produced  by  prolonged  and  injudicious 
attempts  at  intubation. 

After-treatment. — So  far  as  the  tube  itself  is  concerned  no  treat- 
ment is  required.  The  original  disease  is  to  be  treated  as  before.  The 
operation  has  removed  only  one  danger  from  the  patient,  viz.,  that  of 
asphyxia  from  mechanical  obstruction  of  the  larynx.  A  good  expulsive 
cough  should  occur  after  the  tube  is  in  place.  This  is  necessary  to 
clear  the  tube  of  mucus,  as  the  pharynx  and  larynx  are  generally  filled 
with  it  as  a  result  of  tlie  manipulation. 

Tlie  child  sliould  not  be  allowed  to  lie  upon  his  face,  nor  should  he 
he  held  over  the  nurse's  shoulder  face  downward,  for  in  either  position 
a  slight  cough  is  enough  to  expel  the  tube.  Nursing  infants  may  some- 
times continue  at  the  breast  after  the  operation ;  ordinarily  they  have  but 
little  difficulty  in  swallowing.  Older  children  often  experience  consid- 
erable trouble  in  taking  liquids.  This  may  be  overcome  by  the  device  sug- 
gested by  Casselberry,  of  having  the  patient's  head  lower  than  his  body 
while  he  drinks.  When  fluids  causQ  excessive  coughing,  or  at  other 
times  when  they  can  be  taken  only  with  the  greatest  difficulty,  they 
may  be  given  through  a  nasal  tube  or  one  passed  through  the  mouth. 
Semi-solid;  articles,  such  as  condensed  milk,  wine  jelly,  cornstarch,  ice 
cream,  or  scrambled  eggs,  may  be  well  taken  when  fluids  are  not. 
Feeding  is  always  easier  after  the  first  day  or  two,  and  patients  who 
wear  a  tube  for  chronic  disease  soon  experience  no  trouble  whatever, 
showing  that  the  difficulty  depends  more  upon  the  inability  to  co- 
ordinate the  movements  of  the  muscles  of  deglutition  when  the  tube  is 
in  place  than  upon  mechanical  causes,  for  the  head  of  the  tube  is  ef- 
fectually covered  by  the  epiglottis. 

When  the  tube  is  removed  by  extubation  or  coughed  up,  the  dyspnea 
does  not  usually  return  for  two  or  three  hours,  but  may  come  back  at 
once.  It  may  happen  that  the  tube  is  coughed  up  and  not  seen  by  the 
nurse,  or  it  may  be  coughed  up  and  swallowed  by  the  child.  When 
called  because  of  dyspnea  after  operation,  the  physician  should  make  a 
digital  examination  of  the  pharynx  to  discover  if  the  tube  is  still  in 
place.  Swallowing  the  tube  generally  causes  no  harm  to  the  child,  for 
tubes  have  repeatedly  passed  through  the  intestines.  Should  the  tube 
be  coughed  out  at  any  time  its  introduction  should  be  delayed  until 
dyspnea  returns. 

It  sometimes  happens  that  the  tube  is  coughed  out  soon  after  its 
introduction  because  too  small  a  size  has  been  used.  At  other  times 
this  occurs  repeatedly  even  with  tubes  of  the  proper  size.     Such  cases 


1056  THE  SPECIFIC  INFECTIOUS  DISEASES 

are  probably  due  to  paralysis  of  the  laryngeal  muscles.  As  patients 
in  such  circumstances  are  unable  to  breathe  for  even  a  few  minutes 
without  the  tube  it. is  usually  necessary  with  repeated  self  extubation  to 
perform  tracheotomy. 

The  entrance  of  food  into  the  bronchi  through  the  tube  is  a  danger 
that  does  not  exist,  and  bronchopneumonia  following  intubation  does 
not  depend  upon  this  cause. 

Deep  ulceration  at  the  head  of  the  tube  rarely  occurs,  provided  prop- 
erly made  tubes  are  employed,  but  superficial  ulceration  is  almost  in- 
variably produced  at  the  base  of  the  epiglottis  and  in  the  trachea  at 
the  lower  end  of  the  tube.  Deep  ulcers  extending  to  tlie  tracheal  rings 
may  occur  in  ill-conditioned  children,  usually  in  connection  with  other 
complications  serious  enough  to  cause  death. 

Spontaneous  descent  of  the  tube  into  the  larynx  is  almost  impossible, 
and  it  can  not  be  crowded  down  without  using  considerable  force  and 
severely  lacerating  the  larynx. 

Sudden  blocking  of  the  lower  end  of  the  tul)e  by  membrane  loosened 
from  the  trachea  or  bronchi  occasionally  occurs.  The  usual  result  of 
this  is  the  immediate  expulsion  of  the  tube  by  coughing,  the  discharge 
of  the  loose  meml^rane  following.  This  condition  is  one  of  the  safety 
valves  of  the  operation.  One  of  the  strong  points  in  favor  of  intubation 
is  that  the  forcible  cough  which  the  patient  is  able  to  make  on  account  of 
the  narrow  opening  of  the  tube,  often  enables  him  to  expel  large  accu- 
mulations of  mucus,  and  even  membrane,  more  readily  than  through  a 
much  larger  tracheal  opening. 

The  period  for  which  the  tube  is  required  varies  much  in  different 
cases.  It  has  been  materially  shortened  by  the  use  of  antitoxin.  The 
average  time  of  wearing  the  tube  is  about  five  days,  and  in  many  it  ca]i 
be  dispensed  with  in  two  or  three  days.  An  attempt  should  be  made 
to  have  the  child  go  without  the  tube  whenever  the  temperature  reaches 
normal.  If  complications  are  present  that  still  cause  fever  extubation 
should  not  be  deferred  beyond  the  fifth  or  sixth  day.  The  majority  of 
cases  do  not  require  re-intubation.  If  this  is  necessary,  extubation  should 
be  done  again  in  three  or  four  days  and  repeated  thereafter  at  this  in- 
terval until  the  tube'  is  no  longer  necessary.  If,  after  several  weeks  the 
tube  cannot  be  dispensed  with  the  treatment  described  later  for  retained 
intubation  tubes  should  be  adopted. 

Removal  of  the  Tube — Extubation. — This  is  rather  more  difficult 
than  its  introduction.  The  general  arrangement  of  the  patient  and 
assistants  is  the  same  as  for  introduction.  The  left  index  finger  is  placed 
upon  the  head  of  the  tube,  which  is  steadied  externally  by  the  thumb  of 
the  same  hand.  The  beak  of  the  extractor  is  introduced  within  the  open- 
ing of  the  tube,  its  jaws  are  then  separated  by  pressure  iipon  the  lever 


INTUBATION  1057 

at  the  handle,  and  the  instrument  withdrawn,  very  slight  force  being 
required. 

The  tube  is  first  removed  tentatively,  the  physician  waiting  to  see  if 
dyspnea  returns.  It  is  well  to  give  a  full  dose  of  morphin  an  hour 
before  the  removal  of  tlife  tube,  since  tbis  operation  is  almost  invariably 
followed  by  a  marked  degree  of  laryngeal  spasm  which  lasts  for  ten  or 
fifteen  minutes.  To  avoid  the  production  of  vomiting  and  the  entrance 
of  food  into  the  larynx,  food  should  not  be  given  for  three  hours  previ- 
ously. If  dyspnea  does  not  return  in  the  course  of  three  or  four  hours, 
the  probabilities  are  that  the  tube  will  no  longer  be  required.  It  is  excep- 
tional that  the  patient  has  great  difficulty  in  dispensing  with  the  tube, 
as  so  often  happens  after  tracheotomy. 

The  only  objection  of  much  force  urged  against  intubation  is  that 
asphyxia  may  be  produced  by  crowding  down  loose  membrane  into  the 
larynx.  This  is  an  infrequent  accident;  should  it  happen,  and  the 
asphyxia  not  be  relieved  by  removing'  the  tube  and  inserting  another, 
tracheotomy  may  be  performed. 

There  is  always  some  degree  of  hoarseness  following  intubation,  but 
in  the  majority  of  cases  it  disappears  within  a  week,  occasionally  it  con- 
tinues as  long  as  three  or  four  weeks,  hut  it  is  very  rarely  if  ever  perma- 
nent. The  duration  of  the  aphonia  seems  to  have  little  relation  to  the 
length  of  time  the  tube  is  worn,  unless  this  is  many  v^eeks. 

Experience  has  clearly  proved  that  intubation  relieves  the  dyspnea 
due  to  laryngeal  stenosis  promptly,  efficiently,  and  certainly;  it  does  this 
Avithout  many  of  the  dangers  and  objectionable  features  of  tracheotomy, 
while  at  the  same  time  it  does  not  deprive  the  patient  of  any  essential 
advantage  which  trncheotomy  affords. 

Retained  Intubation  Tubes — Prolonged  Intubation. — Dif&eulty  is 
experienced  in  dispensing  with  the  intubation  tube  much  less  frequently 
than  with  the  cannida  after  tracheotomy;  yet  when  this  condition  occurs 
it  is  the  cause  of  much  concern  and  even  danger.  Trouble  of  this  sort 
is  seen  in  about  five  per  cent  of  the  cases  of  intubation.  In  the  majority 
of  these  the  patient  is  able  to  do  without  the  tube  in  a  few  weeks,  and 
such  cases  require  very  close  attention,  but  no  special  treatment  other 
than  the  substitution  at  times  of  a  special  O'Dwyer  tube  with  an  extra 
large  "retaining  swell."  But  occasionally  there  are  met  with  cases  in 
which  every  effort  to  dispense  with  the  tube  proves  futile.  Although 
the  children  breathe  well  with  the  tube  in  place,  still  if  it  is  removed 
or  expelled  by  coughing,  in  a  short  time,  varying  from  a  few  minutes  to 
several  days,  the  dyspnea  returns  with  such  severity  that  the  tube  must 
be  replaced  to  prevent  asphyxia.  Inasmuch  as  these  patients  sometimes 
expel  the  tube  several  times  a  day,  surgeons  have  often  resorted  to  trache- 
otomy to  avert  the  danger  of  suffocation,  which  might  easily  occur  if  no 


1058  THE  SPECIFIC  INFECTIOUS  DISEASES  ^ 

one  were  at  hand  who  could  replace  the  tube.  This  operation,  however, 
gives  only  temporary  relief.  ]\[any  of  these  children,  after  wearing 
tubes  of  one  sort  or  another  for  years,  ultimately  die  from  some  accident 
connected  with  the  tube  or  from  pneumonia. 

The  causes  and  the  exact  pathological  condition  underlying  this  dif- 
ficulty are  subjects  regarding  which  there  has  been  much  difference  of 
opinion.  The  cause  of  the  returning  dyspnea  is  probalily  subglottic 
swelling  and  edema  which  occur  in  tissues  wliich  are  tlie  seat  of  chronic 
inflammation,  as  soon  as  tlie  pressure  of  the  tube  is  removed.  In  a  few 
cases  a. cicatricial  condition,  the  result  of  previous  ulceration,  has  been 
found ;  but  it  is  doubtful  if  granulations,  so  frequent  a  cause  of  retained 
cannula  after  tracheotomy,  play  an  important  part.  The  chronic  in- 
flammation of  the  mucous  and  submucous  tissues  of  the  subglottic  region 
of  the  larynx  which  produces  the  symptoms,  is  aggravated  by  a  faulty 
tube  or  a  clumsy  operation,  but  it  may  occur  under  the  most  favorable 
conditions. 

For  the  relief  of  this  condition,  O'Dwyer  advised  in  recent  cases  the 
application  of  astringents  by  means  of  an  intubation  tube  coated  with 
gelatine  with  which  some  astringent  was  combined.  For  those  patients 
who  cough  out  the  tube  frequently,  tracheotomy  is  at  times  a  necessity 
to  prevent  sudden  death.  But  this  does  not  affect  the  original  condition, 
for  the  same  diilRculty  exists  in  doing  without  the  tracheal  cannula.  The 
operations  of  laryngotomy,  curetting,  etc.,  have  been  such  signal  failures 
as  to  discourage  one  from  repeating  them. 

The  most  successful  method  of  treatment  thus  far  proposed  is  that 
of  Eogers,  which  consists  in  increasing  intra-laryngeal  pressure  b}^  the 
insertion  of  larger  and  larger  intubation  tubes.  This  is  not  to  be  adopted 
until  long  after  all  acute  symptoms  have  subsided.  The  first  tube  used 
is  as  large  a  one  as  can  be  introduced  without  force ;  after  a  few  weeks, 
the  next  larger  size,  and  after  a  longer  interval,  possibly  a  still  larger  one. 
When  the  very  large  tube  has  been  worn  for  several  weeks  one  is  usually 
able  to  dispense  with  all  tubes. 

True  cicatricial  stenosis  may  best  be  relieved  by  opening  the  trachea 
and  dilat:ing  from  below,  and  afterward  inserting  an  intubation  tube. 
When  there  is  complete  destruction  of  the  cricoid  cartilage,  as  sometimes 
occurs,  tracheotomy  is  the  only  remedy,  but  this  is  only  palliative,  as  the 
tube  must  be  worn  permanently. 


TYPHOID  FEVER  10.39 

CHAPTER    IX 
TYPHOID  FEVER 

Typhoid  fever  is  an  acute  infectious  disease  due  to  a  specific  organ- 
ism— Ebertli's  bacillus.  It  may  affect  the  fetus  in  utero,  or  the  newly- 
born  child,  and  it  is  seen  in  infancy  and  throughout  childhood. 

Paratyphoid. — This  is  a  disease  in  all  respects  similar  to  typhoid  fever 
and  one  that  cannot  be  differentiated  from  it  except  by  bacteriological 
examination.  It  may  be  due  to  organisms  known  as  paratyphoid  "xV 
and  paratyphoid  "B."  This  disease  is  much  less  common  than  true 
typhoid,  but  small  epidemics  from  time  to  time  appear.  These  are 
usually  due  to  paratyphoid  "B"  which,  in  this  country  at  least,  is  much 
more  common  than  paratyphoid  ^'A.^'  There  are  no  clear  distinguishing 
features  between  them.  Widal  reactions  in  these  infections  and  in  true 
typhoid  somewhat  overlap  one  another;  but  they  may,  in  certain  in- 
stances, be  fairly  distinct  so  that  from  the  Widal  alone  the  diagnosis  can 
be  suspected".  ISTot  many  autopsies  have  been  reported  after  infection 
with  these  organisms ;  but  in  general-  the  lesions  do  not  differ  markedly 
from  those  of  true  typhoid. 

.  Fetal  Typhoid. — ^When  a  pregnant  woman  develops  typhoid  fever, 
infection  of  the  child  in  utero  is  a  frequent  but  not  an  invariable  occur- 
rence. The  fetal  form  of  the  disease  is  a  general  blood-infection,  since 
the  intestines  are  not  functionally  active.  The  most  common  result  is 
death  of  the  fetus  and  consequent  abortion;  but  the  child  may  be  born 
alive  still  suffering  from  the  infection.  On  account  of  the  infant's  feeble 
resistance  death  usuallj^  occurs. 

IiifaidiJe  Typhoid. — Modern  methods  of  diagnosis,  particularly  blood 
cultures,  have  answered  the  question,  long  discussed,  as  to  the  frequency 
of  infantile  typhoid.  It  is  a  relatively  rare  disease.  In  over  14,000 
admissions  to  the  Babies'  Hospital,  ISTew  York,  covering  a  period  of 
thirteen  years,  but  eleven  cases  of  typhoid  were  observed  under  two  years 
of  age  and  but  five  cases  of  one  year  or  under,  the  youngest  case 
observed  being  in  a  child  eight  months  old.  In  Philadelphia,  where 
there  has  been  much  more  typhoid  generally  than  in  New  York,  Griffith 
reports  under  his  personal  observation  or  in  the  Children's  Hospital 
forty-five  cases  under  two  years  and  nine  under  one  year;  his  youngest 
cases  were  aged  three,  five,  and  nine  months  respectively.  Typhoid  has 
been  seen  by  Murchison  at  six  months  and  by  Ogle  at  four  and  a  half 
months,  the  diagnosis  being,  in  both  instances,  confirmed  by  autopsy.  It 
is  during  epidemics  that  most  of  the  infantile  cases  are  seen,  but  even 
in  epidemics  it  is  surprising  that  so  few  infants  are  attacked. 


1060  THE  SPECIFIC  INFECTIOUS  DISEASES 

Typlwid  in  childhood  is  by  no  means  rare,  but  it  is  uo]t  imtil  after 
the  fifth  year  that  it  can  be  said  to  occur  frequently.  The  following 
figures,  embracing  groups  of  cases  reported  by  eight  writers,  represent  the 
relative  frequency  with  which  the  disease  is  seen  at  the  different  ages : 
Of  970  cases,  eight  per  cent  occurned  under  five  years,  forty-two  per  cent 
between  five  and  ten  years,  and  fifty  per  cent  between  ten  and  fifteen 
years. 

Typhoid  fever  is  almost  invariably  contracted  by  drinking  water  or 
milk  which  contains  the  germs  of  the  disease.  The  infrequency  of 
typhoid  even  in  infants  who  are  artificially  fed  is  explained,  in  part  at 
least,  by  the  fact  that  most  of  the  water  and  a  large  part  of  the  cow's 
milk  taken  have  been  previously  boiled,  or  heated  in  some  manner. 

Lesions. — In  a  general  way  these  resemble  those  of  adults  except  in 
severity.  In  a  considerable  number  of  the  cases  the  pathological  process 
in  the  intestines  does  not  go  on  to  ulceration;  and  when  ulcers  form  they 
are  seldom  large  or  deep,  and  perforation  is  very  rare.  Montmollin  gives 
the  following  facts  concerning  twenty-three  autopsies,  most  of  them,  how- 
ever, being  in  children  over  eight  years  old :  ulcers  were  present  in  seven- 
teen cases;  they  were  situated  in  the  lower  ileum  in  sixteen,  and  in  ten 
they  were  only  there ;  in  the  ascending  colon  in  nine,  and  only  there  in 
one  case;  perforation  occurred  in  three  cases,  in  every  instance  in  the 
lower  ileum.  Autopsies  made  upon  infants  may  show  even  less  severe 
intestinal  lesions  than  those  mentioned.  In  fact,  some  cases  in  which 
the  clinical  diagnosis  was  beyond  question,  have  shown  only  moderate 
redness  and  swelling  of  Peyer's  patches,  the  solitary  follicles  and  the 
mesenteric  lymph  nodes — lesions  which  are  exceedingly  frequent  in  cases 
of  simple  diarrhea.  In  a  doubtful  case  such  post  mortem  findings  do  not 
establish  the  diagnosis  of  typhoid.  Indeed,  they  prove  nothing  unless 
cultures  from  the  intestinal  contents,  the  mesenteric  glands,  or  other 
organs,  show  the  typhoid  bacillus.  Enlargement  of  the  spleen  is  prac- 
tically constant.  The  degenerative  changes  in  the  heart,  the  kidneys,  and 
the  liver  are  much  less  frequent  and  generally  less  severe  than  in  adults. 

Symptoms. — The  peculiar  features  of  typhoid  in  early  life  are  seen 
only  in  children  under  ten  years  old ;  for  after  this  time  the  disease  does 
not  differ  essentially  from  the  adult  type.  In  brief,  the  typhoid  of  early 
childhood  may  be  described  as  a  fever  characterized  more  often  by  nerv- 
ous symptoms  than  by  intestinal  symptoms. 

Onset. — A  sudden-  onset  with  well-marked  symptoms — fever,  pros- 
tration, vomiting,  etc. — is  not  uncommon ;  in  fact,  it  is  more  frequently 
seen  than  the  insidious  beginning,  with  lassitude,  headache,  coated 
tongue,  anorexia,  and  gradual  rise  in  temperature.  In  eases  developing 
abruptly  it  often  appears  as  if  an  acute  indigestion  had  been  the  means 
of  precipitating  the  attack.     The  most  frequent  initial  symptoms  are 


TYPHOID  FEVER  1061 

vomiting,  diarrhea,  prostration,  headache,  anorexia,  and  fever.  Chills 
are  rare;  occasionally  there  is  abdominal  pain  or  tenderness.  Epistaxis 
occurs  as  an  early  symptom  much  less  frequently  than  in  adults. 

Condition  of  the  Boivels. — There  is  no  constant  relation  between  the 
severity  of  the  intestinal  lesions  and  the  condition  of  the  bowels.  Tak- 
ing large  groups  of  eases  together,  diarrhea  is  present  in  only  about  half 
the  total  number.  It  is  rarely  profuse,  from  two  to  four  discharges  a  day 
being  the  average.  The  appearance  of  the  stools  is  seldom  character- 
istic; they  are  usually  thin  and  fluid,  often  containing  mucus.  Consti- 
pation may  be  present  at  the  beginning  only,  or  throughout  the  attack. 
Tympanites  is  generally  moderate,  and  is  often  entirely  absent;  it  usu- 
ally accompanies  constipation.  Marked  iliac  tenderness  and  gurgling 
are  infrequent. 

Spleen. — By  the  end  of  the  first  week  this  is  usually  found  to  be  en- 
larged to  a  sufficient  degree  to  be  recognized  by  palpation.  In  most  cases 
it  extends  but  an  inch  or  an  inch  and  a  half  below  the  ribs,  but  at  times 
it  may  be  three  inches  or  more;  persistent  enlargement  may  indicate 
that  the  disease  is  not  at  an  end  even  though  the  temperature  has  reached 
tlie  normal,  and  a  relapse  should  be  expected. 

Eruption. — It  is  the  experience  of  nearly  all  who  have  seen  much  of 
typhoid  in  children  that  the  eruption  is  less  constant,  usually  less  abun- 
dant, and  less  characteristic  than  in  adults,  but  appears  rather  earlier. 
We  have,  however,  seen  it  so  abundant  as  to  suggest  measles.  The  typical 
eruption  consists  of  small,  scattered,  rose-colored  spots,  which  appear 
chiefly  or  solely  upon  the  abdomen  at  the  beginning  of  the  second  week. 
They  come  in  successive  crops,  each  one  of  which  generally  lasts  three 
days,  the  whole  duration  of  the  eruption  being  about  ten  days. 

Prostration,  Emaciation,  etc. — As  a  rule  the  prostration  is  quite  suffi- 
cient to  keep  a  child  in  bed  after  the  first  few  days.  The  general  weak- 
ness after  this  time  is  in  direct  proportion  to  the  height  of  the  tempera- 
ture. Loss  of  flesh  is  steady  and  usually  marked;  and  in  a  prolonged 
attack  there  may  be  emaciation. 

Temperature. — In  the  cases  with  a  gradual  onset,  the  typical  tem- 
perature curve  is  one  which  rises  steadily  for  from  two  to  seven  days, 
fluctuates  within  the  limits  of  one  to  three  degrees  during  the  second 
week,  and  steadily  declines  during  the  third  week,  reaching  the  normal 
on  the  average  at  the  end  of  the  third  week.  In  cases  Math  an  abrupt 
onset,  the  temperature  rises  at  once  to  from  102.5°  to  105°  F.,  but  sub- 
sequently may  run  the  same  course  as  in  the  first  group. 

The  following  are  the  most  important  variations  from  tbe  tempera- 
ture curve  of  adults :  the  initial  rise  is  much  more  frequently  rapid ; 
during  the  second  week  the  remittent  character  is  less  marked;  the 
average  duration  is  shorter.     In  young  children  the  projiortion  of  cases 


1062 


THE  SPECIFIC  INFECTIOUS  DISEASES 


in  which  the  fever  lasts  only  from  eight  to  fourteen  days  is  quite  large 
(Fig.  171).  After  the  age  of  ten  years  the  type  of  the  fever  is  much 
like  that  seen  in  adults.  The  maximum  temperature  in  the  mild  eases 
is  103°  or  101°  F.;  in  the  severe  ones  it  often  reaches  105°  or  106°  F., 

but  rarely  goes  above  this 
point.  The  range  is  usually 
higher  than  in  adult  cases 
of  the  same  severity.  At 
the  beginning  of  convales- 
cence a  subnormal  tempera- 
ture is  very  frequent,  and 
by  many  writers  is  consid- 
ered to  be  the  rule.  A  sec- 
ondary rise  is  most  fre- 
quently due  to  errors  in 
diet,  but  may  occur  from 
the  development  of  compli- 
cations. A  sudden  fall  often 
indicates  either  perforation 
or  intestinal  hemorrhage. 
Relapses  occur  in  approximately  10  per  cent  of  the  cases.  They  follow 
about  the  same  course  as  in  adults  (Fig.  172). 

Nervous  Symptoms. — In  many  cases  these  are  more  prominent  in 
severe  cases  than  the  intestinal  symptoms,  and  are  directly  proportionate 
to  the  height  of  the  temperature.    The  extreme  nervous  symptoms  belong- 


DAY 

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103° 

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Fig.  171. — Typhoid  Feveb  of  Short  Duration 
IN  A  Child  Thirteen  Months  Odd.  Spleen 
enlarged;  eruption  typical;  no  diarrhea  and 
only  moderate  abdominal  distention.  There 
were  two  other  cases  in  the  family,  all  being 
due  to  the  same  cause — infected  milk.  (After 
Northrup.) 


DAY 

8 

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10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

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31 

32 

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33 

36 

37 

38 

39 

40 

41 

42 

43 

t 

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2 

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106° 
105" 
104° 
103° 
102° 
101° 
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WJ° 
93° 
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Fig.  172. — Typhoid  Fever  with  Relapse.  Child  two  and  a  half  years  old;  early  tem- 
perature high  and  symptoms  typical;  natural  fall  on  fourteenth  day;  rise  on  seven- 
teenth day  apparently  due  to  otitis;  relapse  on  twenty-fourth  day,  with  fresh  erup- 
tion and  return  of  splenic  swelling  which  had  disappeared.  Temperature  was  sub- 
normal at  the  end  both  of  primary  and  secondary  fever. 


ing  to  the  typhoid  state  in  adults  are  rare  in  childhood,  except  in  patients 
over  ten  years  old.  Headache  and  mild  delirium  at  night  are  very  fre- 
quent, the  former  being  seen  in  tlie  majority  of  cases.  Young  children 
are  usually  dull,  apathetic,  and  often  in  a  state  of  semi-stupor.  Oc- 
casionally the  disease  may  closely  simulate  meningitis.     The  nervous 


TYPHOID  FEVER  1063 

symptoms  are  usually  most  severe  in  the  second,  or  early  in  the  third 
week,  and  subside  as  the  temperature  declines,  but  may  continue  for 
several  days  thereafter.  Exaggerated  reflexes  and  ankle  clonus  are  not 
infrequent  and  may  persist  Avell  on  into  convalescence  in  severe  cases. 

Pulse. — This  is  increased  in  frequency,  but  not  to  the  degree  that 
is  seen  in  most  diseases  of  childhood  with  a  similar  elevation  of  temper- 
ature. The  force  and  rhythm  of  the  pulse  are  usually  good,  irregularity 
and  dicrotism  being  rare  in  children  as  compared  with  adults. 

Unne. — A  small  amount  of  albumin  is  found  in  the  urine  of  most 
of  the  severe  cases  at  the  height  of  the  disease,  and  is  due  to  acute  renal 
degeneration ;  but  a  marked  degree  of  nephritis  is  infrequent.  In  from 
one-fourth  to  one-third  of  the  cases  typhoid  bacilli  are  found  in  the 
urine,  generally  in  pure  culture.  They  usually  appear  in  the  latter  part 
of  the  disease,  the  second  or  third  week,  and  may  continue  for  months 
or  even  years.  They  are  sometimes  accompanied  by  evidence  of  cystitis 
or  nephritis.  Their  number  is  in  some  cases  so  large  as  to  render  the 
urine  turbid;  in  others  they  give  no  indication  of  their  presence.  Ehr- 
lich's  diazo  reaction  is  usually  present  at  the  height  of  the  fever. 

Blood. — The  characteristic  blood  picture  in  typhoid  is  a  low  leucocyte 
count,  generally  under  10,000,  accompanied  usually  by  a  slightly  increased 
proportion  of  lymphocytes.  Blood  cultures,  with  great  uniformity,  show 
the  bacilli  even  in  the  first  week  of  the  disease.  These  usually  have  dis- 
appeared from  the  blood  by  the  third  week. 

Intestinal  Hemorrhage. — Of  946  collected  cases,  mainly  from  hospital" 
rej)orts,  intestinal  hemorrhage  occurred  in  thirty,  or  about  three  per 
cent;  the  majority  of  these  were  in  children  over  ten  years  old.  Of 
"twenty-four  collected  cases  of  hemorrhage  in  children,  ten  terminated 
fatally.  The  youngest  case  of  this  nature  which  has  come  under  our  own 
notice  was  in  a  child  of  four  and  a  half  years. 

Intestinal  Perforation. — This  is  even  more  rare  than  hemorrhage. 
In  1,038  collected  cases,  this  accident  occurred  but  twelve  times,  or  in 
1.1  per  cent.  Perforation  is  indicated  by  a  sudden  fall  in  the  tem- 
perature, with  collapse ;  usually  there  is  vomiting  and  the  rapid  devel- 
opment of  tympanites  with  leucocytosis. 

Complications  and  Sequelae. — The  complications  of  typhoid  in  early 
life  are  infrequent  and  usually  mild.  Bronchitis  is  present  in  most  of 
the  severe  cases.  Pneumonia  has  been  noted  in  nine  per  cent  of  the  cases 
reported  by  various  authors.  Both  serous  and  purulent  effusions  into 
the  chest  are  occasionally  seen,  and  sometimes  abscess  of  the  lung. 

Complications  referable  to  the  nervous  system  are  not  very  frequent, 
but  are  of  much  interest.  Meningitis  is  extremely  rare.  Morse  has 
collected  twenty-one  cases  of  aphasia,  in  two  of  which  it  was  clearly  due 
to  embolism ;  in  the  remainder,  however,  it  apparently  was  not  dependent 


1064  THE  SPECIFIC  INFECTIOUS  DISEASES 

upon  any  organic  lesion.  In  two-tliirds  of  the  cases  it  came  on  during 
convalescence,  and  in  nearl}^  all  complete  recovery  occurred  after  an 
average  duration  of  three  weeks.  Aphasia  usually  followed  a  severe  type 
of  the  disease,  and  in  most  of  the  cases  was  not  accompanied  by  any  other 
paralysis  or  by  mental  disturbance.  Insanity  is  a  rare  sequel  of  typhoid 
in  children,  the  usual  type  being  acute  mania.  Eecovery  is  usually  com- 
plete. Chorea  is  seen  rather  oftener  than  after  the  other  infectious  dis- 
eases. 

Otitis  is  not  an  infrequent  complication,  occurring  much  oftener  than 
in  adults.  It  is  principally  seen  in  young  children  and  during  the  cold 
season.  Among  the  less  frequent  complications  may  be  mentioned :  paro- 
titis, which  is  usually  suppurative  and  is  seen  in  septic  cases ;  abscess 
of  the  liver,  examples  of  which  have  been  reported  by  Bokai,  Asch,  and 
others;  gangrenous  inflammation  of  the  mouth  or  genitals;  pericarditis, 
endocarditis,  and  peritonitis,  suppurative  inflammations  of  joints,  mul- 
tiple abscesses  and  furunculosis.  Tuberculosis  of  the  lungs  or  bones  not 
infrequently  follows  typhoid. 

Diagnosis. — The  diagnostic  symptoms  of  typhoid  are,  the  Widal  blood 
reaction,  the  discovery  of  the  bacilli  in  the  blood,  urine  or  feces,  the  erup- 
tion, the  course  of  the  temperature,  the  enlargement  of  the  spleen  and  the 
abdominal  symptoms — diarrhea,  tympanites,  hemorrhage,  and  perfora- 
tion. 

The  AVidal  reaction  is  present  at  some  period  in  from  ninety-five  to 
ninety-eight  per  cent  of  the  cases,  and 'thus  becomes  the  most  valuable 
single  symptom  for  diagnosis.  It  is  seldom  obtained  before  the  seventh 
day  and  frequently  not  before  the  tenth  or  twelfth ;  it  may  not  be  present 
until  convalescence  or  a  relapse.  Eepeated  tests  should  always  be  made 
if  the  first  reaction  is  negative  or  doubtful.  The  reaction  is  therefore 
of  much  less  value  for  an  early  than  for  an  exact  diagnosis.  A  positive 
reaction  may  be  present  if  the  patient  has  previously  had  typhoid,  some- 
thing much  less  likely  to  be  the  case  with  children  than  with  adults;  in 
rare  instances  it  has  been  obtained  in  other  diseases  or  in  health  when  no 
history  of  ^Drevious  typhoid  existed.  Both  these  conditions,  however,  are 
very  exceptional,  and  a  j^ositive  reaction  may  as  a  rule  be  taken  to  estab- 
lish the  diagnosis. 

Typhoid  bacilli  may  be  demonstrated  in  the  stools  by  culture  in  a 
large  proportion  of  tlie  cases.  They  are  found  in  the  urine,  usually  in 
the  latter  part  of  the  disease,  in  about  one-third  the  cases.  Tlieir  dis- 
covery in  either  of  these  discharges  is  conclusive  evidence  of  previous  or 
existing  typhoid.  An  examination  of  both  urine  and  feces  should,  if 
possible,  be  made  in  all  doubtful  cases. 

The  course  of  the  temperature  is  an  important  aid  to  diagnosis,  but 
alone  is  not  to  be  depended  upon.    The  characteristic  feature  is  a  fever 


TYPHOID  FEVER  1065 

which  continues  for  two,  three,  or  four  weeks,  and  subsides  gradually. 
The  variations  from  the  adult  type  have  already  been  mentioned,  also 
the  frequency  of  the  eruption,  the  enlargement  of  the  spleen,  and  the 
abdominal  symptoms.  We  are  not  Avarranted  in  making  the  diagnosis 
of  typhoid,  if  repeated  tests  fail  to  show  tlie  Widal  reaction  or  if  the 
eruption  and  splenic  enlargement  are  absent,  and  no  bacilli  can  be 
demonstrated  in  the  blood  or  discharges,  no  matter  what  the  course  of 
the  temperature  may  be. 

One  should  hesitate  to  make  the  diagnosis  of  typhoid  in  a  child 
under  two  years  old,  unless  typhoid  is  prevalent  in  the  community.  The 
great  majority  of  sporadic  cases  reported  as  occurring  in  infancy  are 
probably  not  typhoid.  After  the  fifth  year  the  disease  is  more  frequent, 
and  its  symptoms  in  general  resemble  those  seen  in  adults,  except  in 
severity. 

A  differential  diagnosis  is  to  be  made  from  malarial  fever,  ileocolitis, 
meningitis,  tuberculosis,  and  from  other  ill-defined  continuous  fevers  of 
unknown  origin.  From  malarial  fever  the  diagnosis  is  to  be  made  by 
the  temperature  curve,  the  organisms  in  the  blood,  and  the  effect  of 
quinin.  In  most  of  the  cases  of  malaria  the  temperature  will  be  found 
to  touch  the  normal  at  some  time  in  the  twenty-four  hours.  The  admin- 
istration of  full  doses  of  quinin  is  a  diagnostic  test  of  much  practical 
importance;  an  irregular  or  remittent  fever  which  yields  promptly  to 
quinin  is  most  certainly  not  typhoid. 

Ileocolitis  and  typhoid  fever  are  not  often  confounded.  The  former 
is  chiefly  seen  in  the  first  three  years  of  life,  a  time  when  typhoid  is  rare. 
The  intestinal  symptoms  of  ileocolitis  are  marked  even  though  the  tem- 
perature is  not  high,  and  they  are  altogether  more  severe  than  is  usual 
in  typhoid;  while  enlargement  of  the  spleen,  tympanites,  and  the  erup- 
tion are  not  present. 

The  cerebral  symptoms  of  typhoid  may  be  difficult  to  distinguish  from 
meningitis,  unless  one  has  watched  their  development.  Irregular  respira- 
tion, a  slow,  irregular  pulse,  localized  paralysis  and  complete  coma  are 
seldom,  if  ever,  seen  in  typhoid,  and  a  retracted  abdomen  very  rarely, 
while  the  enlarged  spleen  and  the  peculiar  eruption  are  not  seen  in  men- 
ingitis. 

General  tuberculosis  very  often  resembles  typhoid  so  closely  that  a 
differential  diagnosis  is  almost  impossible  from  symptoms  alone  until 
local  signs  of  tuberculosis  have  appeared,  usually  in  the  lungs.  The 
cutaneous  test  is  in  most  cases  a  valuable  aid. 

Prognosis. — Of  2,633  cases  in  children,  collected  from  the  reports  of 
twelve  different  writers,  the  mortality  was  5.4  per  cent.  These  are,  how- 
ever, almost  all  taken  from  hospital  reports,  where  as  a  rule  the  mildest 
cases  are  not  brought  for  treatment.     The  mortalitv  of  the  disease  in 


1066  THE  SPECIFIC  INFECTIOUS  DISEASES 

children  over  three  years  old  probably  does  not  exceed  three  or  fonr  per 
cent.  Death  seldom  occnrs  from  the  disease  itself,  but  usually  from  some 
accident  or  complication,  the  most  frequent  being  pneumonia  and  intes- 
tinal hemorrhage  or  perforation.  Griffith's  collection  of  cases  occurring 
in  infancy  indicates  a  much  higher  mortality  for  this  period.  The  death- 
rate  for  the  first  year  reached  nearly  fifty  per  cent. 

Treatment. — The  usually  low  mortality  of  this  disease  shows  how 
successful  all  methods  of  treatment  are  likely  to  be  considered.  In  the 
great  majority  of  cases  very  little  active  treatment  is  required.  Every 
patient  with  typhoid  should  be  put  to  bed  and  kept  there  during  the  . 
febrile  period,  and  a  few  days  beyond  it,  no  matter  how  mild  the  attack 
may  be.  The  diet  should  consist  of  sterilized  milk,  broths,  cereal  gruels, 
milk  toast,  soft  eggs,  custard,  and  plain  ice-cream.  These  articles  should 
be  given  liberally  every  four  or  five  hours,  but  not  pushed  beyond  the 
desire  of  the  patient.  Milk  may  be  diluted,  and  kumyss  or  buttermilk 
may  be  substituted  for  it  if  the  stomach  is  irritable.  Plenty  of  water 
should  be  given.  Solid  food  should  not  be  alloAved  until  the  temperature 
is  normal. 

Both  the  urine  and  feces  should  be  immediately  and  thoroughly  dis- 
infected by  a  solution  of  carbolic  1 :  20.  If  the  movements  are  in  a 
chamber  or  a  bed-pan  they  should  be  covered  with  this  solution  for  at 
least  six  hours  before  they  are  thrown  into  the  water-closet.  If  napkins 
or  diapers  are  used,  they  should  be  soaked  in  some  effective  antiseptic 
solution  for  twelve  hours  and  then  thoroughly  boiled.  Sheets  stained 
by  discharges  should  be  treated  in  the  same  way,  and  all  bed-linen  should 
be  boiled  for  an  hour,  apart  from  the  washing  of  the  family.  The 
efficiency  of  hexamethylenamin  (urotropin)  in  removing  typhoid  bacilli 
from  the  urine  seems  now  to  be  well  established.  It  shovild  be  given  at 
the  close  of  the  attack  in  doses  of  three  to  five  grains,  three  times  a  day, 
and  continued  for  a  week  or  ten  days. 

Diarrhea  calls  for  treatment  only  when  the  movements  exceed  four 
or  five  in  twenty-four  hours.  If  no  more  than  this  number  are  present, 
they  should  not  be  interfered  with.  Opium  and  bismuth  are  undoubt- 
edly the  best  means  for  controlling  excessive  diarrhea,  but  care  should 
be  taken  that  they  are  not  pushed  to  the  degree  of  inducing  constipa- 
tion. 

Constipation  early  in  the  disease  may  be  relieved  by  castor  oil,  but  all 
active  purgation  should  be  avoided.  Later  in  the  disease  irrigation  of 
the  colon  with  tepid  water  is  better  than  anything  else.  On  the  whole, 
constipation  is  more  troublesome  to  overcome  than  diarrhea. 

Tympanites  does  not  often  require  treatment ;  it  may  be  relieved  by 
turpentine  stupes,  by  a  glycerin  suppository,  or  a  small  glycerin  injection 
(one  teaspoonful  of  glycerin  to  four  ounces  of  water),  or,  better  still,  by 


TUBEECULOSIS  1067 

the  use  of  the  rectal  tube.  If  the  distention  is  continuous  and  extreme  it 
may  be  necessary  to  stop  all  food  for  several  hours  until  it  is  relieved. 

Whenever  the  temperature  remains  above  104:°  F.,  antipyretic  meas- 
ures are  indicated.  In  mild  cases  cold  or  tepid  sponging  is  generally 
sufficient.  In  those  which  do  not  yield  to  suV/h  measures,  baths  may  be 
employed.  Not  all  children  bear  baths  well,  and  considerable  discretion 
should  be  used  in  employing  them.  One  should  be  guided  quite  as  much 
by  the  effect  upon  the  pulse  and  the  nervous  system  as  by  the  tempera- 
ture. The  best  method  is  usually  the  graduated  bath ;  the  child  is  placed 
in  the  tub  with  the  water  at  a  temperature  of  95°  or  100°  F. ;  this  is 
gradually  lowered  to  95°,  90°,  or  even  85°  F.,  but  seldom  lower.  The 
body  should  be  actively  rubbed  while  the  child  is  in  the  bath,  to  prevent 
shock  and  cardiac  depression.  The  pack  may  be  substituted  for  the 
bath  when  circumstances  make  the  latter  impracticable.  The  bath  or 
pack  should  be  repeated  in  an  average  case  in  from  three  to  six  hours. 

The  milder  nervous  symptoms — headache,  restlessness,  sleeplessness, 
etc. — may  be  relieved  by  an  occasional  dose  of  phenacetin,  either  alone 
or  in  combination  with  the  bromids,  or  by  cool  or  tepid  sponging;  the 
more  severe  ones  usually  occur  with  high  temperature,  and  are  best  con- 
trolled by  the  bath. 

Stimulants  in  most  of  the  cases  are  not  called  for.  They  are  to  be 
given  according  to  the  indications  afforded  by  the  pulse,  the  first  sound 
of  the  heart,  and  the  child's  general  condition.  They  are  seldom  needed 
earlier  than  the  end  of  the  second  week.  Intestinal  hemorrhage  calls 
for  absolute  quiet,  morphin  hypodermically,  and  an  ice-coil  to  the  abdo- 
men, nothing  being  given  by  mouth  except  stimulants  and  possibly  opium. 
Intestinal  perforation  is  successfully  treated  only  by  early  laparotomy. 


CHAPTEE    X 

TUBERCULOSIS 


Tuberculosis  is  an  infectious,  communicable  disease  due  to  the 
bacillus  tuberculosis  of  Koch.  It  may  be  local  or  general,  and  may  in- 
volve any  organ  and  almost  any  structure  in  the  body. 

Etiolo^. — Age  and  Frequency. — Ko  age  is  exempt  from  tuberculosis. 
It  was  formerly  believed  that  the  disease  was  rare  in  infancy,  but  recent 
observations  have  shown  the  opposite  to  be  the  case. 

Statistics  taken  ebieily  from  three  New  York  institutions  where  only 
infants  and  young  children  are  received  give  the  following  figures  for 
382  cases  of  tuberculosis,  the  diagnosis  being  confirmed  by  autopsy  in 


1068 


THE  SPECIFIC  INFECTIOUS  DISEASES 


nearly  every  instance :  In  the  first  year  there  were  160  cases,  and  of 
these  67  were  under  six  months,  10  of  which  were  undej  three  months 
of  age.  The  frequency  of  tuberculosis  appears  to  increase  steadily  as 
age  advances,  as  shown  by  the  following  table,  in  which  results  found  by 
Yeeder  and  Johnston  in  St.  Louis  are  compared  with  those  of  Hamburger 
and  Monti  and  von  Pirquet  in  Vienna.  The  cutaneous  or  intracutaneous 
test  was  applied  in  all  instances.  Cases  of  clinical  tuberculosis  were  ex- 
cluded. 


Veeder  and  Johnston, 
St.  Louis. 

Hamburger  and  Monti 
Vienna. 

von  Pirquet, 
Vienna. 

Age  (years). 

No.  of 
Cases. 

Percentage  of 
Tuberculosis. 

No.  of 
Cases. 

Percentage  of 
Tuberculosis. 

No.  of 

Cases. 

Percentage  of 
Tuberculosis. 

Under  1     

202 
109 
163 
172 
152 
126 
107 
94 

1.5 
5.5 

19 

23 

29 

30 

34 

38 

23 

46 
131 
113 

76 
61 
48 
34 

0 
9 

27 
51 
61 
72 
94 
94 

388 

89 

162 

[343 

J 
}l47 

0 

1  to    2 

0 

2  to    4 

13 

4  to    6 

6  to    8 

37 

8  to  10 

10  to  12 

70 

12  to  14 

1,125 

21 

532 

51 

1,129 

22.51 

^The  total  incidence  of  tuberculosis  is  small  on  account  of  the  large  number 
of  infants  tested. 

From  the  facts  at  hand  it  would  seem  that  the  percentage  of  children 
with  tuberculosis  is  much  greater  in  Europe  than  in  this  country.  The 
following  table  gives  figures  for  three  institutions  in  New  York,  as  com- 
pared with  data  taken  from  Vienna  and  Munich.  The  difEerence  in  the 
ages  of  the  children  makes  comparison  difficult. 


Frequency  of  Tuberculosis  as  Sh 

own  hy 

Autopsie 

S 

Institution. 

Age  of  Patients. 

No. 

of 

Autopsies 

No.  Show- 
ing Tuber- 
culosis. 

Percentage 

Showing 

Tuberculosis. 

N.  Y.  Infant  Asylum .  . 
Babies'  Hosp.,  1st  series 
Babies' Hosp.,  2d  series 
N.  Y.  Foundling  Hosp. 

Miiller — Munich 

Hamburger — ^Vienna. . 

Nearly  all  under  2^4  years 

IC            it            it         0                  " 

"       "       "     3 

u       "3         " 

Children  of  all  ages 

All  ages  up  to  14  years .... 
r  Including  only  children  \ 
\    of  2  years  and  under.  / 

726 

1,000 

1,320 

1,000 

500 

848 

497 

56 
168 
178 
136 
200 
335 

120 

8 . 0  per  cent 
16.8 
13.5 

13.6        " 
40.0 
40.0        " 

24.4        " 

These  percentages  are  not  to  be  taken  to  represent  the  occurrence 
of-  tuberculosis  in  the  community  generally,  but  only  its  frequency  in 


TUBERCULOSIS  1069 

tile  class  which  furnishes  hospital  and  institution  inmates.  ISTor  are 
these  figures  to  be  interpreted  as  showing  the  percentage  of  active  tuber- 
culosis. In  the  cases  showing  tuberculosis  at  autopsy  nearly  one-third 
of  the  number  died  from  other  diseases,  tuberculosis  being  latent  and 
its  existence  being  discovered  only  post  mortem.  Likewise  in  nearly 
one-fifth  of  the  cases  giving  positive  skin  reactions  there  were  no  evi- 
dences of  active  tuberculosis. 

Predisposing  Causes. — These  include  all  the  conditions  which  bring 
about  a  diminished  resistance  of  the  body  to  tuberculous  infection.  This 
susceptibility  may  be  inherited,  as  when  parents  have  suffered  from  tu- 
berculosis or  other  constitutional  disease — syphilis,  alcoholism,  etc.  It 
may  be  due  to  the  fact  that  children  have  been  reared  in  crowded  city 
tenements,  in  institutions,  or  under  other  unfavorable  surroundings. 
A  local  predisposition  may  be  afforded  by  any  pathological  condition 
of  the  organs  or  mucous  membranes  exposed  to  infection.  Thus,  adenoid 
growths  of  the  pharynx  or  large  tonsils  favor  the  develo])ment  of  tubercu- 
losis of  those  structures  and  secondarily  of  cervical  adenitis ;  and  frequent 
attacks  of  bronchitis  may  precede  pulmonary  tuberculosis.  Certain  infec- 
tious diseases,  particularly  measles,  whooping-cough,  and  influenza,  in- 
crease a  child's  susceptibility  to  tuberculosis,  but  they  chiefly  cause  a 
latent  tuberculosis  to  develop  into  an  active  process.  General  or  pul- 
monary tuberculosis  is  therefore  often  seen  as  a  sequel  to  the  diseases 
mentioned,  the  latent  focus  for  which  has  been  tuberculous  bronchial 
glands. 

Modes  of  Infection. — Intra-uterine  infection,  although  rare,  has  been 
established  by  the  report  of  a  number  of  complete  and  well-authenti- 
cated cases.  Tuberculosis  of  the  placenta  is  more  frequent.  In  most  of 
the  cases  of  congenital  tuberculosis  the  mother  has  been  suffering  from 
the  disease  in  an  advanced  form,  and  the  child  is  either  still-born  or 
dies  soon  after  birth.  Besides  tuberculosis  of  the  placenta,  tubercle 
bacilli  are  found  in  the  organs  of  the  child,  and,  when  life  is  prolonged, 
there  are  generalized  lesions  showing  infection  through  the  blood. 
Cheesy  nodules  have  been  observed  in  the  umbilical  cord.  Intra-uterine 
infection  is  highly  probable  in  many  of  the  children  born  of  tuberculous 
mothers,  who  develop  the  disease  during  the  first  few  months  of  life,  al- 
though they  may  show  no  evidence  of  it  at  birth.  Among  ou^  own  cases 
there  was  one  only  twenty  days  old  and  another  six  weeks  old.  The  chil- 
dren were  born  prematurely  of  mothers  suffering  from  advanced  tubercu- 
losis. Besides  other  lesions,  the  autopsy  showed,  in  the  case  of  one 
mother,  tuberculosis  of  the  endometrium. 

Tuberculosis  may  be  communicated  by  direct  inoculation,  as  in  the 
case  of  a  bite  from  a  person  suffering  from  the  disease,  several  instances 
of  which  are  on  record.     The  rite  of  circumcision  performed  by  a  rabbi 


1070  THE  SPECIFIC  INFECXIOL'S  DISEASES 

suffering  from  tuberculosis  we  have  known  to  cause  the  disease.  One 
of  tlie  most  striking  instances  of  direct  infection  is  that  reported  by 
Eeicli.  In  a  town  of  about  1,300  inhabitants,  the  obstetric  practice  was 
divided  between  two  midwives.  Within  fourteen  montlis  no  less  than 
ten  infants,  who  had  been  delivered  by  one  of  these  women,  died  of 
tuberculous  meningitis.  In  none  of  these  families  was  there  a  history 
of  tuberculosis.  This  midwife  was  found  to  be  suffering  from  pulmonary 
tuberculosis,  and  died  from  that  disease.  It  was  her  custom  to  remove 
the  mucus  from  the  mouth  of  the  newly-born  infants  by  direct  mouth- 
to-mouth  aspiration,  and  then  to  establish  respiration  by  blowing  into 
the  nose.  In  the  practice  of  the  othei  midwife,  who  was  healthy,  no 
cases  of  tuberculosis  occurred,  although  she  treated  the  newly-born  in- 
fants in  the  same  fashion. 

Altogether  the  most  frequent  means  hy  which  young  children  ac- 
cjuire  tuberculosis  is  from  association  with  persons  suffering  from  pul- 
monary tuberculosis.  Some  of  these  are  persons  in  the  active  stage  of 
the  disease ;  many  are  supposed  to  have  been  cured ;  in  others  the  disease 
has  not  yet  developed  so  as  to  be  recognized.  Bacilli  may  be  directly 
conveyed  by  kissing.  Dried  sputum  containing  bacilli  may  become  a 
part  of  the  dust  of  the  room;  it  may  be  inhaled  or  it  may  be  introduced 
into  the  mouths  of  children  by  hands,  toys,  or  other  objects.  The  source 
of  infection  is  usually  one  or  other  parent  or  some  member  of  the  house- 
hold— a  nurse,  caretaker,  servant,  or  a  frequent  visitor.  A  history  of 
such  exposure  was  definitely  traced  in  forty-four  per  cent  of  101  con- 
secutive cases  of  tuberculosis  in  young  children  which  were  investigated 
at  the  Babies'  Hospital.  These  figures  do  not  represent  the  proportion 
of  the  cases  in  which  the  disease  is  so  contracted.  There  is  a  very  much 
larger  number  in  which  this  connection  can  not  be  traced.  Doubtless 
exposure  antedates  symptoms  by  a  number  of  weeks  at  least,  often  by 
several  months.  In  instances  where  it  could  be  pretty  accurately  ascer- 
tained, the  interval  between  exposure  and  development  of  symptoms  was 
from  four  to  tAvelve  weeks. 

Infection  may  take  place  from  beds,  rooms,  sleeping  cars,  or  any 
apartments  previously  occupied  by  tuberculous  patients;  from  dishes  or 
spoons,  from  glasses  at  public  drinking  places;  also  though  very  rarely 
from  the  meat  of  tuberculous  cattle.  Our  own  observations  lead  us  to  the 
conclusion  that  only  a  very  small  proportion  of  children  contract  tuber- 
ciilosis  in  these  indirect  ways.  Infection  through  milk  is,  however,  of 
not  infrequent  occurrence.  (See  Chapter  II,  page  134,  The  Infant's 
Dietary.)  It  has  been  repeatedly  shown  that  a  considerable  per- 
centage of  the  milk  offered  for  sale  in  cities  contains  tubercle 
bacilli.  In  almost  all  instances  they  are  of  the  bovine  type.  How- 
ever, they  are  usually  present  in  small   numbers   and   in  most   cases 


TUBEECULOSIS 


1071 


doubtless  pass  tliroiigli  the  digestive  tract  witlio\it  inducing  infection.^ 
Types  of  Bacilli. — Important  information  in  regard  to  the  source  of 
infection  is  obtained  from  a  study  of  the  type  of  organism  present  in  the 
different  varieties  of  tuberculosis. 

Park  and  Krumvi^iede  give  the  following  table  of  results  of  543  cases 
of  tuberculosis  in  children  studied.  About  one-third  of  these  were  in- 
vestigated by  them  personally ;  the  remaining  two-thirds  were  collected 
cases. 


Children  Under  5}  years 

5  to  16  Years. 

Lesions 

Human 

Bovine  ^ 

Human 

Bovine 

Pulmonary 

35 

2 
15 
10 

74 

17 

5 

76 

28 

27 

2 

0 

1 

0 

24 

14 

7 

15 

10 

1 

4 

0 

0 

0 

14 
4 

36 
8 
5 
3 
1 

10 
3 

41 
4 
2 

0 

Adenitis,  axillary  or  inguinal 

0 

Adenitis,  cervical 

22 

Abdominal 

9 

Generalized 

1 

Generalized,  alimentary  origin 

4 

Generalized  and  meningeal,  alimentary  origin. 
Generalized  and  meningeal 

0 
0 

Meningeal 

0 

Bones  and  joints* 

3 

Skin 

6 

Genito-urinary 

0 

291 

76 

131 

45 

*  Frazer  states  that  "of  a  series  of  oases  of  bone  and  joint  tuberculosis  studied  in  Edinburgh  62 
per  cent  were  bovine  in  their  origin."  Apparently  the  incidence  of  bovine  infection  varies  consider- 
ably in  different  countries.  The  inference  is  that  the  milk  supply  of  Scotland  is  more  likely  to  be 
infected  than  that  of  other  places. 

These  figures  indicate  that  nearly  all  pulmonary  and  meningeal  tu- 
berculosis as  well  as  tuberculosis  of  bones  and  joints  is  human  in  origin, 


^In  this  connection  the  following  incident  is  interesting  as  bearing  upon 
the  other  side  of  the  question:  Near  a  large  American  city  was  a  fancy  stock 
farm  of  registered  Jersey  cows,  which  supplied  milk  for  table  use  and  infant 
feeding  to  a  large  number  of  families  in  the  wealthiest  part  of  the  city,  for  a 
period  of  over  ten  years.  At  the  end  of  that  time  the  tuberculin  test  was  used 
for  the  first  time,  and  45  per  cent  of  these  cows  were  fovmd  to  be  tuberculous, 
and  were  killed  by  order  of  the  State  Board  of  Health.  The  diagnosis  was  con- 
firmed by  autopsies  upon  the  animals  in  every  instance.  An  investigation  was 
instituted  among  the  children  who  had  been  fed  upon  this  milk,  but  in  only  one 
case  of  many  hundreds  could  it  be  learned  that  tuberculosis  had  developed, 
and  in  this  instance  it  was  by  no  means  established  that  the  milk  had  been  the 
source  of  infection.  It  should  be  stated  that  this  was  before  the  days  of  steriliz- 
ing milk  for  infant  feeding.  Besides  the  families  who  took  the  milk  in  the 
manner  mentioned,  the  employees  at  the  farm  were  accustomed  to  drink  the 
skimmed  milk  in  large  quantities  daily  as  a  beverage  in  the  place  of  water. 
Many  of  them  continued  to  do  this  for  years,  and  yet  not  one  of  them  developed 
tuberculosis. 


1072  THE  SPECIFIC  INFECTIOUS  DISEASES 

but  that  on  the  other  hand,  tuberculosis  affecting  chiefly^  the  abdomen  or 
springing  from  the  alimentary  tract,  and  tuberculosis-"of  the  cervical 
glands  is  frequently  bovine  in  origin. 

Infection  from  the  meat  of  tuberculous  animals  is  a  possibility, 
but  hardly  more.  Bollinger's  experiments  in  f-^eding  animals  with  the 
expressed  juice  of  such  meat  gave  negative  results. 

Paths  of  Infection  of  the  Tubercle  Bacillus. — Tubercle  bacilli  may 
gain  entrance  to  the  body  through  the  respiratory  or  the  alimentary 
tract  or  the  skin,  the  last,  however,  being  so  rare  that  it  needs  only  to  be 
mentioned.  In  infancy  and  early  childhood  infection  is  undoubtedly 
most  frequent  through  the  respiratory  tract.  The  situation  of  the  pri- 
mary lesions  strongly  supports  this  view.  The  infection  is  the  result  of 
the  inhalation  of  tubercle  bacilli,  probably  in  dried  sputum,  and  is  there- 
fore nearly  always  an  infection  with  the  human  type  of  the  tubercle  bacil- 
lus.'  Infection  through  the  alimentary  tract  is  by  way  of  the  tonsils  or 
the  intestines,  and  either  the  human  or  bovine  type  of  organism  may  be 
introduced  into  the  body  in  this  way.  If  it  is  tbe  human  type,  in  all 
probability  the  patient  himself  is  suffering  from  pulmonary  tuberculosis 
and  the  tonsils  or  the  intestines  are  infected  from  the  sputum  coughed 
up.  There  is  also  the  possibility  of  human  tubercle  bacilli  being  taken 
into  the  mouth  from  contaminated  articles  or  in  milk.  Bovine  infection 
almost  always  results  from  drinking  milk  from  tuberculous  cows. 

Animal  experiments  have  shown  conclusively  that  bacilli  may  pass 
through  a  mucous  membrane  without  inducing  either  a  macroscopical  or 
microscopical  form  of  tuberculous  disease  but  that  penetration  is  much 
easier  if  the  mucous  membrane  is  the  seat  of  a  catarrhal  inflammation 
or  if  the  epithelium  has  been  injured.  While  it  is  possible  that  infection 
of  the  cervical,  mediastinal  and  tracheobronchial  glands  may  take  place 
without  a  lesion  of  the  mucous  membrane  which  these  lymph  nodes  drain, 
recent  studies  have  shown  that  it  is  very  uncommon.  Thus,  with  tuber- 
culosis of  the  cervical  glands,  pathological  examination  of  the  tonsils 
and  inoculation  experiments  show  that  the  tonsils  are  usually  the  seat 
of  tuberculous  disease.  The  same  is  true  of  the  mesenteric  glands.  To 
superficial  examination,  the  mucous  membrane  of  the  intestinal  tract 
may  appear  normal ;  but  careful  examination  of  it  has  in  our  experience 
almost  always  resulted  in  the  discovery  of  one  or  more  tuberculous  lesions. 
Such  is  the  case  also  with  the  lungs,  as  shown  by  Parrot,  Hervouet,  Kiiss, 
H.  Albrecht  and  Ghon.  The  tubercle  bacilli  which  pass  the  upper  respira- 
tory tract  may  not  be  arrested  until  the  smaller  bronchi  are  reached. 
In  one  of  these  they  set  up  a  localized  tuberculous  process  which  may 
remain  very  small,  but  frequently  reaches  the  size  of  a  pea.  This  area 
undergoes  the  ordinary  changes  induced  by  tbe  tubercle  bacilli  and  event- 
ually necrosis  or  perhaps  calcification  occurs.     The  tuberculous  focus 


TUBERCULOSIS  1073 

is  freqiTently  surrounded  by  fairly  firm  fibrous  tissue.  From  this  original 
pulmonary  focus,  infection  of  the  tracheobronchial  glands  takes  place  by 
way  of  the  lymphatics.  The  focus  may  remain  small  and  apparently 
innocuous.  Further  development  of  the  tuberculosis  may  take  place 
from  the  tracheobronchial  glands,  either  in  the  form  of  a  diffuse  inflam- 
mation spreading  into  the  parenchyma  of  the  lung  along  the  lymphatics, 
or  from  the  softening  and  rupture  of  the  gland  either  into  a  bronchus 
or  into  a  vein.  The  original  tuberculous  lesion  in  the  lung  on  account 
of  its  small  size  may  be  overlooked,  but  careful  examination  will  usually 
disclose  it.  In  a  series  of  169  autopsies  at  the  Babies'  Hospital  upon 
children  (mostly  infants)  with  tuberculous  bronchial  glands,  Bartlett 
and  Wollstein  found  pvdmonary  lesions  in  158  cases,  or  93.5  per  cent. 
Ghon  found,  in  184  autopsies  upon  children  with  tuberculous  bronchial 
glands,  a  primary  pulmonary  focus  in  170,  or  92.4  per  cent.  It  was 
his  opinion  that  more  careful  examination  would  probably  have  revealed 
tlie  focus  in  others.  The  changes  in  the  tuberculous  tracheobronchial 
glands  are  those  of  ordinary  tuberculosis  elsewhere — congestion,  swelling, 
cell  proliferation  and  caseation  or  the  process  may  be  arrested  at  any 
])oint  and  the  products  of  inflammation  become  encapsulated  by  the  pro- 
liferation of  fibrous  tissue  in  which  condition  they  may  remain  latent  in 
the  body  for  an  indefinite  number  of  years,  possibly  for  a  lifetime.  This 
occurs  in  many  children  and  is  consistent  with  every  outward  sign  of 
health,  but  it  is  a  smouldering  ember  which  at  any  time  may  be  fanned 
into  flame  under  the  stimulus  of  an  inflammation  excited  by  some  other 
cause. 

Lesions. — In  the  table  (p.  1074)  are  given  the  lesions  found  in  255 
autopsies,  of  which  we  have  notes.  These  represent  the  lesions  of  infancy 
and  early  childhood,  seventy  per  cent  of  these  children  being  two  years 
old  or  under.  For  comparison  there  are  given  statistics  of  131  autopsies 
from  the  Pendlebury  Hospital,  Manchester,  England.  Few  of  the  chil- 
dren in  this  series  were  under  three  years  old.  The  greater  frequency 
of  abdominal  tuberculosis,  especially  tuberculous  peritonitis,  will  be 
noted.  This  difference  obtains  in  nearly  all  the  English  statistics  of  the 
disease. 

The  Varieties  of  Tuberculosis  seen  at  Different  Ages. — During  the 
first  two  years  of  life,  tuberculosis  most  frequently  involves  the  lungs 
and  bronchial  lymph  nodes.  It  is  the  meningeal  or  pulmonary  process 
which  most  often  is  the  cause  of  death.  Death  from  other  forms  of 
tuberculosis  is  rare  at  this  time  of  life.  Of  232  deaths  from  tuberculosis 
in  the  first  three  years  of  life,  meningitis  was  the  cause  in  93,  tuberculous 
peritonitis  in  only  one,  and  hemorrhage  from  a  tuberculous  ulcer  of  the 
intestine  in  one. 

After  the  second  year,  tuberculosis  of  the  bones,  cervical  and  mesen- 


1074 


THE  SPECIFIC  INFECTIOUS  DISEASES 


Frequency  of  the  Different  Visceral  Lesions  of  Tuberculosis 


Oboans. 


Personal  Cases;' 

255  autopsies  (chiefly  under 

three  years). 


Pendlebury  Hospital  Reports; 

131  autopsies  (chiefly  over 

three  years). 


Lungs 

Pleura 

Bronchial  lymph  nodes. . 

Brain 

Liver 

Spleen 

Kidneys 

Stomach 

Intestines 

Mesenteric  lymph  nodes 

Peritoneum 

Pericardium 

Endocardium 

Thymus 

Suprarenal  capsules 

Pancreas 


93 . 0  per  cent 
76.0 


^In  a  second  series  of  178  autopsies  at  the  Babies'  Hospital  the  lungs  were 
involved  in  92.1  per  cent.;  the  bronchial  lymph  nodes  in  95.5  per  cent.;  the  brain 
in  38.7  per  cent.,  and  the  mesenteric  lymph  nodes  in  63.5  per  cent. 

teric  lymph  nodes,  peritoneum,  and  intestines  becomes  more  frequent, 
and  any  of  them  may  occur  as  the  principal  lesion,  although  at  autopsy 
the  lungs  are  usually  involved  to  some  degree. 

Pulmonary  Lesions. — As  compared  with  that  of  adults,  the  pulmo- 
nary tuberculosis  of  young  children  is  more  widely  diffused,  and  the  pre- 
dominance of  cases  in  which  the  lesion  is  in  the  upper  lobes  is  less 
marked,  though  it  still  exists.  In  those  who  have  passed  the  sixth  or 
seventh  year,  the  pathological  processes  resemble  those  of  adult  life.  Al- 
though localized  tuberculous  processes  are  frequently  met  with  in  patients 
dying  from  other  diseases,  those  who  die  from  tuberculosis  usually  show 
wide-spread  lesions  of  the  lungs. 

1.  Miliary  Tuberculosis  of  the  Lungs. — In  nearly  every  case  of  pul- 
monary tuberculosis,  miliary  tubercles  are  found  in  some  part  of  the  lung, 
usually  upon  the  surface  and  in  the  vicinity  of  some  older  process.  Occa- 
sionally, they  are  distributed  throughout  nearly  the  whole  of  both  lungs. 
In  some  places  the  lung,  with  the  exception  of  these  numerous  gray 
granulations,  appears  quite  normal;  in  others  it  is  congested,  and  shows 
between  the  tubercles  the  lesions  of  simple  bronchopneumonia  in  its 
various  stages.  There  is  also  an  acute  bronchitis  of  the  middle-sized 
and  smaller  bronchi.  The  microscope  shows  that  the  tubercles  usually 
develop  in  the  walls  of  the  small  bronchi  or  the  blood-vessels.  In  their 
gross  appearance,  the  lungs  in  these  cases  resemble  those  in  ordinary 
acute  bronchopneumonia,  with  the  exception  that  everywhere  upon  the 


TUBERCULOSIS  1075 

surface  and  throughout  the  substance  of  the  lung  are  seen  the  small 
gray  granulations,  and  in  most  cases  some  small  yellow  tuberculous 
nodules.  The  pleura  is  usually  normal  except  for  the  presence  of  the 
tubercles.  This  form  of  the  disease  represents  the  rapid  dissemination 
of  tubercle  bacilli  throughout  the  lungs,  the  miliary  tubercles  being  the 
result  of  the  inflammation  excited  by  their  presence. 

2.  Tuberculous  Bronchopneumonia. — This  is  the  most  frequent  and 
the  most  characteristic  form  of  tuberculosis  in  infants  and  young  chil- 
dren, and  it  is  the  one  which  at  this  age  usually  causes  death.  In  this 
form  of  the  disease  there  are  produced  in  the  lung  caseous  nodules,  or 
larger  caseous  areas,  some  of  which  have  usually  undergone  softening  by 
the  time  the  case  comes  to  autopsy.  The  process  generally  runs  a  some- 
what subacute  course.  With  the  lesions  mentioned  there  are  always  asso- 
ciated those  of  simple  bronchopneumonia. 

The  pleura  is  involved  in  almost  every  case.  There  may  be  simply 
dense  connective  tissue  adhesions  which  bind  the  lung  firmly  to  the  chest 
wall,  the  diaphragm,  and  the  pericardium,  or  the  pleura  may  be  greatly 
thickened  and  contain  caseous  deposits.  Occasionally  empyema  is  seen, 
but  it  is  almost  always  sacculated  and  small. 

Both  lungs  are  usually  involved,  but  one  to  a  much  greater  degree 
than  the  other.  There  are  found  large  areas  of  consolidation  which  some- 
times involve  an  entire  lobe,  but  more  often  smaller  areas  are  seen  in 
several  lobes.  These  portions  of  the  lung  appear  much  firmer  and  harder 
than  in  ordinary  pneumonia.  The  upper  lobes  are.  "more  often  affected 
than  the  lower,  and  especially  that  part  of  the  lobe  which  is  near  the  root 
of  the  lung,  on  account  of  its  frequent  association  with  tuberculosis  of 
the  bronchial  glands;  the  disease  very  often  extends  forward  from  this 
point  to  the  middle  lobe  of  the  right,  or  the  corresponding  part  of  the 
left  lung.  On  section  the  affected  part  of  the  lung  usually  shows  many 
caseous  nodules,  varying  in  size  from  a  pin's  head  to  a  walnut,  which 
are  of  a  pale-yellow  color,  and  resemble  caseous  lymph  nodes.  They 
contain  giant  cells  and  are  usually  filled  with  bacilli,  those  which  have 
softened  containing  yellow  pus.  There  is  nearly  always  seen  in  some 
part  of  the  lung  a  large  caseous  area;  and  not  infrequently  there  may 
be  diffuse  caseation  of  almost  an  entire  lobe  (Figs.  174,  175).  Some- 
times no  spot  of  softening  is  seen  even  in  these  large  areas,  but  in  many 
cavities  are  present. 

Softening  and  excavation  represent  the  final  stages  of  the  process 
in  tuberculous  pneumonia.  Softening  usually  begins  in  the  center  of  a 
caseous  part,  often  at  several  points  at  the  same  time.  Areas  of  excava- 
tion large  enough  to  deserve  the  name  of  cavities  were  present  in  about 
half  of  our  autopsies  upon  tuberculous  patients,  two  years  old  and  under. 
They  vary  in  size  from  a  cherry  to  a  hen's  egg,  and  sometimes  a  much 


]076 


THE  SPECIFIC  INFECTIOUS  DISEASES 


larger  one  is  seen  (Fig.  174:).  They  are  usually  rather  deeply  seated, 
and  are  partially  or  entirely  tilled  with  caseous  masses  ^or  pus,  but  yery 
seldom  perforate  the  pleura,  causing  pneumothorax  or  pyopneumothorax. 
It  is  rare  in  a  young  child  to  find  cavities  surrounded  by  dense  fibrous 
walls  such  as  are  seen  in  older  children  or  in  adults;  for  in  infancy  the 


Fig.  173. — Tuberculous  Pneumonia.  A 
vertical  section  through  the  middle  of  the 
right  lung  of  a  child  thirteen  months  old. 
The  greater  part  of  the  upper  lobe  is  uni- 
formly caseous — a  diffuse  tuberculous 
pneumonia;  near  the  center  the  com- 
mencement of  a  cavity  is  seen;  below  it 
has  the  appearance  of  a  consolidation 
from  simple  pneumonia.  The  part  of  the 
lower  lobe  shown  is  normal. 


Fig.  174. — Cavitt  from  Breaking  Down 
OF  Tuberculous  Pneumonl^.  Another 
view  of  the  same  lung,  the  section  being 
made  very  near  the  posterior  border  of 
the  lung.  The  cavity  occupies  at  this 
point  nearly  the  whole  of  the  upper  lobe. 
At  autopsy  this  cavity  contained  numer- 
ous loose  caseous  masses,  the  largest  be- 
ing the  size  of  a  marble.  The  lower  lobe 
is  normal.     (For  historj-,  see  Fig.  179.) 


process  of  softening  once  begun  usually  advances  steadily  until  the  death 
of  the  patient. 

The  bronchial  lymph  nodes  are  in  these  cases  invariably  found  to  be 
tuberculous,  and  not  only  those  at  the  root  of  the  lung,  but  if  a  dissection 
is  made,  a  chain  of  these  tuberculous  glands  will  be  found  to  follow  the 
larger  bronchi  for  some  di,«tance  into  the  lung  (Fig.  175).     Sometimes 


TUBERCULOSIS  1077 

one  may  be  discovered  which  has  softened  and  ulcerated  through  into  a 
small  bronchus. 

Microscopical  examination  of  these  cheesy  nodules  shcvs  that  they 
most  frequently  begin  as  tuberculous  deposits  in  the  walls  of  the  small 
bronchi,  either  in  the  mucous  membrane,  the  fibrous  coat,  or  the  lymphat- 
ics ;  sometimes,  however,  they  begin  in  the  walls  of  a  small  vein  or  artery. 


Fig.  175. — Pulmonary  Tuberculosis,  Extensive  Caseation  of  Left  Lung  and 
Bronchial  Glands.  History. — Colored  child,  2%  years  old;  signs  over  left  lung 
were  feeble  breathing  and  flatness,  suggesting  empyema;  twenty-three  examinations 
of  the  sputum  made  for  bacilli,  all  negative.  For  the  last  three  and  a  half  weeks, 
temperature  showed  a  regular  daily  range  from  100°  to  104°  F. 

Autopsy. — Almost  complete  caseation  of  left  lung;  no  spots  of  softening;  through- 
out right  lung  were  small  tuberculous  nodules  and  miliary  tubercles.  Bronchial 
glands  very  large  and  caseous,  but  none  broken  down;  those  affected  were  not  only 
the  group  at  the  root  of  the  lung  but  the  chain  following  the  main  bronchus  some 
distance  into  the  lung  itself, 

Cell  proliferation  takes  place,  separating  the  coats  of  the  bronchus  or 
blood-vessel,  and  partly  or  entirely  obstructing  its  lumen.  Softening 
may  take  place  and  the  contents  be  discharged  into  the  bronchus  or  blood- 
vessel. About  this  focus  other  changes  of  an  inflammatory  character 
occur,  as  a  result  of  wliich  each  cheesy  nodule  is  surrounded  by  a  zone 
of  simple  bronchopneumonia  which  tends,  in  a  measure  at  least,  to  limit 
the  tuberculous  process.     The  larger  caseous  areas  are  formed  by  an 


1078  THE  SPECIFIC  INFECTIOUS  DISEASES 

extension  of  this  process  to  the  zone  of  pneumonia  whicli  surrounds  it; 
but  in  its  further  growth  it  is  still  preceded  by  a  simple  pneumonia. 
The  rapidity  with  which  the  lesions  advance  differs  much  in  the  different 
cases ;  in  infants  the  progress  is  apt  to  be  continuous  until  the  death  of 
the  patient;  in  older  children  it  is  usually  slower,  and  interrupted  by 
intervals  of  arrest  and  even  of  partial  retrogression. 

Not  infrequently  one  sees  in  the  post-mortem  room  one  or  two  caseous, 
or  less  frequently  calcareous,  nodules  encapsulated  by  firm,  organized  con- 
nective tissue  when  a  most  careful  search  fails  to  show  any  other  tuber- 
culous lesion  in  the  lung.  If,  however,  the  nodules  are  widely  scattered 
through  the  lung,  such  an  arrest  of  the  process  is  not  to  be  expected. 

3.  Chronic  Pulmonary  Tuberculosis,  Chronic  Phthisis. — In  children 
who  have  passed  the  seventh  or  eighth  y^ar  the  pathological  process  re- 
sembles that  seen  in  adults ;  but  in  younger  children,  and  especially  in 
infants,  nothing  corresponding  to  it  is  met  with. 

At  this  period  the  nearest  approach  to  this  condition  is  seen  in  the 
cases  of  tuberculous  bronchopneumonia,  which  run  a  slow,  irregular, 
and  somewhat  chronic  course.  The  essential  features  of  the  process  in 
these  patients  is  a  chronic  interstitial  bronchopneumonia  with  tuber- 
ciilpus  nodules  which  rarely  undergo  softening,  but  usually  become  en- 
capsulated. 

,,The  gross  lesions  closely  resemble  those  of  simple  chronic  broncho- 
pneumonia. There  are  the  same  generalized  pleuritic  adhesions  and  the 
shrunken  cicatricial  condition  of  the  part  of  the  lung  most  affected,  with 
bronchiectasis,  compensatory  emphysema,  etc.  The  tuberculous  nodules 
are  old  and  for  the  most  part  converted  into  dense  fibrous  tissue,  in  the 
center  of.  which,  however,  some  softened,  caseous  areas  are  often  seen. 

Bronchial  Lijniph  Nodes  (hronchial  glands).— The  prominence  of  tbe 
lesions  of  the  lymph  nodes  is  one  of  tbe  most  striking  features  of  tuber- 
culosis in  infancy  and  early  childhood.  Those  which  are  most  frequently 
affected  are  connected  with  the  bronchi.  The  lymph  nodes,  to  which  the 
term  "bronchial  glands"  is  generally  applied,  consist  of  three  groups: 
the  first  of  which  surrounds  the  trachea;  the  second  is  situated  at  the 
bifurcation  of  the  trachea  and  surrounds  the  primary  bronchi ;  while  the 
third  follows  the  course  of  the  bronchi  into  the  lung,  being  found,  ac- 
cording to  anatomists,  as  far  as  the  fourth  division.  The  anatomical 
relations  of  the  different  groups  should  be  borne  in  mind,  since  upon  them 
the  symptoms  principally  depend.  The  first  group,  or  the  peritracheal 
lymph  nodes,  are  in  relation  with  the  superior  vena  cava,  the  pulmonary 
artery,  the  pneumogastric  and  recurrent  laryngeal  nerves;  the  second 
group,  at  the  bifurcation  of  the  trachea,  with  the  esophagus,  pneumo- 
gastric nerve,  and  aorta;  the  third  group,  with  the  bronchi  and  the 
branches  of  the  bronchial  and  pulmonary  arteries  and  veins. 


PLATE  XIII 


Tuberculosis  of  the  Tracheobronchial  Lymph  Nodes 
From  a  fairly  nourished  child,  four  months  old,  who  was  under  observation  for 
three  weeks,  with  slight  fever  and  a  most  severe,  teasing,  dry  cough,  which  was  almost 
constant,  and  upon  which  no  treatment  seemed  to  have  the  slightest  effect.  At  first 
there  were  no  signs  of  disease  in  the  lungs;  later  there  were  a  few  coarse  scattered  rales. 
There  were  small  tuberculous  deposits  throughout  both  lungs,  with  quite  a  large 
area  of  cheesy  pneumonia  in  the  right  middle  lobe,  and  scattered  miliary  tubercles  in 
other  organs. 


■^ 


TUBERCULOSIS  1079 

All  the  groups  are  usually  involved  at  the  same  time,  hut  in  varying 
degrees,  and  in  most  eases  those  helonging  to  one  lung  to  a  greater  extent 
than  the  other ;  in  our  own  cases  those  of  the  right  side  have  much  more 
often  been  involved  than  those  of  the  left.  There  may  be  simply  two 
or  three  tumors  as  large  as  a  hazelnut,  or  there  may  be  a  mass  two 
or  three  inches  in  diameter,  which  is  made  up  of  ten  to  twenty  of  these 
nodes  fused  together  by  inflammatory  products,  completely  surrounding 
the  trachea  and  both  the  large  l^roilchi.  It  is  rare  that  the  individual 
glands  are  more  than  an  inch  in  diameter,  and  most  of  them  are  smaller 
than  this.  A  well-marked  but  not  unusual  example  of  this  condition  is 
shown  in  Plate  XIII.  There  is  usually  found  a  chain  of  these  tuber- 
culous glands  following  the  course  of  the  large  bronchi  for  some  distance 
into  the  lung;  sometimes  these  are  almost  as  large  as  the  external  group 
(Fig.  175)  ;  at  other  times  they  are  not  noticed  unless  a  somewhat  care- 
ful dissection  is  made.  The  process  is  not  infrequently  more  advanced 
in  these  deeply  seated  glands  than  in  those  situated  at  the  root  of  the 
lung;  and  lesions  here  are  also  more  important,  as  it  is  very  frequently 
from  them  that  an  extension  of  the  process  takes  place. 

The  pathological  changes  through  which  these  glands  pass  as  a  re- 
sult of  tuberculous  infection  are  very  ^similar  to  those  already  described 
with  reference  to  the  cervical  glands.  Suppuration  is  less  frequent  than 
in  the  region  of  the  neck,  while  calcific  degeneration  is  much  more  so. 
This  applies  especially  to  children  over  three  years  old.  In  infancy 
suppuration  is  not  infrequent  in  the  bronchial  glands,  while  at  this  age 
calcification  is  relatively  rare.  Although  the  process  has  gone  on  to 
caseation,  these  inflammatory  products  with  bacilli  may  become  encapsu- 
lated, and  may  remain  innocuous  for  an  indefinite  period.  The  bacilli 
may  die  or  may  exist  here,  living,  for  years.  At  any  time  the  old  process 
may  be  lighted  up,  and  a  more  or  less  rapid  dissemination  of  tubercle 
bacilli  take  place  through  the  lungs  or  through  the  whole  body.  Latent 
tuberculosis  more  frequently  exists  in  the  bronchial  lymph  nodes  than 
in  any  other  structure  in  the  body. 

Secondary  lesions  may  be  produced  by  these  lymph  nodes.  The  pneu- 
mogastric  and  recurrent  laryngeal  nerves  may  be  surrounded  by  one  of 
these  cheesy  masses  which  may  cause  pressure  or  irritation.  The  esoph- 
agus, the  trachea,  or  the  bronchi  may  be  compressed  or  opened  by  ulcera- 
tion. The  superior  vena  cava  usually  suffers  only  compression,  but  this  or 
any  of  the  other  large  vessels  may  be  opened.  Ulceration  may  also  take 
place  into  one  of  the  large  or  small  bronchi  or  the  trachea.  If  the  gland 
has  softened  and  broken  down,  and  if  the  bronchus  is  a  small  one,  the  only 
result  of  this  may  be  a  rapid  spreading  of  tuberculous  infection  through- 
out the  lung.  If  sudden  rupture  occurs,  a  large  caseous  mass  may  escape 
into  the  trachea,  or  a  large  bronchus,  with  a  result  similar  to  that  pro- 


1080  THE  SPECIFIC  INFECTIOUS  DISEASES 

chiced  by  any  other  foreign  body.  If  suppuration  occurs,  the  abscess 
may  rupture  into  the  surrounding  cellular  tissue,  causing  mediastinal  or 
retro-esophageal  abscess.  This  may  open  externally  at  the  suprasternal 
notch,  or  in  the  first  or  second  intercostal  space,  or  may  ulcerate  into  any 
of  the  large  vessels,  the  esophagus,  or  the  pericardium. 

Pleura. — This  is  rarely  normal  in  any  case  of  tuberculosis.  In  acute 
general  tuberculosis  the  only  lesion  may  be  a  deposit  of  miliary  tubercles 
upon  the  visceral  pleura.  In  most  of  the  other  cases  there  are  found 
fibrous  adhesions  over  the  part  of  the  lung  involved,  binding  it  to  the 
pericardium,  the  diaphragm,  or  the  chest  wall.  The  amount  of  thicken- 
ing of  the  pleura  varies  a  good  deal,  but  is  rarely  great.  Pleurisy  with 
a  serous  effusion  is  not  common  in  infants  or  young  children ;  when  it 
occurs  it  is  apt  to  be  sacculated.  Hemorrhagic  exudation  is  very  rare 
at  this  age.  Empyema  is  also  rare,  being  seen  in  but  five  per  cent  of 
our  cases,  and  then  it  has  been  small  and  sacculated.  Pneumothorax  and 
pyopneumothorax  are  very  Tare  in  children  under  three  years  of  age. 

Heart. — It  is  exceptional  for  the  pericardium  to  be  affected  even  in 
the  most  generalized  forms  of  acute  miliary  tuberculosis.  In  such  cases 
the  usual  lesion  is  a  deposit  of  a  few  gray  tubercles  upon  the  visceral 
surface.  In  chronic  cases  other  lesions  analogous  to  those  of  the  pleura 
may  be  seen,  but  very  infrequently  in  childhood.  Usually  only  localized 
adhesions  are  present,  but  we  have  seen  complete  obliteration  of  the  peri- 
cardial sac  from  tuberculous  inflammation  in  an  infant  of  eleven  months. 

In  several  instances  we  have  seen  miliary  tubercles  and  minute  cheesy 
nodules  upon  the  mural  endocardium,  most  frequently  in  the  conns  ar- 
teriosus of  the  right  ventricle.  One  case,  an  infant  sixteen  months  old, 
had  such  lesions  in  both  ventricles  and  in  addition  miliary  tubercles  upon 
the  tricuspid  valve. 

Brain. — Tuberculosis  of  the  brain  is  very  common  during  infancy, 
being  then  associated  in  nearly  all  cases  with  general  tuberculosis.  Mili- 
ary tubercles  are  occasionally  found  in  small  numbers  in  eases  which  have 
presented  no  symptoms.  The  lesions  of  tuberculous  meningitis  have  al- 
ready been  descril^ed.  Cheesy  nodules  are  rare  in  infancy,  being  noted 
in  but  2.5  per  cent  of  our  own  autopsies,  which  were  mainly  on  children 
under  three  years  old;  while  in  the  Pendlebury  Hospital  cases,  including 
those  between  four  and  twelve  years  old,  they  were  noted  in  24.4  per  cent. 
These  nodules  vary  in  size  from  a  pea  to  a  hen's  Qgg',  they  are  usually 
associated  with  tuberculous  meningitis,  but  they  may  exist  alone.  When 
they  are  large  they  rank  as  cerebral  tumors,  being  most  frequently  seen 
in  the  cerebellum. 

Liver. — This  is  frequently  involved  in  general  tuberculosis,  although 
it  is  doubtful  if  it  is  ever  the  seat  of  primary  infection  except  in  the  con- 
genital cases.    Ugi^ally  the  only  lesion  is  the  presence  of  miliary  tubercles 


TUBERCULOSIS  1081 

on  its  surface  and  in  its  substance,  and  in  most  cases  these  are  not  nu- 
merous. They  are  found  in  about  tw'o-thirds  of  the  cases.  In  a  smaller 
number  there  are  tuberculous  nodules  of  various  sizes,  especially  about 
the  biliary  ducts.  In  nearly  every  protracted  case  the  liver  is  markedly 
fatty.  In  very  late  cases  of  tuberculosis  of  the  bones,  it  is  frequently  the 
seat  of  amyloid  degeneration. 

Spleen. — This  is  more  frequently  affected  than  the  liver,  but  the 
lesions  are  similar.  The  size  of  the  spleen  is  not  much  increased  if  only 
miliary  tubercles  are  present ;  but  with  tuberculous  nodules  it  may  be 
greatly  enlarged.  Amyloid  degeneration  is  found  under  the  same  condi- 
tions as  in  the  liver. 

Stomach. — Tuberculosis  of  the  stomach  is  one  of  the  rare  lesions; 
both  its  contents  and  its  acid  reaction  seem  to  protect  it  against  direct 
infection  from  the  mouth.  Tuberculous  ulcers  were  seen  in  five  of  our 
autopsies,  which  is  a  larger  proportion  than  is  usually  noted. 

Intestines. — That  these  are  less  seriously  affected  in  infants  than  in 
older  children  is  rather  surprising  when  we  consider  how  susceptible  are 
the  intestines  of  infants  to  other  forms  of  infection.  The  explanation 
of  this  difference  seems  to  be  that  in  infancy  intestinal  infection  is  usually 
secondary  to  disease  of  the  lungs,  primary  lesions  being  relatively  rare. 
Infants  die  from  the-  more  rapid  tuberculous  processes  in  the  lungs  or 
brain  before  there  has  been  time  or  opportunity  for  secondary  intestinal 
lesions  of  importance  to  occur.  The  intestinal  lesions  and  those  of  the 
mesenteric  lymph  nodes  with  which  they  are  almost  invariably  associ;ated> 
are  described  elsewhere. 

Peritoneum. — In  early  infancy  the  peritoneum  is  not  often  involved 
even  in  general  tuberculosis,  and  at  this  age  it  is  very  rare  for  it  to  be  the 
seat  of  the  principal  tuberculous  process.  In  older  children  it  is  more 
frequent.  In  most  cases  of  general  tuberculosis  there  are  only  deposits 
of  miliary  tubercles;  less  frequently  there  are  tuberculous  nodules  with 
other  inflammatory  products.  The  lesions  in  these  cases  are  described 
with  Diseases  of  the  Peritoneum. 

Thymus  Gland. — In  several  of  our  cases  tuberculous  nodules  have 
been  found  in  the  thymus  gland,  the  size  varying  from  a  small  pea  to  a 
hazelnut.  All  the  cases  showed  also  widely  disseminated  tuberculous 
lesions. 

Pancreas. — In  a  very  few  of  our  cases  this  organ  also  was  the  seat  of 
small  tuberculous  nodules,  all  of  Ihem  being  cases  of  general  tuberculosis. 

Urogenital  Organs. — Serious  tuberculosis  of  any  part  of  the  urinary 
tract  is  very  rare  in  children.  Miliary  tubercles  have  been  found  in  the 
kidneys  in  about  one-third  of  our  autopsies  on  tuberculous  patients.  They 
are  generally  few  in  number.  Large  tuberculous  nodules  of  the  kidney 
are  very  rare  before  the  fourteenth  year,    Tuberculous  nodules  are  rarely 


1082  THE  SPECIFIC  INFECTIOUS  DISEASES 

found  in  the  suprarenal  capsules.  Tuberculosis  of  the  testicle  is  very 
rare  in  children.  We  have  seen  but  a  single  instance  of  it.  This  was  in 
an  eight  months  old  child.  We  have  records  of  two  cases  of  tuberculosis 
of  the  prepuce  and  inguinal  glands  following  ritual  circumcision,  in  both 
cases  followed  by  generalized  infection. 

Tuberpulosis  of  the  bones  and  of  the  external  lymphrnodes  has  already 
been  described. 

THE  CLINICAL  FORMS  OF  TUBERCULOSIS 

I.  General  Tuberculosis. — Cases  of  tuberculosis  present  a  wide 
variety  in  their  symptomatology,  depending  upon  the  seat  of  infection, 
the  rapidity  with  which  the  bacilli  are  disseminated  through  the  body,  or 
the  numbers  in  which  they  enter.  The  general  symptoms  often  precede 
the  local  ones,  but  are  not  recognized  as  those  cf  tuberculosis.  Often  it 
is  not  susiJected  until  the  process  is  quite  well  advanced  in  some  one 
organ. 

Ix  Infants. — The  early  symptoms  in  infancy  are  often  only  those  of 
failing  nutrition.  The  patients  are  pale,  thin,  do  not  gain  in  weight 
no  matter  how  fed,  and  finally  lose  steadily  without  sufScient  reason. 
There  may  be  no  cough  or  fever  sufficient  to  attract  attention,  and  the 
case  may  even  go  on  to  a  fatal  termination  without  anything  else  than 
simple  marasmus  having  been  suspected,  tuberculosis  being  first  recog- 
nized at  the  autopsy. 

More  frequently,  however,  there  are  developed  toward  the  end  of  the 
illness  both  the  symptoms  and  signs  o'f  pulmonary  disease  and  fever. 
These  are  generally  found  together,  as  the  process  in  the  lungs  is  usually 
the  cause  of  the  rise  of  temperature.  The  febrile  symptoms  are  often 
not  seen  until  the  last  few  weeks  of  life.  The  course  of  the  temperature 
is  irregular.  It  is  never  of  the  hectic  type  and  rarely  high.  The  usual 
range  is  between  100°  and  102°  F.  The  pulmonary  symptoms  are  gen- 
erally few  and  not  very  well  marked.  There  is  some  cough,  but  it  is 
rarely  severe.  The  breathing  is  more  rapid  than  would  be  explained  by 
the  temperature  alone.  Severe  dyspnea  and  cyanosis  are  rare,  and  are 
seen  only  at  the  close  of  the  disease.  The  physical  signs  are  those  of 
either  localized  or  general  bronchitis.  Digestive  symptoms  are  usually 
present  late  in  the  disease,  but  diarrhea  is  rarely  due  to  a  tuberculous 
lesion  of  the  intestines. 

The  progress  of  the  case  after  constitutional  symptoms  develop  is 
usually  steadily  downward,  and  the  child  lives  but  a  few  weeks  at  most. 
Death  generally  occurs  from  progressive  asthenia  without  the  develop- 
ment of  any  new  symptoms,  or  cerebral  symptoms  rapidly  develop  and 
the  child  is  carried  off  in  a  few  days  by  tuberculous  meningitis.     Some- 


TUBERCULOSIS  1083 

times  there  is  a  rapid  spreading  of  the  disease  in  the  lungs,  and  death 
occurs  with  symptoms  of  acute  pneumonia. 

General  tuberculosis  in  infants  is  to  be  differentiated  from  marasmus 
with  bronchitis;  rarely  it  may  be  confounded  with  hereditary  syphilis. 

In  Older  Children. — The  development  of  active  general  tubercu- 
losis in  older  children  is  usually  preceded  by  a  protracted  period  of 
indefinite  symptoms.  They  are  persistently  anemic  without  evident  rea- 
son; they  lose  weight;  digestion  is  disturbed;  the  appetite  is  capri- 
cious; they  sleep  badly;  they  are  irritable,  fretful,  and  easily  fatigued. 
These  symptoms  indicate  only  a  gradual  decline  in  general  health,  and 
may  readily  be  explained  by  many  other  causes  than  tuberculosis.  They 
should,  however,  excite  a  suspicion  of  tuberculosis  in  a  child  who  by 
surroundings  or  inheritance  is  predisposed  to  that  disease. 

After  these  indefinite  symptoms  have  lasted  for  a  few  weeks  fever  is 
added.  Sometimes  the  prodromal  symptoms  are  absent  or  unnoticed, 
and  fever  is  the  first  evident  symptom.  From  the  beginning  of  fever 
some  cases  progress  rapidly  to  a  fatal  termination  in  three  or  four  weeks. 
In  the  majority,  however,  the  disease  runs  a  slower  course.  The  fever 
often  exists  without  evident  cause  and  without  any  local  manifestations 
of  disease.  The  temperature  is  not  often  high,  but  it  is  continuous.  The 
tympanites  and  the  rose-colored  spots  are  not  present,  but  the  general 
aspect  of  the  patient  is  strikingly  suggestive  of  typhoid  fever.  But  the 
course  of  the  temperature  and  the  duration  of  the  illness  show  that  we 
have  to  deal  with  some  other  condition. 

After  the  fever  has  lasted  from  one  to  three  weeks  there  develop  some 
signs  of  localized  tuberculosis,  generally  in  the  lungs,  or  the  fever  may 
decline  gradually,  and  although  the  patient  improves  he  does  not  get 
well.  He  is  still  weak  and  does  not  gain  in  weight,  and  the  thermometer 
shows  the  existence  of  a  very  slight  amount  of  fever.  Before  long  he 
may  grow  rapidly  worse  and  the  course  of  the  temperature  becomes  ir- 
regular, with  alternate  exacerbations  and  remissions.  Such  an  irregular 
and  inexplicable  fever  sometimes  puzzles  the  physician  for  several  weeks 
before  the  characteristic  features  which  stamp  the  process  as  tuberculous 
are  present.  Before  very  long  wasting  is  added  to  the  fever.  This  may 
not  be  rapid,  but  is  progressive.  The  tuberculous  cachexia  is  frequently 
unmistakable;  but  in  most  of  the  cases  one  must  wait  for  the  process 
to  advance  far  enough  in  some  one  of  the  organs  to  give  local  signs  or 
S}'Tnptoms  before  he  can  be  sure  of  tuberculosis.  In  four  cases  out  of  five 
this  is  in  the  lungs,  and  frequently  repeated  examinations  of  the  sputum 
may  reveal  the  bacilli.  Less  often  it  is  in  the  peritoneum,  the  brain, 
or  a  general  infection  of  the  lymph  glands  throughout  the  body.  If  in 
the  lungs,  the  process  manifests  itself  as  a  broncliopneumonia  whose 
tuberculous  character  may  sometimes  be  suspected  from  its  location — the 


1084  THE  SPECIFIC  INFECTIOUS  DISEASES 

apex  or  the  middle  of  the  lung  in  front — ^but  chiefly  from  the  fact  that 
the  general  symptoms,  fever  and  wasting,  have  so  long  preceded  the  local 
signs.  From  this  time,  the  course  may  be  that  of  a  typical  tuberculous 
bronchopneumonia. 

If  the  tuberculous  process  is  localized  in  the  brain,  there  may  be  vom- 
iting, headache,  drowsiness,  irregular  piilse,  irregular  respiration,  and 
finally  convulsions  and  coma; — in  short,  the  symptoms  of  tuberculous 
meningitis;  if  in  the  peritoneiim,  there  are  abdominal  distention  from 
gas  or  fluid,  tenderness,  pain,  diarrhea,  or  constipation ;  if  in  the  lymph 
glands,  there  is  a  general  enlargement  of  those  situated  externally,  some- 
times with  symptoms  indicating  similar  changes  in  those  at  the  root  of 
the  lung. 

II.  Pulmonary  Tuberculosis. — Tuberculosis  of  the  lungs  in  children 
may  be  seen  in  a  variety  of  clinical  forms  which  correspond  with  the 
different  pathological  conditions.  The  pathological  conditions  are  often 
associated,  yet  the  main  clinical  types  are  sufficiently  distinct  to  give 
quite  a  definite  picture.  These  types  are:  (1)  miliary  tuberculosis  of 
the  lungs;  (2)  bronchitis  with  small,  scattered,  tuberculous  nodules;  (3) 
tuberculous  bronchopneumonia  with  areas  of  consolidation,  often  ex- 
tensive, which  may  be  followed  by  caseation  and  excavation,  or  by  chronic 
fibrous  induration. 

MiLiAET  Tuberculosis  of  the  Lungs. — This  is  not  a  common  form 
of  pulmonary  tuberculosis,  but  may  be  met  with  even  in  young  infants. 
Both  the  general  and  pulmonary  symptoms  and  the  physical  signs  are 
rather  obscure  and  indefinite,  and  often  the  diagnosis  is  not  made.  Oc- 
casionally the  only  symptoms  are  those  of  marasmus,  neither  fever  nor 
physical  signs  in  the  chest  being  present  (Fig.  176).  As  we  have  seen 
it  in  young  children,  it  has  seldom  been  attended  by  high  temperature, 
101°  to  103°  F.  being  the  usual  range.  Throughout  the  greater  part  of 
the  disease  it  is  often  lower  tlian  this,  and  toward  the  close  perhaps  rather 
higher.  It  is  not  a  hectic  type  of  fever,  and  it  seldom  touches  the  normal 
line. 

The  duration  of  the  disease  in  these  cases,  after  fairly  definite  symp- 
toms begin,  varies  from  ten  days  to  a  month.  At  first,  and  often  for 
two  or  three  weeks,  the  temperature  is  almost  the  only  symptom.  Cough 
is  slight,  inconstant,  and  seldom  loose.  There  is  no  sputum.  The  respi- 
rations are  only  moderately  accelerated,  in  many  cases  not  enough  to 
draw  attention  to  the  lungs  as  the  seat  of  disease.  There  is  no  rapid 
wasting,  the  loss  in  weight  being  usually  not  more  than  would  be  ex- 
pected with  any  other  febrile  disease.  None  of  the  other  symptoms  sug- 
gests tuberculosis.  The  usual  problem  in  diagnosis  is  to  discover  the 
cause  of  the  fever.  Often  the  most  careful  examinations  of  the  chest 
made  daily  reveal  nothing  more  than  a  few  scattered  rfiles.    These  change 


TUBERCULOSIS 


1085 


in  position  from  time  to  time,  and  it  frequently  happens  that  for  days 
no  rales  are  heard.  After  the  disease  has  progressed  somewhat  further, 
the  liver  and  spleen  are  generally  enlarged.  Cerebral  symptoms  may  de- 
velop, and  the  case  terminate  as  tuberculous  menifigitis,  but  more  often 
it  is  the  pulmonary  symptoms  which  are  dominant.  The  respirations 
become  more  rapid ;  the  cough  is  frequent,  but  rarely  loose ;  there  may 
be  attacks  of  cyanosis.  Still  the  only  definite  signs  are  the  rales,  now 
fine  and  moist,  and  diffused  generally  over  the  chest.     The  case  usually 


Fig,  176. — Miliary  Tuberculosis  of  the  Lungs.  Infant  fourteen  months  old;  symp- 
toms of  marasmus;  no  elevation  of  temperature;  tuberculides  of  the  skin;  positive 
von  Pirquet  reaction;  no  pulmonary  signs  or  symptoms.  The  radiograph  shows 
great  numbers  of  small  tuberculous  deposits  scattered  through  both  lungs. 


ends  in  death  by  exhaustion,  l)ut  without  rapid  or  marked  wasting.  One 
of  tbe  most  striking  things  in  the  clinical  picture  is  the  disproportion 
between  the  severity  of  the  general  and  pulmonary  symptoms  and  the 
few  physical  signs  in  the  chest. 

Tuberculous  Bronchitis. — This  is  not  an  infrequent  condition 
even  in  infancy.  In  many,  perhaps  in  most,  cases  it  marks  the  earliest 
clinical  stage  of  a  tuberculous  bronchopneumonia,  but  this  is  not  always 
true.  The  condition  seems,  therefore,  of  sufficient  importance  to  require 
separate  consideration.  Besides  bronchitis,  there  are  found  at  autopsy  a 
few  small  tuberculous  nodnles  and  tuberculosis  of  the  l)r()ncliial  glands, 
although  these  may  give  neither  signs  nor  symptoms  during  life.  The 
36  "  . 


1086  THE  SPECIFIC  INFECTIOUS  DISEASES 

symptoms  of  this  condition  are  few  and  not  distinctive,  and  may  differ 
in  no  respect  from  bronchitis  due  to  other  causes.  Tuberculosis  may  not 
even  be  suspected  until  the  lesion  has  so  far  developed  as  to  be  classed 
as  tuberculous  bronchopneumonia.  Cough  is  present,  but  has  nothing 
characteristic  about  it  except  its  persistence.  Fever  may  be  absent  for 
a  long  time,  but  comes  as  the  disease  advances.  Then  it  is  low  and 
very  irregular,  the  temperature  generally  varying  from  99°  to  101.5°  F. 
Jiere  may  be  slow  but  progressive  loss  in  weight,  or  the  infant  may 
gain  regularly  for  a  number  of  weeks  in  spite  of  the  cough.  This  fact 
often  leads  to  a  mistake  in  diagnosis.  The  nutrition  is  influenced  much 
more  by  the  condition  of  the  digestive  organs  than  by  the  tuberculous 
process.  Other  symptoms  generally  regarded  as  belonging  to  early  tu- 
berculosis, such  as  pallor,  anemia,  perspiration,  etc.,  are  usually  absent. 
The  physical  signs  are  few  and  not  characteristic.  Scattered  rales,  some- 
times coarse  and  sometimes  finer,  but  inconstant,  are  all  the  signs  that 
are  present  for  a  long  time,  often  several  weeks. 

Cases  like  these  are  recognized  as  tuberculous  only  by  finding  bacilli 
in  the  sputum  or  by  the  tuberculin  test.  It  has  been  our  custom  to 
consider  as  probably  tuberculous  every  infant-  who  has  been  for  any 
length  of  time  in  contact  with  a  tuberculous  parent  or  other  member  of 
a,  household.  Eegarding  all  such  infants  as  suspicious  has  led  us  in 
hospital  practice  to  search  the  sputum  carefully  for  bacilli,  with  the  result 
that  we  have  found  them,  sometimes  in  great  numbers,  in  infants  whose 
only  outward  symptom  was  a  moderate  cough,  and  who  were  admitted  to 
the  hospital  for  some  other  reason.  At  other  times  the  condition  has  been 
unexpectedly  discovered  by  making  routine  tuberciTlin  skin  tests.  A 
typical  reaction  having  been  obtained  in  a  child  not  hitherto  suspected, 
the  diagnosis  has  been  subsequently  confirmed  by  finding  bacilli  in  the 
sputum,  although  the  only  signs  in  the  chest  were  a  few  rales  and  the 
only  outward  symptom  a  moderate  cough.  How  many  infants  there  are 
with  such  a  form  of  tuberculosis  and  how  long  such  a  condition  may  con- 
tinue without  more  definite  signs  developing,  one  can  only  conjecture; 
but  the  number  of  such  cases  is,  we  are  convinced,  not  small.  They  form 
a  very  distinct  but  important  group  of  tuberculous  cases.  The  regularity 
with  which  bacilli  are  present  in  the  sputum  indicates  what  a  factor 
they  may  be  in  spreading  the  disease.  How  many  recover  and  in  how 
many  the  disease  goes  on  to  the  development  of  more  serious  lesions  it  is 
impossible  to  say. 

Tuberculous  Bronchopneumonia. — This  is  altogether  the  most 
frequent  form  of  tuberculosis  seen  in  young  children.  It  may  be  primary 
in  the  lungs  or  it  may  be  secondary  to  tuberculosis  elsewhere,  most  fre- 
quently in  the  bronchial  glands.  It  may  be  preceded  by  constitutional 
symptoms  such  as  those  described  under  the  head  of  general  tuberculosis. 


TUBERCULOSIS  1087 

It  may  follow  single  or  repeated  attacks  of  what  was  apparently  a  simple 
acute  bronchitis  or  bronchopneumonia,  whether  that  occurred  as  a  pri- 
mary disease  or  was  in  turn  a  sequel  to  one  of  tlie  infectious  diseases, 
especially  measles,  whooping-cough,  or  influenza. 

Tuberculous  bronchopneumonia,  as  a  rule,  begins  gradually,  and  its 
course  is  less  rapid  than  simple  bronchopneumonia,  its  progress  being 
generally  marked  by  weeks.  When  primary  it  is  often  preceded  by 
symptoms  described  as  tuberculous  bronchitis.  When  it  follows  one 
of  the  infectious  diseases,  it  is  usually  engrafted  upon  the  original  dis- 
ease without  any  intervening  symptoms.  The  early  symptoms  are  cough, 
rapid  respiration,  fever,  progressive  weakness,  and  anemia.  The  weight 
may  be  at  first  stationary,  ijut  soon  tliere  is  steady  loss,  which  may  con- 
tinue until  there  is  marked  enuiciation.  At  first  the  usualrange  of  tem- 
perature is  from  100°  to  102°  F. ;  later  it  is  rather  higher  than  this.  In 
many  of  the  cases  it  differs  little' from  the  temperature  of  simple  broncho- 
pneumonia. Sometimes  the  general  symptoms  are  severe  and  the  physical 
signs  wide-sj^read,  and  yet  the  range  of  temperature  is  not  high.  To 
be  sure,  this  is  occasionally  seen  in  simple  bronchopneumonia,  but  it  is 
more  frequent  in  tuberculosis.  The  cough  early  in  the  disease  is  slight, 
but  later  becomes  severe  and  often  distressing.  In  infants  and  young 
children  it  may  be  of  a  paroxysmal  character,  resembling  pertussis. 
Expectoration  is  not  often  seen  in  those  under  five  years  old.  Bloody 
expectoration  is  very  rare  in  children. 

The  conditions  in  the  lungs  which  give  physical  signs  are  bronchitis 
of  the  smaller  tubes  with  areas  of  complete  or  partial  consolidation.  In 
character,  these  signs  are  identical  with  those  of  simple  bronchopneu- 
monia. They  may  be  scattered  throughout  the  whole  of  both  lungs;  but 
when  localized  they  are  more  frequently  in  the  upper  than  in  the  lower 
lobes,  and  more  frequently  in  front  than  behind.  Although  both  lungs 
are  involved,  they  are  usually  not  affected  to  the  same  degree.  The 
patient  may  die  before  signs  of  complete  consolidation  are  present ;  more 
often  there  gradually  develop  areas  of  consolidation,  as  shown  by  bron- 
chial breathing  and  voice  and  dulness.  In  some  cases  although  wide- 
spread lesions  are  found  at  autopsy  the  physical  signs  during  life  are 
few  and  indefinite ;  sometimes  there  may  be  almost  none.     (See  Eig.  176.) 

From  the  beginning  of  acute  symptoms  the  progress  of  the  disease  is 
steadily  downward,  death  occurring  as  in  simple  bronchopneumonia. 
'I'hc  end  is  marked  by  cyanosis,  great  dyspnea,  weak  pulse,  and  extreme 
prostration.  In  a  few  cases  there  develop  cerebral  symptoms,  indicating 
tuberculous  disease  of  the  brain.  Such  symptoms  may  be  the  first  to 
lead  the  physician  to  suspect  the  process  to  be  a  tuberculous  one.  But 
even  this  is  not  conclusive,  for  one  may  be  dealing  with  an  acute  menin- 
gitis due  to  the  pneumococcus.     Lumbar  puncture  will  decide. 


1088 


THE  SPECIFIC  INFECTIOUS  DISEASES 


In  the  more  protracted  cases  there  are  found  in  the  lungs  caseous 
nodules,  with  larger  areas  of  caseous  pneumonia,  and  usually  some  area^ 
of  softening.  The  process  is  not  usually  so  generalized  as  in  the  cases 
just  described,  but  as  in  them  there  is  always  associated  a  certain  amount 
of  simple  pneumonia.  The  pathological  process  may  terminate  (1)  in 
diffuse  caseation,  or   (2)  in  localized  caseation  and  excavation,  or  (3) 


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Fig.  177. — Tuberculosis  Following  Measles.  Child  sixteen  months  old,  inmate  of 
an  institution.  Chart  begins  on  fifth  day  of  a  severe,  but  uncomplicated  attack 
of  measles,  and  shows  a  natural  decline  to  normal.  Fever  then  returned  and  con- 
tinued till  death,  twelve  weeks  later.  Record  for  the  period  which  is  omitted  was 
much  like  that  which  immediately  precedes  and  follows.  Early  symptoms  not  acute, 
only  slow  wasting,  slight  cough  and  fever,  with  scattered  rales  throughout  chest. 
Signs  of  consolidation  not  distinct  till  eighth  week,  then  present  in  right  upper  lobe. 
Toward  the  end,  rapid  emaciation,  marked  pulmonary  symptoms,  and  signs  of  cavity 
at  right  apex.  Autopsy  showed  a  large  cavity,  extensive  tuberculous  deposits 
throughout  both  lungs  and  in  nearly  all  abdominal  organs. 


in  partial  resolution  and  the  development  of  a  chronic  fibroid  pneu- 
monia. In  the  first  two  varieties  the  progress  is  as  a  rule  steadily  down- 
ward to  a  fatal  termination,  which  takes  place  in  from  one  to  three 
months.  In  the  third  form,  which  is  described  later,  there  is  partial 
recovery. 

The  mode  of  onset  will  depend  upon  the  conditions  under  which  the 
disease  develops.  When  the  general  symptoms  of  tuberculosis  have  pre- 
ceded those  in  the  lungs,  the  evolution  of  the  latter  is  gradual,  with 
cough,  rapid  breathing,  dyspnea,  increased  prostration,  etc.     When  the 


TUBERCULOSIS 


1089 


pulmonary  symptoms  are  present  from  the  beginning,  they  are  the  same 
as  in  simple  bronchopneumonia,  with  the  exception  that  they  usually 
come  on  less  acutely.  The  latter  is  true  of  cases  which  are  secondary  to 
soijie  other  form  of  tuberculosis  in  the  bones,  peritoneum,  etc. 

When  pulmonary  tuberculosis  follows  measles  (Fig.  177)  or  whoop- 
ing-cough whicli  lias  l)een  complicated  by  simple  pneumonia,  the  early 
symptoms  may  present  no  nnusual  features.  After  two  or  three  weeks 
the  temperature  gradually  falls,  and  the  physical  signs  improve,  but 
neither  quite  disappears.  The  cough  continues,  though  its  severity  some- 
what abates.  In  the  course  of  a  few  weeks  the  child,  who  has  meanwhile 
improved  somewhat  in  his  general  condition,  becomes  distinctly  worse, 
often  without  any  assignable  cause.  The  temperature  rises  to  102°  or 
103°  P.;  the  cough  increases,  and  an  extension  of  the  disease  in  the 


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Fig.  178. — Tuberculous  Pneumoota  ;  General  Tuberculosis.  Patient  eleven  months 
old,  and  under  observation  at  the  time  he  was  taken  sick.  Chart  of  entire  illness 
is  given.  Disease  began  as  an  acute  pneumonia  in  lower  part  of  left  axilla  and  spread 
to  entire  lower  lobe.  Early  signs  of  consolidation;  at  end  of  two  weeks,  flatness  so 
marked  that  a  needle  was  inserted,  fluid  being  suspected.  Vomited  frequently,  and 
had  loose  discharges  from  bowels  throughout  the  illness;  abdomen  much  swollen  for 
last  two  weeks.  Autopsy  showed  cheesy  pneumonia  of  part  of  the  upper  and  the  entire 
left  lower  lobe,  where  there  were  two  small  cavities.  Recent  tubercles  found  through- 
out right  lung,  and  extensive  deposits  in  abdominal  organs  with  peritonitis,  and  intes- 
tinal ulcers. 

lungs  is  evident  by  the  physical  signs.  In  other  cases  the  progress  of 
the  disease  after  a  pneumonia  which  complicates  measles  is  without  an 
intervening  period  of  apparent  improvement.  It  sometimes  happens  that 
the  attack  of  measles  or  whooping-cough  is  not  accompanied  by  any  seri- 
ous pulmonary  symptoms,  and  the  case  goes  on  to  apparent  recovery,  ex- 
cept that  there  remain  anemia,  a  slight  cough,  and  fever.  The  tempera- 
ture, although  not  high,  persists ;  but  it  may  be  two  or  three  weeks  before 
there  are  present  definite  symptoms  and  signs  of  disease  in  the  lungs. 

Fever  is  a  constant  accompaniment  of  all  active  tuberculous  processes 
iji  the  lungs  in  the  child  as  in  the  adult,  it  being  absent  only  during  the 
periods  of  remission  which  occur  in  the  cases  of  slow  and  irregular  prog- 
ress. It  is  a  very  important  guide  to  the  progress  of  the  disease.  The 
early  fever  may  depend  in  part  upon  coexisting  bronchopneumonia,  and 
its  course  may  resemble  that  of  simple  pneumonia  of  the  protracted 
variety.    There  is  no  typical  curve.    The  fever  is  not  often  steadily  high. 


i^ 


1090 


THE  SPECIFIC  INFECTIOUS  DISEASES 


and  in  many  cases  it  is  never  so  (Fig.  178).  It  frequently  runs  for 
several  days  between  99°  and  102°  F.,  and  then,  without  evident  cause, 
rises  to  104°  F.  or  over.  In  infants  the  morning  temperature  is  fre- 
quently subnormal,  although  the  evening  temperaiUre  may  be  102°  or 
103°  F.  Even  toward  the  close  of  the  disease,  when  softening  and  break- 
ing down  are  actively  going  on,  the  regular  hectic  temperature  of  adults 
is  rarely  seen  in  a  young  child  (Fig.  179).  While  the  presence  of  fever 
is  of  great  significance,  its  course  has  almost  no  diagnostic  importance 
in  early  life.  Especially  should  one  beware  of  drawing  the  conclusion 
that,  because  the  type  of  fever  is  not  hectic,  there  is  no  breaking  down 
of  the  lung. 

Sweating  belongs  only  to  the  late  stage  of  the  disease,  and  is  usually 


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Fig.  179. — Tuberculous  Pneumonia  with  Extensive  Softening  and  Excavation. 
A  delicate  child,  thirteen  months  old;  weight,  10  pounds;  came  under  observation 
four  weeks  before  death,  with  consolidation  at  apex  of  right  lung.  Signs  increased 
in  intensity,  and  extended  in  area  until  there  were  heard,  from  clavicle  to  below  the 
nipple,  exaggerated  bronchial  voice  and  breathing  and  many  moist  rales;  percussion 
note  was  flat;  behind,  the  same  signs  at  extreme  apex.  No  distinct  signs  of  a  cavitj^; 
no  hectic  fever;  no  sweating.  Autopsy  showed  large  cavity  (Fig.  173)  at  ri~ht  apex 
partly  filled  with  caseous  masses;  diffuse  caseous  pneumonia  (Fig.  174)  of  the  rest 
of  right  upper  lobe,  with  scattered  deposits  in  the  other  lobes,  the  opposite  lung,  and 
a  few  in  the  abdominal  organs. 


associated  with  tlie  hectic  type  of  fever ;  both  these  are  regular  symptoms 
in  children  over  seven  years  old,  but  not  in  very  young  cliildren. 
^  Wasting,  like  fever,  is  characteristic  of  most  active  tuberculous 
l/processes.  When  fever  and  wasting  are  associated,  tuberculosis  should  be 
suspected,  no  matter  how  obscure  the  other  symptoms  may  be.  The 
wasting  is  not  always  rapid,  but  it  is  usually  continuous.  In  infants  and 
very  young  children  exceptions  to  this  rule  are  not  infrequent,  the  prog- 
ress in  weight  depending  more  upon  the  feeding  and  condition  of  the 
digestive  organs  than  upon  the  tuberculous  process.  In  the  early  stage 
of  the  disease,  wasting  is  especially  suggestive  when  it  continues  without 
apparent  cause  after  measles  or  pertussis,  or  when  it  persists  under  other 
circumstances  in  spite  of  a  good  appetite  and  apparently  good  digestion. 
It  may  at  first  be  so  slight  as  not  to  be  noticed  unless  the  scales  are  em- 
ployed.    In  obscure  eases  this  steady  loss  of  weight  is  a  point  of  much 


TUBERCULOSIS  1091 

diagnostic  value,  and  is  frequently  overlooked.    Toward  the  close  of  the 
disease  there  is  rapid  and  frequently  extreme  emaciation. 

Cough  is  almost  invariably  present;  it  may  be  hard,  dry,  or  sup- 
pressed; it  sometimes  occurs  in  paroxysms  resembling  pertussis,  which 
may  or  may  not  depend  upon  the  presence  of  enlarged  bronchial  glands. 

Expectoration  is  absent  in  infants,  the  material  coughed  up  being 
swallowed.  In  children  over  seven  years  old  there  often  is  a  profuse 
muco-purulent  expectoration,  but  it  is  very  exceptional  below  this  age. 

Hemoptysis  is  a  rare  symptom,  but  not  unknown  even  in  young 
children.  Henoch  has  reported  a  case  of  fatal  hemoptysis  in  a  child  ten 
months  old,  where  the  hemorrhage  was  due  to  the  rupture  of  an  aneu- 
rism in  the  wall  of  a  cavity.  Herz,  in  247  clinical  cases  of  tuberculosis 
in  children,  records  8  of  hemoptysis — 4  of  them  in  children  under  five 
years,  and  the  youngest  only  eighteen  months  old.  The  records  of  131 
autopsies  on  tuberculous  children  in  the  Pendlebury  Hospital  show  that 
hemoptysis  wa«  four  times  a  cause  of  death;  two  of  these  patients  were 
under  five  years,  and  one  was  only  twelve  months  old.  We  have  never 
met  with  a  case  of  hemoptysis  in  a  child  under  five  years  old. 

The  respiration  is  accelerated,  and  usually  out  of  proportion  to  the 
rise  in  temperature.  As  the  lung  becomes  more  and  more  extensively 
invaded  there  is  constant  dyspnea.  The  pulse  is  rapid  in  the  early  stage, 
and  continues  so  throughout  the  disease ;  toward  the  end  it  becomes  weak 
and  irregular. 

Pleuritic  pains  in  the  chest  are  not  frequent  in  children.  Gastro- 
intestinal symptoms,  such  as  indigestion,  vomiting,  diarrhea,  etc.,  are 
generally  present,  but  are  not  peculiar  to  this  disease.  They  usually 
depend  upon  the  patient's  general  condition,  only  exceptionally  upon 
tuberculous  disease  of  the  stomach  or  intestines.  The  characteristic 
symptoms  of  intestinal  tuberculosis — abdominal  pain,  tenderness,  uncon- 
trollable diarrhea,  and  intestinal  hemorrhage — are  seldom  met  with 
in  children  under  five  years.  Careful  palpation  of  the  abdomen  may 
disclose  the  presence  of  enlarged  mesenteric  glands.  When  these  are 
not  readily  felt  through  the  abdominal  walls,  they  may  sometimes  be 
discovered  by  a  rectal  examination. 

The  spleen  is  often  enlarged,  sometimes  very  much  so,  but  this  does 
not  occur  with  sufficient  frequency  to  be  of  much  diagnostic  value.  It 
may  be  due  to  tuberculous  deposits,  to  causes  connected  with  the  lungs 
or  heart,  or  to  fever.  The  liver  is  not  often  enlarged  from  tuberculous 
deposits,  but  may  be  so  from  amyloid  or  fatty  degeneration,  or  from 
obstructed  circulation,  as  in  the  case  of  the  spleen. 

Dropsy  is  rare.  It  may  depend  upon  anemia,  upon  complicating 
nephritis,  especially  amyloid  degeneration,  upon  cardiac  or  pulmonary 
conditions  leading  to  interference  with  the  return  circulation,  or  upon 


1092  THE  SPECIFIC  INFECTIOUS  DISEASES 

pressure  of  tuberculous  retroperitoneal  or  mesenteric  glands  upon  the 
inferior  vena  cava.  Clubbing  of  the  fingers  is  occasionally  seen  in  cases 
running  a  very  protracted  course.  _ 

Anemia  is  commonly  associated  with  wasting^  and  it  is  of  special 
importance  when  the  latter  is  slight  or  absent.  It  is  a  frequent  sequel 
of  acute  disease  in  infancy  when  not  dependent  on  tuberculosis;  when, 
however,  it  is  associated  with  low  fever,  cough,  and  persistence  of  rales 
in  the  chest,  it  should  excite  apprehension. 

Chkonio  Tuberculous  Pneumonia. — In  young  children  this  is  a 
chronic  interstitial  pneumonia  associated  with  tuberculous  deposits. 
These  cases  have  usually  had  their  beginning  in  one  of  the  acute  forms. 
There  is  a  slow  convalescence  and  apparent  recovery,  although  this  is  not 
complete.  Often  a  slight  cough  remains,  or  returns  from  the  slightest 
exposure  or  other  exciting  cause.  The  child  does  not  regain  his  former 
weight  or  vigor,  and  careful  examination  of  the  lungs  shows  that  some 
abnormal  signs  remain. 

After  a  few  months,  possibly,  the  child  has  another  attack  resembling 
the  first.  It  is  accompanied  by  fever,  cough,  and  perhaps  there  is  a 
fresh  consolidation  of  some  part  of  the  lung,  generally  in  the  neighbor- 
hood of  the  old  disease.  All  active  symptoms  finally  subside,  and  most 
of  the  signs  of  recent  disease  disappear ;  but  it  is  then  usually  found  that 
the  condition  of  the  lung  is  not  quite  so  good  as  before  this  second 
illness.  The  acute  attacks  may  be  repeated  several  times  and  pass 
under  the  name  of  bronchitis,  bronchopneumonia,  or  pleurisy.  They 
may  extend  over  a  period  of  years.  The  general  health  in  the  interval 
is  not  good,  there  being  present  in  most  cases  anemia,  with  the  usual 
symptoms  of  malnutrition;  these  children  are  regarded  as  very  delicate. 

The  course  of  this  disease  thus  differs  in  no  essential  particulars  from 
that  of  simple  chronic  bronchopneumonia ;  the  physical  signs  likewise 
are  identical  in  character,  although  they  may  differ  in  their  location. 
They  are  generally  found  in  the  same  conditions  as  are  the  signs  in  the 
more  rapid  forms  of  pulmonary  tuberculosis  in  early  childhood.  A  fatal 
result  in  these  cases  is  usually  brought  about  by  the  development  of  acute 
tuberculous  pneumonia  or  miliary  tuberculosis  of  the  lungs,  by  tubercu- 
lous meningitis,  or  by  a  simple  bronchopneumonia. 

Physical  Signs  of  Pulmonary  Tuberculosis. — Speaking  gener- 
ally, except  in  situation  there  is  little  difference  in  a  young  child  between 
the  signs  of  a  bronchitis  or  bronchopneumonia  due  to  the  tubercle  bacil- 
lus, and  those  of  the  same  lesions  when  due  to  other  causes.  Cavities, 
although  present  at  autopsy  in  most  of  the  advanced  cases,  are  seldom 
of  such  size  or  so  situated  as  to  be  recognized  during  life.  In  children 
over  six  or  seven  years  old,  the  signs  are  essentially  like  those  in  adults. 

The  upper  lobes  are  the  seat  of  the  most  advanced  disease  twice  as 


TUBP]RCULOSIS  1093 

frequently  as  the  lower  lobes,  and  the  right  lung  rather  more  frequently 
than  the  left.  The  region  most  often  involved  is  the  middle  zone  of  the 
lung.  If  the  signs  appear  first  behind  they  are  usually  in  the  inter- 
scapular space;  if  in  the  lateral  part  of  the  chest,  they  are  in  the  middle 
or  upper  part  of  the  axilla ;  if  in  front,  they  are  in  the  mammary  region. 
The  explanation  is  found  in  the  fact  that  the  disease  in  infants  and 
young  children  so  often  extends  from  the  lymph  nodes  at  the  root  of  the 
lung  to  the  lung  itself.  The  physical  signs  themselves  may  be  grouped 
under  four  heads,  corresponding  to  the  pathological  conditions  existing 
in  the  disease,  viz.,  (1)  bronchitis;  (2)  partial  consolidation;  (3)  com- 
plete consolidation;  (4)  excavation.  The  early  signs  are  almost  identi- 
cal with  those  described  in  bronchopneumonia.  As  a  rule,  however,  the 
transition  of  the  signs  from  one  stage  to  another  is  much  slower  in  tuber- 
culous than  in  simple  bronchopneumonia. 

Tuberculous  bronchitis  gives  rales  which  may  be  of  all  sizes  and 
varieties,  localized  or  general.  If  the  process  goes  on  to  a  partial  con- 
solidation there  are  gradually  developed  in  addition  slightly  impaired 
resonance  or  even  dulness,  bronchovesicular  respiration,  and  increased 
voice.  These  signs  are  usually  over  a  localized  area.  Later  the  signs  of 
complete  consolidation  are  present — marked  dulness,  increased  fremitus, 
bronchial  respiration,  and  voice, — but  still  rales  and  friction  sounds  are 
generally  heard. 

The  later  signs  depend  upon  what  course  the  pathological  process 
follows.  If  it  terminates  in  a  diffuse  or  localized  caseation,  the  signs 
differ  little  from  those  of  a  lobar  pneumonia  with  extensive  and  complete 
consolidation  except  that  the  dulness  on  percussion  is  usually  greater. 
There  may  be  even  flatness  so  marked  as  to  suggest  the  presence  of  a 
pleural  effusion.  Empyema  is  the  diagnosis  often  made.  These  signs 
may  persist  until  the  death  of  the  patient  from  exhaustion. 

If  the  caseation  is  localized  and  followed  by  excavation,  the  signs 
of  a  cavity  may  be  present.  Cavities,  however,  are  often  so  small  and 
deeply  seated  as  not  to  give  definite  physical  signs.  Furthermore,  they 
are  frequently  filled  with  thick  pus  or  cheesy  matter,  and  rarely  com- 
municate freely  with  the  bronchi.  If  large  and  superficial  they  give  the 
same  signs  as  in  adults.  Like  the  areas  of  tuberculous  pneumonia,  they 
are  most  frequent  in  the  middle  zone  of  the  lung  in  front  or  laterally. 
In  the  young  child  similar  signs  are  often  present  when  there  are  only 
dilated  bronchi  associated  with  a  fibroid  condition,  or  when  a  superficial 
bronchus  is  surrounded  by  an  area  of  diffuse  caseation.  Cavities  are  very 
often  diagnosticated  when  they  do  not  exist,  and  quite  as  often  overlooked 
when  present. 

If  the  acute  process  terminates  in  a  chronic  tuberculous  pneumonia 
the  signs  are  those  of  an  unresolved  or  slowly  resolving  pneumonia,  in 


1094  THE  SPECIFIC  INFECTIOUS  DISEASES 

which  the  area  of  consolidation  gradually  diminishes,  but  the  signs  do 
not  altogether  disappear.  When  recovery  goes  further  there  may  remain 
only  some  dulness  on  percussion,  bronchovesicular  respiration,  rales,  and 
friction  sounds.  Such  signs  may  last  indefinitely^  exacerbations  and 
remissions  occurring  from  time  to  time.  These  signs  can  not  be  dis- 
tinguished from  those  of  simple  chronic  bronchopneumonia. 

Diagnosis  of  Pulmonaey  Tuberculosis. — The  family  history,  sur- 
roundings and  previous  condition  of  the  patient  are  important,  also  the 
mode  of  onset,  the  course  of  the  disease,  and  the  evidence  afforded  by  the 
j)hysical  examination,  Not  only  should  the  health  of  the  parents  and 
other  children  be  investigated,  but  that  of  other  members  of  the  house- 
hold and  frequent  visitors.  The  occurrence  of  bone  and  joint  disease  as 
well  as  pulmonary  disease  should  be  considered.  Surroundings  favoring 
the  development  of  tuberculosis  are  city  residence,  especially  if  in  a  tene- 
ment house,  or  an  institution.  One  should  regard  as  important,  habitual 
underweight,  anemia  and  general  malnutrition.  Of  previous  diseases  in 
the  patient  the  most  significant  are  pneumonia,  measles  or  pertussis  with 
prolonged  convalescence,  and  persistent  or  frequently  recurring  attacks  of 
l^ronchitis.  In  the  milder  or  early  cases  the  two  important  symptoms  axe 
cough  and  fever;  the  cough  is  more  significant  when  persistent  and 
accompanied  by  mucopurulent  expectoration.  Hemoptysis  among  chil- 
dren is  so  rare  as  to  aid  little  in  diagnosis.  Fever,  to  be  of  diagnostic 
value,  should  be  at  least  99.5°  F.  in  the  mouth  or  100.5°  F.  rectal  for  a 
considerable  period,  usually  several  weeks.  Wasting  is  important  when 
present  but  its  absence  by  nomeans  excludes  tuberculosis,  since  it  depends 
more  upon  the  condition  of  the  digestive  organs  and  the  feeding  than 
upon  the  local  disease.  Sweating  is  not  a  common  symptom  in  children. 
The  physical  signs  which  are  of  especial  diagnostic  value  are  persistent 
localized  rales  anteriorly,  either  in  the  region  of  the  nipples,  or  between 
the  nipples  and  axillae,  or  at  the  apices.  To  these  signs  should  be  added 
a  positive  von  Pirquet  reaction,  which  test  should  be  repeated  at  least 
once  to  avoid  error.  Additional  information  is  sometimes  afforded  by  the 
X-ray  examination,  though  the  plates  need  to  be  interpreted  by  one  with 
much  experience.  These  findings  are  always  to  be  taken  in  conjunction 
with  physical  signs  and  rational  symptoms. 

In  the  more  acute  or  more  advanced  cases,  tuberculosis  has  to  be 
distinguished  chiefly  from  simple  bronchopneumonia.  The  onset  of  sim- 
ple pneumonia  is  usually  rapid,  often  abrupt;  tuberculous  pneumonia 
usually  develops  more  gradually.  Constitutional  symptoms  may  precede 
the  local  ones  by  several  days  or  even  weeks.  In  tuberculosis  one  is  often 
struck  by  the  disproportion  between  the  general  symptoms  and  the  phys- 
ical signs.  One  may  see  with  tuberculosis,  rapid  wasting,  prostration, 
cough  and  high  fever  with  physical  signs  which  are  few,  irregular  and 


TUBERCULOSIS  1095 

inconstant.  Again  strongly  suggestive  of  tuberculosis  are  very  extensive 
physical  signs,  especially  persistent  generalized  fine  rales  without  con- 
solidation, accompanied  by  severe  dyspnea,  even  cyanosis,  and  yet  with 
a  temperature  only  moderately  elevated. 

The  course  of  the  temperature  can  not  be  depended  upon  in  diagnosis. 
A  high  leucocyte  count,  e.  g.,  above  25,000,  especially  when  accompanied 
by  a  high  polymorphonuclear  percentage,  strongly  favors  pneumonia. 
The  X-ray  examination  is  often  of  more  value  in  these  than  in  the  less 
acute  cases.  The  cutaneous  tuberculin  test  gives  positive  results  in  nearly 
all  cases  except  those  which  are  extremely  prostrated.  Meningitis  de- 
veloping during  a  pulmonary  disease  of  doubtful  character  is  generally 
tuberculous.  But  acute  pneumococcus  meningitis  may  occur  in  very 
similar  circumstances. 

Examination  for  Bacilli. — Discovery  of  the  bacilli  in  the  sputum  is 
of  course  conclusive  and  is  by  no  means  so  difficult,  even  with  very  small 
patients,  as  has  been  supposed ;  but  in  most  cases  repeated  examinations 
are  necessary.  Infants  do  not  expectorate,  but  cough  up  the  bronchial 
secretion  into  the  pharynx  and  swallow  it.  Sputum  must  therefore 
usually  be  obtained  from  the  pharynx.  To  obtain  the  sputum  in  an 
infant  one  should  excite  a  cough  by  irritating  the  pharynx,  and  then  catch 
upon  a  small  swab  the  sputum  brought  up  into  view.  By  the  procedure 
mentioned  it  is  not  usually  more  difficult  to  obtain  good  sputum  in  very 
young  patients  than  in  adults.  Bacilli  are  seldom  found  in  clear,  glairy 
mucus,  but  in  mucopurulent  masses.  Following  the  method  described, 
bacilli  have  been  found  in  the  great  majority  of  our  hospital  cases  of 
pulmonary  tuberculosis  in  infants,  although  in  more  than  half  of  them 
the  disease  was  not  advanced,  judging  by  symptoms  and  physical  signs. 

Bacilli  may  readily  be  found  in  the  stools  of  many  children  suffering 
from  tuberculosis.  Their  presence  does  not  necessarily  indicate  a  tuber- 
culous lesion  of  the  intestines,  for  their  source  is  more  frequently  a 
pulmonary  lesion,  the  bacilli  being  coughed  up  and  swallowed.  Hence, 
it  is  sometimes  easier  to  find  them  in  the  stools  than  in  the  sputum. 
They  must  be  carefully  differentiated  from  the  smegma  bacilli. 

III.  Chronic  Phthisis. — This  form  of  tuberculosis,  with  its  chronic 
hectic  fever,  slow' cavity-formation,  progressive  emaciation,  night  sweats, 
etc.,  is  very  rarely  seen  before  the  fifth  year,  and  it  is  not  at  all  frequent 
until  the  tenth  or  twelfth  year.  In  its  symptoms,  course,  termination, 
and  physical  signs,  it  resembles  the  same  disease  in  adults,  and  need  not 
be  described  at  length  here. 

IV.  Tuberculosis  of  the  Bronchial  Lymph  Nodes  (Bronchial  Glands) . 
— This  condition  is  usually  associated  with  some  form  of  pulmonary 
tuberculosis,  but  it  may  exist  as  altogether  the  most  important  tuber- 
culous lesion. 


1096  THE  SPECIFIC  INFECTIOUS  DISEASES 

The  s}Tnptoins  are  usually  associated  with  those  of  pulmonary  or  gen- 
eral tuberculosis;  but  they  may  occur  \rhen  the  pulmonary  changes  are 
too  few  to  be  recognized  either  by  symptoms  or  physical  signs.  From  the 
great  frequency  with  which  this  lesion  is  found  in  infants  and  young 
children,  it  might  be  expected  that  local  symj^toms  woidd  be  common 
in  such  patients.  They  are,  however,  in  our  experience,  quite  exceptional. 
Most  of  the  cases  in  which  well-marked  symptoms  occur  are  in  children 
over  two  years  old,  and  it  is  between  the  third  and  tenth  years  that  they 
are  usually  seen.  In  infancy^  death  in  most  cases  occurs  from  the  pul- 
monary disease. 

General  symptoms  may  or  may  not  precede  the  local  ones.  The 
latter  are  chiefly  mechanical,  and  depend  upon  the  size  of  the  glands  and 
upon  their  anatomical  relations,  and  very  little  or  not  at  all  upon  the 
nature  of  the  changes  in  them.  The  most  important  relations,  so  far  as 
the  production  of  symptoms  is  concerned,  are  those  which  they  bear  to 
the  pneumogastric  and  recurrent  laryngeal  nerves,  the  superior  vena 
cava,  the  trachea,  and  bronchi;  those  less  important  are  to  the  aorta, 
pulmonary  artery,  and  esophagus. 

Pressure  upon  or  irritation  of  the  pneumogastric  or  recurrent  nerves 
produces  cough,  dyspnea,  and  sometimes  a  change  in  the  voice.  The 
cough  is  hoarse,  persistent,  and  teasing,  and  frequently  occurs  in  parox- 
ysms which  in  many  respects  resemble  those  of  pertussis,  but  it  usually 
lacks  the  characteristic  whoop,  and  is  not  accompanied  by  the  expectora- 
tion of  a  mass  of  tenacious  mucus.  These  paroxysms  are  severe  and  often 
prolonged.  The  dyspnea,  like  the  cough,  is  paroxysmal,  and  sometimes 
strongly  resembles  ordinary  spasmodic  croup;  at  other  times  it  is  like  a 
severe  attack  of  asthma.  Such  symptoms  may  come  and  go,  but  they  are 
frequently  prolonged,  and  usually  in  the  interval  between  the  severe 
seizures  the  patient  is  not  wholly  free  from  dysj)nea.  Although  the  chief 
cause  of  dyspnea  is  no  doubt  nerve  irritation,  it  may  be  due  in  part  to 
pressure  upon  the  trachea  or  one  of  the  large  bronchi.  In  dyspnea  from 
pressure  on  the  trachea  the  head  is  usually  thrown  back,  and  the  obstruc- 
tion is  more  frequently  on  expiration  than  on  inspiration. 

After  such  symptoms  as  those  mentioned  have  existed  for  a  few  days 
or  weeks,  and  in  some  cases  without  any  warning,  there  may  occur  a  sud- 
den attack  of  asphyxia  which  may  prove  fatal.  This  is  generally  due  to 
ulceration  of  a  caseous  gland  into  the  trachea  or  a  large  bronchus  and 
the  escape  of  a  large  mass  into  the  air  passages,  where  it  produces  the 
same  effects  as  does  any  other  foreign  body. 

Of  fifteen  cases  of  this  kind  collected  by  Loeb,  death  by  suffocation 
occurred  in  most  in  from  five  to  ten  minutes  after  the  first  definite  symp- 
toms; in  some  the  fatal  attack  was  preceded  for  some  time  by  milder 
attacks  or  by  a  cough;  in  others  no  previous  symptoms  were  present, 


TUBERCULOSIS  1007 

the  child  being  apparently  in  perfect  health.  Earely  after  "ulceration  into 
tlie  trachea  the  patient  has  recovered  after  conghing  up  a  large  amount 
of  pns. 

Pressure  npon  the  superior  vena  cava  is  usually  associated  with  spas- 
modic dyspnea  and  cough,  and  causes  cyanosis  of  the  face  and  blueness 
of  the  lips.  There  is  frequently  a  puffiness  of  the  face,  and  there  may 
be  marked  edema.  The  coexistence  of  cyanosis  with  such  edema,  when 
the  urine  is  free  from  signs  of  renal  disease,  should  always  lead  one  to 
suspect  pressure  at  the  root  of  the  lung.  In  some  rare  cases  the  interfer- 
ence with  the  return  circulation  has  been  so  marked  that  meningeal 
hemorrhage  has  resulted.  By  a  process  of  ulceration  set  up  in  these 
glands  they  may  open,  not  only  into  the  air  passages,  but  into  the  peri- 
cardium, the  esophagus,  or  any  of  the  large  vessels.  The  last  mentioned 
is  usually  followed  by  instant  death.  Aldibert  reports  two  cases  in 
which  the  pulmonary  artery  was  opened,  death  occurring  from  hemoptysis, 
as  there  was  also  a  communication  with  one  of  the  large  bronchi.  In 
Vogel's  case  the  subclavian  vein  was  perforated,  and  death  resulted  from 
the  entrance  of  air.  If  ulceration  takes  place  into  the  surrounding  con- 
nective tissue,  a  mediastinal  abscess  may  result,  producing  any  of  the 
pressure  symptoms  noted  above,  and,  in  addition,  dysphagia  from  pres- 
sure on  the  esophagus.  Such  an  abscess  may  point  in  the  suprasternal 
notch ;  it  may  open  through  the  chest  anteriorly  between  the  ribs  or  at  the 
xiphoid  cartilage ;  or  it  may  burrow  along  the  esophagus  to  the  peritoneal 
cavity.  As  a  rule,  however,  patients  die  of  general  tuberculosis  before 
the  local  conditions  have  advanced  so  far. 

Physical  Signs. — In  order  to  produce  signs  the  mass  of  lymph  nodes 
must  be  large  enough  to  form  a  considerable  mediastinal  tumor,  or  be  so 
situated  as  to  produce  pressure  upon  the  trachea  or  bronchi.  Only  large' 
packets  of  glands  can  be  made  out  by  physical  signs.  The  large  masses 
may  give  dulness  over  the  first  piece  of  the  sternum,  or,  more  frequently, 
behind  in  the  interscapular  space,  usually  between  the  third  and  seventh 
dorsal  vertebrae.  Normally,  whispered  bronchophony  usually  ceases  at  or 
just  below  the  level  of  the  fourth  dorsal  vertebra.  When  it  extends  below 
this  point  it  is  suggestive  of  enlarged  bronchial  glands  (D'Espine's  sign) . 
It  is  usually  more  marked  upon  the  right  than  the  left  side.  There  may 
be  also  voice  and  breathing  of  a  somewhat  amphoric  but  with  a  distinctly 
nasal  quality.  The  signs  are  sometimes  indistinguishable  from  those 
heard  over  a  small  cavity.  Taken  in  connection  with  a  positive  cutaneous 
tuberculin  test  and  X-ray  findings,  these  signs  are  of  much  significance. 
If  one  of  the  primary  bronchi  or  one  of  its  lobar  divisions  is  compressed, 
there  may  be  very  feeble  respiration  over  one  lung  or  one  lobe;  if  the 
pressure  is  sufficient  to  prevent  the  entrance  of  air,  or  if  one  of  these 
large  tubes  has  been  plugged  by  a  caseous  mass,  there  is  an  absence  of 


1098 


THE  SPECIFIC  INFECTIOUS  DISEASES 


respiratory  murmur  over  a  single  lobe  or  an  entire  lung.    This  sign  is  of 
great  diagnostic  value,  but  it  is  not  often  present. 

Diagnosis. — Mediastinal  glandular  tumors  may  occur  in  Hodgkin's 
disease  and  in  malignant  disease;  but  both  are  relatively  very  rare  and 
usually  present  other  diagnostic  symptoms.  Practically,  in  almost  every 
case^  marked  enlargement  of  the  bronchial  glands  is  due  to  tuberculosis. 
The  only  really  trustworthy  means  of  diagnosis  in  most  cases  is  afforded 
by  the  X-ray,  though  considerable  experience  is  requisite  in  the  inter- 
pretation of  the  plates;  the  radiographic  shadovs^  usually  shows  better 


Fig.  180. — Tuberculous  Bronchial  Glands.     A  very  large  mass  upon  the  right  side, 
A,  A;  a  smaller  one  upon  the  left  side,  B,  B. 


on  the  right  side  than  on  the  left  on  account  of  the  heart  (Fig.  180). 
Especially  significant  are  evidences  of  calcification,  which  may  be  found 
even  in  very  young  children.  (We  have  autopsy  records  of  such  changes 
in  infants  only  seven  months  old.)  More  stress  is  in  some  cases  to  be 
laid  upon  symptoms  than  physical  signs  for  diagnosis;  the  most  im- 
portant symptoms  are  the  association  of  a  spasmodic  cough  with  parox- 
ysms of  dyspnea  resembling  asthma  or  croup  and  severe  congestion  or 
edema  of  the  face.  The  chief  difficulty  in  diagnosis  is  foimd  in  those 
cases  Avhich  present  few  or  no  other  signs  of  tuberculosis,  and  which 
come  first  under  observation  with  attacks  of  dyspnea  or  asphyxia  resem- 
bling those  seen  in  laryngeal  stenosis.  In  many  such  cases  tracheotomy 
has  l)een  done  without  finding  any  cause  for  the  dyspnea,  the  autopsy 


TUBERCULOSIS  1099 

showing  it  to  be  due  to  the  ulceration  and  impaction  of  a  caseous  gland. 
The  development  in  a  child  of  a  chronic  abscess  in  the  anterior  mediasti- 
num is  almost  always  due  to  tuberculous  glands;  and  so  is  one  in  the 
posterior  mediastinum,  provided  Pott's  disease  can  be  excluded. 

The  Tuberculin  Tests. — For  general  diagnostic  use  in  children  von 
Pirquet's  cutaneous  test  is  so  far  superior  to  the  other  tests  suggested  that 
only  this  need  be  considered  in  detail. 

The  forearm  is  the  most  convenient  part  for  applying  the  test.  The 
skin  is  carefully  washed  with  alcohol  or  ether.  A  small  drop  of  pure 
tuberculin  (Koch's  O.T.)  is  placed  upon  the  skin.  With  an  instru- 
ment resembling  a  tiny  chisel  a  very  slight  scarification  for  control  is 
made  at  a  distance  of  two  or  three  inches  from  this  drop.  A  similar 
scarification  is  then  made  through  the  drop.  Linear  scratches  one-quarter 
inch  in  length  lightly  made  with  a  sterile  needle,  serve  equally  well  as  a 
means  of  inoculation  and  control.  The  child  should  be  watched,  and  if 
very  young  the  arm  should  be  held  until  the  skin  is  quite  dry  to  prevent 
infection  by  rubbing.  As  an  added  precaution  it  may  be  covered  with 
a  piece  of  sterile  gauze.  The  reaction  consists  in  a  red  areola  about  the 
point  or  along  the  scratch  made.  This  generally  begins  in  from  twelve 
to  eighteen  hours,  rarely  later  than  twenty-four  hours,  and  reaches 
its  height  during  the  next  twenty-four  hours.  The  size  of  the  areola 
indicates  the  degree  of  reaction.  It  continues  in  most  cases  for  from 
one  to  three  days  and  slowly  fades,  often  being  followed  by  a  slight 
local  desquamation.  Earely  there  may  be  vesiculation.  There  is  in  most 
of  the  cases  slight  induration  of  the  skin  readily  appreciable  to  the  touch. 
The  more  marked  reactions  continue  for  from  four  to  ten  days.  Any 
definite  inflammatory  reaction  which  follows  this  course  may  be  regarded 
as  positive.  The  arm  should  be  observed  daily  to  note  the  results.  There 
seems  to  be  no  relation  between  the  intensity  of  the  reaction  and  the 
extent  or  the  activity  of  the  tuberculous  disease. 

The  Significance  of  the  Tuberculin  Test. — The  cutaneous  test  gives 
positive  evidence  if  tuberculosis  is  present,  in  all  except  the  most  pros- 
trated cases  and  those  in  the  late  stages  of  the  disease,  when  diagnosis 
is  rarely  difficult  from  the  other  symptoms.  .  Exceptions  are,  in  our 
experience,  extremely  rare.  Much  importance  is  therefore  to  be  attached 
to  a  negative  reaction.  For  greater  certainty  the  test  should  be  repeated 
in  suspicious  cases.  The  interpretation  of  a  positive  reaction  is  much 
modified  by  the  age  of  the  patient.  Under  one  year  a  positive  reaction 
usually  indicates  an  active  tuberculous  process.  Many  have  even  taken 
the  ground  that  an  infant  under  one  year  with  a  positive  reaction  is 
doomed.  We  do  not  think  the  outlook  quite  so  hopeless ;  but  such  a  reac- 
tion is  certainly  of  grave  import.  During  the  second  year  a  positive 
reaction  is  not  so  serious ;  it  is  often  seen  in  infants  who  have  not  at  the 


1100  THE  SPECIFIC  INFECTIOUS  DISEASES 

time  and  do  not  develop  active  tuberculosis.  After  infancy  the  test  be- 
comes less  aTid  less  an  indication  of  an  active  tuberculosis  and  the  inter- 
pretation of  a  positive  reaction  is  more  difficult.  It  is  always  to  be  taken 
in  conjunction  with  the  clinical  symptoms.  A  negative  reaction  with 
clinical  sjinptoms  suggestive  of  tuberculosis  is  always  to  be  regarded  as 
significant.  It  almost  certainly  excludes  tuberculosis  except  in  condi- 
tions of  extreme  prostration.  Great  difficulty  may  exist  in  the  interpre- 
tation of  a  positive  reaction  under  two  conditions.  The  first  is  in  an 
apparently  healthy  child  with  a  prolonged  unexplained  temperature  but 
no  physical  signs  of  pulmonary  disease.  In  such  circumstances  the 
existence  of  active  tuberculosis  is  probable  after  other  conditions  have 
been  excluded.  The  X-ray  may  shed  light  upon  the  case.  The  second 
condition  includes  the  cases  in  which  acute  pulmonary  disease  is  pres- 
ent in  a  patient  who  gives  a  positive  reaction.  The  course  and  ter- 
mination of  the  disease  may  ultimately  establish  the  fact  that  the 
process  in  the  lung  was  non-tuberculous.  But  because  of  the  positive 
reaction  grave  suspicion  of  tuberculosis  may  exist.  Much  needless  alarm 
may  therefore  be  excited  by  a  positive  reaction,  which  really  demonstrates 
only  that  the  child  has  somewhere  a  tuberculous  focus,  but  does  not 
prove  the  existing  disease  to  be  a  tuberculous  process.  The  tuberculin 
reaction  is  always  to  be  interpreted  in  conjunction  with  the  general  symp- 
toms and  the  physical  signs.  As  a  rule,  in  older  children  a  negative 
reaction  is,  of  more  significance  than  a  positive  one.  During  active 
measles  the  test  can  not  always  be  relied  upon. 

The  tuberculin  test  should  not  be  allowed  to  displace  the  examination 
for  bacilli  either  in  the  sputimi  or  cerebrospinal  fluid,  though  the  latter 
involves  much  more  labor.  The  positive  reaction  furnishes  reliable  evi- 
dence of  the  existence  of  a  tuberculous  process,  but  as  to  whether  this  is 
active  or  latent  gives  no  information. 

Tuberculides  of  the  Skin. — These  are  at  times  of  considerable  value 
in  the  diagnosis  of  general  tuberculosis.  Although  seldom  seen  in  the 
most  acute  varieties,  they  are  not  uncommon  in  the  more  slowly  pro- 
gressing forms.  The  distribiition  of  the  lesions  is  fairly  constant.  They 
are  found  chiefly  on  the  buttocks,  lower  abdomen,  genitalia  and 
thighs.  The  number  present  is  generally  small,  half  a  dozen  to  a  dozen ; 
but  they  are  sometimes  numerous  and  may  be  widely  distributed.  The 
lesion  somewhat  resembles  that  of  varicella.  It  begins  as  a  minute  red 
papule,  which  is  soon  surmounted  by  a  small  vesicle.  This  dries  to  form 
a  crust.  If  the  crust  is  removed  a  small  pit-like  depression  remains 
which  heals  quickly,  leaving  a  white,  glistening  scar  surrounded  by  a 
pigmented  border.  The  lesion  runs  its  entire  course  in  two  or  three 
weeks.  Tubercle  bacilli  are  often  present  in  the  lesions  but  are  difficult 
to  demonstrate.    Tuberculides  of  the  skin  in  vouug  children  are  evidence 


TUBERCULOSIS  1101 

of  a  widely  clisseiuiiiated  process  and  are  a  very  bad  prognostic  sign. 
Such  patients  rarely  survive  more  than  a  few  weeks. 

General  Prognosis  of  Tuberculosis. — The  outlook  for  a  child  under 
two  years  with  general  or  pulmonary  tuberculosis  is  very  bad.  So  long 
as  the  disease  remains  confined  to  the  lymph  nodes,  the  child  is  not 
usually  in  danger,  except  from  accidents  connected  with  their  softening 
and  ulceration,  which  after  all  are  rare.  Spontaneous  cure  may  occur 
in  these  glands  in  the  same  way  as  in  others  in  the  body,  viz.,  by  encap- 
sulation, calcification,  etc.  Such  a  result  is  no  doubt  a  very  frequent  one ; 
exactly  how  often  it  occurs  it  is  impossible  to  say;  but  when  once  the 
disease  has  gained  any  headway  in  the  lung  itself,  its  steady  advance  is 
almost  certain  to  be  the  course  in  a  young  child.  In  those  who  are  older 
and  have  more  resistance  the  chances  of  an  arrest  of  the  process  are  much 
greater. 

If  the  bacilli  have  gained  entrance  into  the  body  in  any  considerable 
numbers,  even  though  they  are  shut  up  in  an  encapsulated,  caseous, 
bronchial  gland,  the  patient  is  never  free  from  the  danger  of  general 
infection. 

Prophylaxis. — The  prevention  of  tuberculosis  must  have  constant  ref- 
erence to  its  cause.  The  first  essential  is  the  destruction  of  the  tubercle 
bacilli  wherever  they  exist.  Since  most  of  those  existing  in  the  air 
are  derived  from  the  sputum  of  patients  affected  with  pulmonary  tuber- 
culosis, it  should  be  insisted  upon,  everywhere  and  at  all  times,  that  the 
sputum  from  such  cases  should  be  collected  in  special  cups  or  cloths  and 
destroyed  either  by  germicides  or  by  fire.  The  next  point  is  to  avoid  need- 
less exposure.  A  tuberculous  mother  should  on  no  account  nurse  her  child 
nor  kiss  it  upon  the  mouth.  A  wet-nurse  likewise  should  be  free  from 
any  tuberculous  taint.  ISTo  nurse  or  other  care-taker  should  ever  be 
employed  about  children  who  has,  or  ever  has  had,  pulmonary  tuber- 
culosis. It  is  wise  to  exclude  also  those  who  suffered  when  children  from 
tuberculosis  of  the  bones  or  the  cervical  glands,  although  the  danger 
from  such  persons  is  extremely  slight.  If  active  tuberculosis  exists  in 
any  member  of  the  family,  a  young  child  should  be  kept  away  from  the 
room,  and  if  possible  should  not  reside  in  the  house.  On  no  account 
should  infected  persons  be  allowed  to  kiss  children  or  sleep  in  the  same 
bed  with  them.  The  danger  from  drinking-cups  and  other  dishes  should 
not  be  forgotten.  A  tuberculous  person  should  either  have  his  special 
dishes,  or  the  utmost  care  should  be  taken  to  boil  all  those  which  he  has 
used.  Cows  whose  milk  is  used  for  children  should  be  under  regular 
veterinary  inspection  and  should  have  passed  the  tuberculin  test.  In  any 
case  when  the  slightest  doubt  regarding  the  health  of  tbe  cows  exists,  or 
^vhen  the  source  of  the  milk  is  unknown,  the  milk  should  be  pasteurized. 
The  danger  of  infection  through  the  alimentary  canal  is  very  much  less 


1102  THE  SPECIFIC  INFECTIOUS  DISEASES 

than  through,  the  respiratory  tract,  and  consequently  the  precautions  jEirst 
mentioned  are  much  more  important  than  those  relating  to  the  food, 
although  the  latter  should  on  no  account  be  neglected. 

In  the  case  of  delicate  children  and  those  with  tuberculous  parents  or 
with  other  tuberculous  near  relatives,  everything  possible  should  be  done 
to  fortify  them  against  the  disease.  They  should  be  kept  under  more  or 
less  constant  medical  supervision.  Attacks  of  bronchitis  or  broncho- 
pneumonia should  be  Avatched  with  the  greatest  solicitude.  Exposure  to 
influenza,  measles  or  pertussis  should  especially  be  avoided.  The  coun- 
try rather  than  the  city  should  be  chosen  for  residence,  and  the  child 
should,  if  possible,  spend  the  winter  and  spring  in  some  warm,'  dry  cli- 
mate. Parents  should  be  distinctly  taught  that  watchfulness  and  care  do 
not  mean  coddling  or  the  keeping  of  children  in  the  house  the  greater  part 
of  the  time.  Such  children  should  live  as  much  as  possible  in  the  open 
air,  and  every  form  of  sport  encouraged  which  tends  to  keep  them  there. 
Overheated  houses  are  one  of  the  most  prolific  agencies  in  perpetuating 
a  delicate  condition  of  health.  Plenty  of  fresh  air  in  sleeping  apart- 
ments should  always  be  insisted  upon.  All  catarrhal  troubles  of  the  nose 
and  pharynx  should  receive  early  and  prompt  attention,  especially  should 
hypertrophied  tonsils  and  adenoid  growths  of  the  pharynx  be  removed, 
since  these  are  conditions  which  form  a  most  favorable  nidus  for  the 
growth  of  tubercle  bacilli. 

Treatment  of  General  and  Pulmonary  Tuberculosis. — If  fresh  air  and 
a  proper  climate  are  necessary  for  the  cure  of  this  disease  in  adults,  they 
are  tenfold  more  necessary  in  the  case  of  children.  Without  them  there 
is  little  hope  for  a  child  with  active  pulmonary  tuberculosis.  Nowhere 
do  these  cases  do  so  badly  as  in  a  hospital  located  in  a  city,  and  no  class 
of  hospital  cases  do  worse  than  these.  The  same  regions  that  are  bene- 
ficial for  adult  cases  usually  agree  with  children,  with  the  exception  that 
the  latter,  as  a  rule,  do  better  in  a  warm  than  in  a  cold  climate.  Plenty 
of  fresh  air  and  sunshine  are  essential.  A  child  must  be  where  he  can 
be  kept  in  the  open  air  for  the  greater  part  of  each  day,  in  spite  of 
fever,  cough,  or  other  acute  symptoms. 

For  the  most  acute  cases  when  the  children  are  confined  to  the  bed, 
the  largest,  best-ventilated,  and  sunniest  room  available  should  be  secured, 
and  the  windows  should  be  constantly  open.  The  general  management  of 
such  cases  is  the  same  as  for  those  with  acute  pneumonia. 

There  is  no  specific  remedy  for  tuberculosis.  The  diet  is  a  matter  of 
the  utmost  importance.  Tuberculous  patients  must  be  fed  like  most 
other  sick  children,  care  being  taken  not  to  disturb  the  digestion  by  the 
imnecessary  use  of  drugs.  For  a  staple  article  of  diet,  milk  is  the  best, 
and  when  this  is  not  well  borne  some  of  its  substitutes — buttermilk, 
kumyss,  zoolak,  etc. — ^may  be  tried.     Cream  is  almost  as  useful  as  cod- 


SYPHILIS  1103 

liver  oil,  and  should  be  given  in  one  form  or  another  whenever  the 
child's  digestion  can  tolerate  it. 

Tuberculin  in  the  treatment  of  this  disease  in  young  children  has  been 
most  disappointing  in  its  results.  Its  value  has  not  yet  been  demon- 
strated. There  always  exists  the  possibility  of  lighting  up  a  latent  process 
in  the  lungs.  It  should  be  given  with  the  greatest  caution  in  active  febrile 
cases.  The  method  of  using  it  is  discussed  under  the  treatment  of  Tuber- 
culous Adenitis. 

Cod-liver  oil  is  usually  best  given  in  a  fresh  emulsion,  although  some 
children  bear  the  pure  oil  better  than  its  preparations.  Inunctions  of 
this  or  other  oils  are  of  some  value  when  not  well  tolerated  by  the  stom- 
ach.   Arsenic  and  iron  are  useful  as  general  tonics. 


CHAPTER  XI 
SYPHILIS 


Syphilis  is  a  communicable  disease  due  to  a  specific  organism,  the 
spirochefa  pallida  of  Schaudinn.  In  acquired  syphilis  this  is  found  in 
the  primary  lesion,  in  the  mucous  patches  and  in  the  lymph  nodes.  In 
hereditary  syphilis  it  is  found  in  the  cutaneous  lesions,  in  the  fissures 
at  the  angle  of  the  mouth  and  in  the  mucous  patches  of  the  buccal 
cavity.  Math  less  regularity  in  the  internal  organs,  except  the  liver,  which 
usually  harbors  the  organism  in  immense  numbers.  While  in  the  still- 
born child  and  in  early  cases,  the  number  of  organisms  found  is  very 
great,  they  are  not  so  numerous  at  a  later  period,  and  they  diminish  rap- 
idly after  treatment  is  begun.  In  the  late  lesions  the  spirochetae  are 
not  numerous,  and  are  difficult  to  demonstrate. 

In  infancy  and  childhood  both  the  acquired  and  the  hereditary  forms 
of  syphilis  are  seen. 

ACQUIRED  SYPHILIS 

While  acquired  syphilis  is  very  much  less  frequent  than  the  hered- 
itary variety,  it  is  by  no  means  a  very  rare  disease  in  early  life.  It  is  not 
improbable  that  some  of  the  manifestations  of  syphilis  in  later  childhood 
which  are  usually  denominated  "late  hereditary  syphilis,"  are  really  due 
to  the  acquired  form. 

Etiology. — An  infant  may  be  infected  by  the  mother  during  parturi- 
tion; but  this  is  extremely  rare  and  can  take  place  only  Avhen  there  are 
lesions  upon  the  motlier's  genitals.     Infection  is  more  likely  to  ])o  from 


1104  THE  SPECIFIC  INFECTIOUS  DISEASES 

a  mother  who  contracts  syphilis  subsequent  to  the  birth  of  the  child, 
and  may  occur  through  nursing  or  accidental  contact  by  kissing,  etc. 
In  either  of  these  ways,  or  from  a  venereal  sore  upon  the  nipple,  a  child 
may  be  infected  by  a  wet-nurse.  Whether  syphilis  can  be  communicated 
through  the  milk  when  the  nipple  is  perfectly  healthy  and  free  from 
fissures,  is  exceedingly  doubtful. 

Syphilis  may  be  communicated  directly  from  a  syphilitic  child  to  one 
who  is  healthy,  by  kissing,  by  sexual  contact,  or  indirectly  by  means  of 
bottles,  spoons,  cups,  clothing,  etc.  The  latter  mode  of  infection  is  most 
likely  to  occur  in  institutions.  Vaccination  was  formerly  a  not  infre- 
quent mode  of  communicating  syphilis,  but  has  been  practically  elimi- 
nated by  the  general  introduction  of  bovine  virus.  Cases  have  been  re- 
corded where  the  disease  has  ])een  conveyed  by  the  rite  cf  circumcision, 
either  from  the  mouth  or  the  instruments  of  the  operator. 

The  relative  frequency  of  the  different  sources  of  infection  is  shown 
by  Fournier's  statistics  of  40  cases :  The  source  of  infection  was  the 
parents  in  19;  nurses,  in  8;  servants,  in  4;  sexual  contact,  in  4;  vaccina- 
tion, in  2 ;  other  children,  in  2 ;  a  physician,  in  1.  The  ages  at  which 
the  disease  was  acquired  in  this  series  of  cases  were  as  follows :  During 
the  first  3'ear,  19 ;  during  the  second  year,  10 ;  during  the  third  and 
fourth  years,  7 ;  from  the  fifth  to  the  fourteenth  year,  6. 

Symptoms.— The  symptoms  of  acquired  syphilis  in  children  are  in  all 
respects  similar  to  the  same  disease  in  the  adult.  A  primary  sore  is 
present  at  the  site  of  infection,  which  is  most  frequently  the  lips,  the 
mouth,  or  some  part  of  the  face;  very  rarely  is  it  seen  on  the  genitals. 
There  are  few  individual  symptoms  belonging  to  hereditary  syphilis  which 
may  not  also  l)e  present  when  the  disease  is  acquired.  Its  course,  how- 
ever, is  very  much  milder  in  the  latter  and  a  fatal  termination  is  rare. 
Fournier  states  that  of  his  forty-two  cases  only  one  died  of  marasmus. 
This  marked  contrast  to  hereditary  syphilis  is  due  chiefly  to  the  fact  that 
in  the  acquired  variety  the  infant  is  rarely  infected  during  the  early 
mouths  of  life,  a  time  when  hereditary  syphilis  is  so  fatal. 

Tertiary  symptoms  may  appear  at  an}'  time  from  three  to  twenty 
years  after  the  original  infection. 

The  treatment  is  the  same  as  that  of  hereditary  syphilis. 

HEREDITARY   SYPHILIS 

Etiology. — If  both  parents  are  syphilitic,  the  child  is  usually  but  not 
invariably  so.  The  symptoms,  however,  are  not  more  severe  than  when 
the  inheritance  is  from  one  parent  only.  The  likelihood  of  transmission 
depends  upon  the  stage  of  the  disease  in  the  parents.  If  the  mother 
is  suffering  from  secondary  symptoms,  transmission  is  almost  certain. 


HEEEDITARY  SYPHILIS  1105 

If  active  treatment  has  been  employed  for  several  months,  if  the  child  is 
born  at  a  period  when  no  active  symptoms  are  present,  or  if  the  symptoms 
are  of  a  tertiary  cliaracter,  the  offspring  will  probably  escape.  First-born 
cbildren  are  more  likely  to  suffer  severely  from  syphilis  than  the  later 
ones,  provided  infection  of  the  parents  has  taken  place  prior  to  the  birth 
of  all  the  children. 

The  transmission  of  syphilis  from  the  father  without  the  intermedi- 
ate infection  of  the  mother  was  once  held  to  be  not  only  possible  but  fre- 
quent. At  the  present  time,  however,  this  question  must  be  placed  among 
those  not  yet  definitely  settled.  There  can  be  no  doubt  that  in  the  vast 
majority  of  the  cases  the  infection  of  the  child  is  from  the  mother. 

If  both  parents  are  healthy  at  the  time  of  conception  and  the  mother 
becomes  infected  during  her  pregnancy  the  child  may  or  may  not  be 
syphilitic.  Transmission  to  the  child  is  much  less  likely  to  occur  if  the 
mother  is  infected  during  the  last  two  months  of  her  pregnancy  than 
earlier,  although,  as  Hutchinson's  cases  conclusively  show,  there  is  no 
certainty  that  the  child  will  escape.  Diday  states  that  if  the  mother  is 
infected  before  the  fourth  week  and  proper  treatment  is  instituted,  the 
child  will  usually  escape  on  account  of  the  relation  of  the  embryo  to  the 
maternal  circulation  during  this  early  period. 

In  1837  Colles  enunciated  the  following  proposition,  the  truth  of 
which  has  been  abundantly  verified  since  his  time:  "A  new-born  child 
affected  with  inherited  syphilis,  even  although  it  may  have  symptoms  in 
the  mouth,  never  causes  ulceration  of  the  breasts  which  it  sucks  if  it  be 
the  mother  wdio  suckles  it,  although  continuing  capable  of  infecting  a 
strange  nurse."  From  the  careful  analysis  of  many  cases  and  with  the 
great  assistance  derived  from  the  Wassermann  reaction  the  conclusion 
seems  irresistible  that  the  mother  who  bears  a  syphilitic  child  is  immune 
to  syphilis  for  the  reason  that  she  herself  is  suffering  from  syphilis,  or 
a  modification  of  that  disease.  The  mother  in  these  circumstances  can 
not  be  inoculated  either  by  her  syphilitic  nursing  infant  or  artificially. 

That  hereditary  syphilis  is  contagious  is  conclusively  shown  by  a 
number  of  recorded  instances  in  which  a  healthy  wet-nurse  has  been 
infected  by  a  syphilitic  infant.  We  have  ourselves  seen  one  such  instance. 
However,  such  examples  of  contagion  are  rare,  and  many  writers  of  large 
experience  state  that  they  have  never  seen  it.  It  is  certainly  true  that 
the  danger  of  spreading  infection  from  a  case  of  hereditary  syphilis  has 
been  exaggerated. 

Lesions. — Death  may  occur  with  syphilis,  and  yet  the  autopsy  may 
reveal  no  characteristic  anatomical  changes,  and  in  fact  there  may  be 
no  demonstrable  changes  in  arjy  of  the  organs  except  the  presence  of  the 
spirochetae.  This  is  particularly  true  of  infants  dying  in  the  first  weeks 
of  life. 


U06  THE  SPECIFIC  INFECTIOUS  DISEASES 

Bones. — In  the  case  of  a  syphilitic  fetus,  a  still-born  child,  or  one  dy- 
ing soon  after  birth,  the  changes  in  the  bones  are  more  uniformly  present 
than  are  any  other  lesions.  They  are,  in  fact,  rarely  wanting,  and  it  is  by 
them  alone  that  syphilis  is  often  recognized  post  mortem,  but  it  may  re- 
quire a  microscopical  examination  to  establish  the  diagnosis.  The  long 
bones  are  principally  affected,  the  most  important  changes  being  found  at 
the  junction  of  the  shaft  with  the  epiphyseal  cartilage.  The  lesion  is 
termed  an  epiphyseal  osteochondritis.  There  are  two  varieties:  in  one 
there  is  an  inhibition  of  bone  formation  around  the  columns  of  calcified 
cartilage,  though  the  destruction  of  cartilage  cells  by  the  vessel  loops  and 
the  formation  of  bone  marrow  goes  on  unchecked  and  in  a  normal  man- 
ner. In  the  other,  there  is,  in  addition  to  the  delay  in  bone  formation, 
the  development  of  granulation  tissue  that  springs  from  the  cartilage 
canals  and  that  grows  between  the  shaft  and  the  epiphysis,  and,  perforat- 
ing the  column  of  cartilage  cells,  invades  the  epiphysis.  The  granulation 
tissue  may  grow  so  luxuriantly  as  to  separate  the  epiphysis  from  the  shaft 
and  in  either  case  the  bone  is  so  weakened  at  the  epiphyseal  line  that 
fracture  through  it  readily  takes  place  as  the  result  of  slight  traumatism, 
either  in  intra-uterine  life  or  after  birth.  Thus  results  separation  of 
the  epiphysis,  a  frequent  manifestation  of  severe  hereditary  syphilis. 
With  either  form  of  osteochondritis  there  is  a  broad  yellow  line  to  be 
made  out  macroscopically  at  the  junction  of  the  epiphysis  and  shaft ;  with 
the  excessive  formation  of  granulation  tissue  and  the  invasion  of  the 
epiphysis  the  line  is  an  irregular  one. 

While  the  osseous  changes  are  widely  distributed  throughout  the  body 
they  are  not  of  equal  intensity.  The  lower  end  of  the  femur  and  radius 
and  the  upper  end  of  the  tibia  and  humerus  are  most  severely  affected. 
Complete  recovery  from  the  lesion  is  possible.  Acute  suppurative  epi- 
physitis and  arthritis  may  occur  in  syphilis  but  they  are  to  be  regarded  as 
of  pyemic  rather  than  of  syphilitic  origin. 

Osteoperiostitis  is  common  in  hereditary  syphilis.  In  young  infants 
it  is  found  as  a  very  generalized  lesion,  affecting  the  shafts  of  the  long 
bones,  especially  those  of  the  leg,  forearm,  and  hands.  The  swelling  is 
usually  at  the  end  of  the  shaft.  With  increasing  age  the  tendency  is  to 
involve  the  shaft  nearer  its  middle.  The  lesion  in  infants  is  largely 
periosteal.  Later  the  bone  participates  more  and  more  in  tlie  process; 
there  is  a  formation  of  new  bone  which  is  firm  and  very  compact  or  it 
may  consist  of  a  coarsely  spongy  structure.  The  periosteal  swellings 
with  appropriate  treatment  may  entirely  disappear  by  absorption.  The 
new-formed  bone  largely  persists. 

Gummata  of  the  bones  are  rare  in  -infancy.  With  older  children 
gummata  may  form  on  the  long  bones  or  the  skull.  They  are  not  essen- 
tially different  from  those  occurring  with  acquired  syphilis. 


HEREDITARY  SYPHILIS  1107 

Liver. — This  is  probably  more  frequently  involved  in  the  fetus  and 
newly-born  infant  than  any  other  organ.  The  syphilitic  lesions  of  the 
liver  consist  in  an  interstitial  hepatitis,  a  gummatous  hepatitis,  or  a  com- 
bination of  the  two  varieties.  In  the  interstitial  form,  which  is  most  fre- 
quent in  infancy,  the  liver  is  enlarged,  frequently  very  much  so,  and 
firm.  On  cross  section  the  markings  are  indistinct.  Microscopically, 
there  is  a  great  increase  in  connective  tissiie  which  is  diffusely  scattered 
throughout  the  whole  organ  and'even  between  the  individual  liver  cells. 
There  may  be  also  bands  of  connective  tissue  invading  the  liver  in  dif- 
ferent directions.  As  the  connective  tissue  contracts  an  irregularity  of 
the  surface  of  the  liver  develops.  Groups  of  miliary  syphilomata  may  also 
be  found. 

The  gummatous  form  is  not  frequent  in  early  infancy,  but  belongs  to 
a  little  later  period.  In  this  there  may  be  miliary  syphilomata  with 
interstitial  changes,  and  in  addition  the  formation  of  small  or  large 
gummatous  tumors  which  may  be  softened  at  the  center.  They  are  sur- 
rounded by  zones  of  new  connective  tissue  and  the  liver  cells  are 
atrophied.    Amyloid  changes  may  be  present. 

In  the  late  form  of  hereditary  syphilis,  usually  seen  in  children  over 
four  or  five  years  old,  the  liver  is  occasionally  affected.  The  lesions 
resemble  those  of  the  congenital  variety.  There  are  found  cirrhotic 
changes,  which  may  be  diffuse  or  circumscribed,  and  gummatous  deposits, 
which  vary  from  a  minute  size  to  that  of  a  cherry ;  there  may  be  amjdoid 
degeneration. 

Spleen. — This  is  almost  invariably  much  enlarged  in  newly-born  chil- 
dren with  syphilis  and  in  syphilitic  fetuses,  but  nothing  characteristic  is 
found  under  the  microscope.  In  older  children  the  enlargement  of  the 
spleen  may  be  even  greater.  The  organ  may  be  the  seat  of  interstitial 
changes,  and  sometimes  there  may  be  small  gummatous  deposits.  These 
changes  are  rare  in  children  imder  two  years  of  age. 

Respiratory  Si/stem. — In  syphilitic  infants  who  are  still-born  and  in 
those  who  die  soon  after  birth,  there  is  occasionally  found  in  the  lungs 
what  is  known  as  "white  pneumonia."  The  lungs  are  nearly  white  or 
slightly  red.  They  are  firm  and  contain  little  or  no  air.  The  alveoli  are 
filled  with  desquamated  cells  and  leucocytes.  There  is  an  increase  in  the 
connective  tissue  of  the  alveolar  walls,  bronchi,  and  blood  vessels.  There 
may  also  be  gummata  scattered  through  the  lungs.  These  are  usually 
small. 

The  trachea  and  bronchi  are  in  rare  cases  the  seat  of  stenosis,  which 
results  from  cicatrization  following  the  softening  of  gummatous  deposits 
in  their  walls.  Lesions  of  the  larynx  other  than  a  chronic  catarrhal  in- 
flammation of  the  mucous  membrane,  are  also  infrequent.  The  lesion 
usually  found  is  perichonclritis,  which  more  often  involves  the  epiglottis 


1108  THE  SPECIFIC  INFECTIOUS  DISEASES 

than  any  other  part.  Sometimes  there  is  the  formation  of  papillomatous 
masses;  but  ulceration  and  stenosis  are  both  rare. 

The  nasal  mucous  membrane  in  the  early  stage  of  the  disease  is  very 
constantly  the  seat  of  a  chronic  catarrhal  inflammation,  which  may  be 
accompanied  by  superficial  ulceration.  In  the  late  cases  there  is  deeper 
ulceration,  from  the  breaking  down  of  gummata,  with  extension  to  the 
periosteum,  cartilages,  and  bones,  causing  perforation  of  the  septum, 
necrosis  of  the  bones,  etc. 

Nervous  System. — Syphilis  may  affect  the  meninges,  the  blood  ves- 
sels or  the  brain  itself.  There  may  be  merely  a  diffuse  thickening  of  the 
meninges  with  which  there  is  usually  associated  a  certain  amount  of 
encephalitis,  or  there  may  be  miliary  gunimata  scattered  throughout  the 
meninges  but  especially  at  the  base.  As  the  result  of  the  chronic  syph- 
ilitic meningitis,  adhesions  may  form  at  the  base,  obliterating  the  fora- 
men of  Magendie  and  at  times  leadmg  to  hydrocephalus.  Syphilitic  en- 
darteritis is  very  common  and  consists  in  a  thickening  of  the  vessel 
wall  with  proliferation  of  the  intima  and  reduction  in  the  caliber  of  the 
vessel.  There  is  also  a  perivascular  proliferation  of  connective  tissue. 
The  changes  that  have  been  described  are  found  in  direct  proportion  to 
the  severity  of  the  syphilitic  infection.  In  infants  dying  in  uiero  or 
shortly  after  birth  they  are  frequent.  In  those  with  a  mild  infection,  the 
lesions  may  be  slight  or  absent.  Large  gummata  are  unusual  at  any 
time. 

Later  in  childhood,  syphilis  of  the  brain  is  not  very  uncommon.  The 
lesions  are  chiefly  the  result  of  the  vascular  changes  and  consist  in  lo£al- 
ized  or  diffuse  sclerosis  with  greater  or  less  atrophy  of  the  convolutions. 
The  lesions  of  juvenile  paresis  and  taSes  cto  not  differ  from  those  that 
are  the  result  of  acqiiired  syphilis. 

Heart  and  Arteries. — These  are  very  frequently  affected,,  even  in 
young  infants.  Adler,  of  four  cases  examined,  found  two  in  which  well- 
marked  lesions  were  present  in  infants  under  four  months.  Warthin 
has  emphasized  the  importance  of  systematic. study  of  the  heart  for  evi- 
dences of  syphilis.  He  has  found  lesions  and  has  demonstrated  the 
organism  when  no  other  evidences  of  s^^philis  were  to  be  found  in  the 
body.  The  lesions  consist  of  a  diffuse  or  localized  interstitial  myocarditis 
with  endarteritis  of  the  coronary  arteries  and  small  blood  vessels. 

Digestive  System. — Chronic  catarrhal  pharyngitis  is  almost  a  con- 
stant symptom  of  the  early  cases.  Later  there  is  seen  superficial  or  deep 
ulceration  of  the  pharynx,  tonsils,  or  fauces,  which  may  lead  to  perfora- 
tion of  the  soft  or  hard  palate. 

There  are  no  frequent  lesions  of  the  stomach  or  intestines  either 
with  early  or  late  syphilis.  In  infants  dying  early  with  very  extensive 
lesions  ulcerations  are  sometimes  found  in  the  small  intestine.    They  are 


HEEEDITARY  SYPHILIS  1109 

niLiltip]e  and  cxtriid  Iransxcrst'ly  across  the  intestine.  They  cause  no 
symptoms.  The  rectum  is  occasionally  the  seat  of  ulceration,  and  con- 
dylomata may  form  about  the  anus  even  in  young  children. 

Pancreas. — Changes  in  the  pancreas  are  frequent  with  severe  infec- 
tions; with  mild  infections  they  are  usually  absent.  They  consist  in  a 
diffuse  production  of  connective  tissue  which  replaces,  to  a  greater  or 
less  extent,  the  parenchyma  of  the  organ.  In  the  most  extreme  cases 
there  may  be  no  glandular  tissue  remaining.  The  islands  of  Langerhans 
are  usually  not  destroyed. 

Thymus. — Occasionally  there  are  found  in  syphilis  numerous  small 
abscesses  in  tlie  substance  of  the  thymus  gland.  Tliey  are  filled  with  a 
l)uru]ent  material  consisting  of  leucocytes  with  great  numbers  of  spi- 
rochetes. The  giandidar  tissue  is  also  infiltrated  with  leucocytes.  These 
abscesses  of  DuBois  are  very  characteristic  of  syphilis. 

Ortjaiis  of  Special  Sense. — Otitis  is  a  frequent  accompanime]it  of  the 
early  syphilitic  pharyngitis.  It  is  very  likely  to  l)ecome  chronic,  and  in 
many  cases  results  in  a  permanent  impairment  of  hearing.  Iritis  is  rela- 
tively rare  in  children,  but  it  may  occur  even  in  intra-uterine  life,  as 
shown  by  the  presence  of  adhesions  in  newly-born  children.  It  is  usually 
seen  in  infants  four  or  five  months  old;  and  is  always  serious.  Interstitial 
keratitis  occurs  frequently  as  a  later  manifestation  of  syphilis.  Choroid- 
itis and  optic  neuritis  are  both  occasionally  seen,  but  they  are  rare. 

Genito-urhmrij  Orfjaiis. — Nearly  all  these  may  be  affected,  but  gener- 
ally in  the  late  period  of  the  disease.  There  may  l)e  chronic  interstitial 
nephritis  and  more  rarely  gummatous  deposits  in  the  kidney,  interstitial 
changes  in  the  suprarenal  bodies,  and  orchitis,  which  usually  affects  the 
body  of  the  organ,  rarely  the  epididymis;  it  is  generally  an  interstitial 
inflammation,  with  or  without  gummatous  deposits. 

Symptoms. — As  the  result  of  syphilis,  abortion  may  take  place  at  any 
period  of  pregnancy,  with  the  discharge  of  a  dead  or  macerated  fetus,  or 
the  child  may  be  still-born  at  term,  or  it  may  l)e  born  alive  prematurely, 
but  with  so  feeble  a  vitality  that  it  survives  but  a  few  hours.  In  these 
circumstances  it  is  often  difficult  and  sometimes  impossible  to  decide 
})ositively  with  reference  to  the  existence  of  syphilis.  Maceration  of 
the  fetus  or  peeling  of  the  skiij  is  no  proof,  and  even  the  examination 
of  the  internal  organs  may  not  be  conclusive,  except  for  the  presence  of 
spirochetae.  Lomer  examined  43  fetuses,  all  dying  before  the  thirtieth 
week  of  pregnancy;  he  found  the  spleen  and  liver  enlarged  in  all,  and 
marked  bone  changes  in  21:  Birch-Hirschfeld  examined  108  newly-born 
syphilitic  infants;  he  found  the  spleen  invariably  enlarged;  typical  bone 
changes  were  present  in  3-5,  but  in  many  cases  the  bones  were  normal. 
More  recent  studies  of  the  bones  have  shown  them  to  be  involved  in  a 
much  larger  proportion  of  cases  than  is  given  by  these  writers.    Mervis, 


1110  THE  SPECIFIC  INFECTIOUS  DISEASES 

from  ail  examination  of  92  syphilitic  fetuses,  states  that  no  eruption 
upon  the  skin  was  found  earlier  than  the  eighth  month. 

Symptoms  are  present  at  birth  in  only  a^  small  number  of  ca^es.  In 
such  there  is  usually  a  very^  severe  degree  of  infection,  and  the  infants 
do  not  often  live  more  than  a  few  days.  Upon  the  skin  there  may  be 
seen  an  eruption  of  pustules,  paries,  or  bulla£<  The  bullae  are  usually 
upon  the  soles  and  palms,  but  may  be  found  upon  other  parts  of  the  body. 
The'name  "syphilitic  pempjiigus"  is  often  given  to  this  condition.  The 
IniUae  are  at  first  small,  then  may  coalesce  and  form  larger  ones  two 
inches  or  more  in  diameter.  They  contain  a  turbid  serum  which  is  some- 
times tinged  with  blood,  and  sometimes  yellow  from  pus.  Pustules,  when 
jjresent,  are  usually  seen  upon  the  face  or  scalp.  The  general  appearance 
of  these  infants  is  wretched  in  the  extreme.  The  body  is  wasted,  the  skin 
Avrinkled,  and  temperature  subnormal.  The  spleen  is  usually  enlarged 
and  often  the  liver  also.  Death  usually  occurs  from  inanition  within 
two  weeks. 

In  the  great  majority  of  cases  the  infant  appears  healthy  at  birth, 
and  continues  sO  for  a  variable  time  before  the  manifestation  of  the  char- 
acteristic symptoms  of  syphilis.  As  a  rule,  the  more  intense  the  infec- 
tion, the  earlier  the  symptoms  make  their  appearance.  The  earliest  symp- 
toms are  generally  seen  between  the  second  and  the  sixth  weeks.  If 
three  months  pass  without  evidence  of  syphilis,  the  probabilities  are  that 
the  child  will  escape.  Miller  (^loscow)  gives  the  following  statistics  of 
the  time  of  beginning  of  symptoms  in  1,000  cases: 

Symptoms  appeared  during  the  first  week 85  cases. 

"                   "             "         "second  week 138  " 

"    third  week 240  " 

"                   "             "         "    fourth  week 177  " 

"                  "            "         "    fifth  week 86  " 

«                   "             "         "    sixth  week 54  " 

«                   "             "         "    seventh  week 50  " 

«                   "             "         "    eighth  week 30  " 

after  the  eighth  week  ..  •. 140  " 

Sometimes  the  constitutional  symptoms — wasting,  cachexia,  etc. — ■ 
are  noticed  before  the  local  ones,  but  usually  this  is  not  the  case.  Gener- 
ally the  fir^  symptom  is  the  coryza  or  "snuffles,"  which  resembles  an 
ordinary  cold  in  the  head,  except  that  it  persists.  It  is  often  accompanied 
by  a  hoarse  cry,  indicating  that  the  larynx  participates  in  the  catarrhal 
inflammation.  Soon  the  eruption  makes  its  appearance,  being  generally 
first  seen  upon  the  hands,  feet,  and  face.  Fissujes  and  mucous  patches 
may  be  seen  upon  the  lips,  about  the  anus,  and  elsewhere.  There  is  often 
slight  fever,  from  99°  to  101°  F.  There  may  also  be  observed  excessive 
tenderness  and  swelling  about  the  shoulders,  elbows,  wrists,  or  ankles, 


HEEEDITARY  S^  I'llTTJS 


1111 


due  to  epiphysitis,  which  may  cause  the  child  to  cry  from  the  slightest 
amount  of  handling,  and  the  limbs  may  be  moved  so  little  that  paralysis 
is  suspected. 

In  a  severe  case,  ,as  these  local  symptoms  develop,  the  infant's  gen- 
eral nutrition  su^rs.  He  loses  steadily  in  weight,  he  becomes  extremely 
anemic,  and  whines  and  frets  almost  continually,  but  especially  at  night. 
The  features  have  a  pitiful,  drawn  expression ;  the  face  is  wrinkled,  giv- 
ing the  infant  a  very  old  appearance.  The  skin  has  a  peculiar  sallow 
color,  which  has  been  well  described  as  cafe  au  Mi.  The  symptoms 
may  continue  until  a  condition  of  extreme  marasmus  is  reached,  or 
death  may  occur  from  some  intercurrent  affection  of  the  Inngs  or  diges- 
tive organs.  Wasting  is, 
however,  very  common  in 
infants  that  are  premature 
or  very  small  at  birth.  Even 
without  hereditary  syphilis 
the  question  of  nutrition  is 
then  a  difficult  one.  Indi- 
rectly by  causing  prematur- 
ity, the  syphilis  is  responsi- 
ble. It  is  remarkable  to  see 
how  well  some  children  with 
extensive  evidences  of  syph- 
ilis thrive,  provided  they 
were  full-term  infants  and 
are  breast  fed. 

In  the  milder  forms  of 
infection  the  severe  consti- 
tutional symptoms  described 
are  not  seen,  although  the 

local  evidences  of  disease  are  well  marked.  The  severity  of  the  symptoms 
is  also  much  modified  by  treatment,  especially  when  this  is  begun 
early. 

The  most  important  local  symptoms  are  the  coryza,  eruption,  fissures 
about  the  mouth  and  anus,  mucous  patches,  painful  swellings  at  the  ex- 
tremities of  the  long  bones,  pseudoparalysis,  and  onychia.  ' 

Coryza. — In  most  of  the  cases  this  is  the  first  symptom.  Beginning 
like  an  ordinary  catarrh,  it  is  distinguished  by  its  severity  and  its  per- 
sistence. There  is  a  copious  discharge  of  mucus  and  serum,  often  tinged 
Avith  blood.  Thick  crusts  form,  which  produce  the  usual  symptoms  of 
nasal  obstruction;  there  is  great  difficulty  in  nursing;  the  infant  breathes 
through  the  mouth,  and  the  mucous  membrane  of  the  mouth  is  dry,  caus- 
ing great  discomfort.     ]f  untreated,- the  process,  which  at  first  involves 


Fig.  isi. 


-Early  Eruption  of  Hereditary  Syph- 
ilis.    Infant,  two  months  old. 


1112 


THE  SPECIFIC  IXFECTIOUS  DISEASES 


the  mucous  luembraiiG  only,  may  extend  to  the  submiTcoiis  tissiie,  causing 
ulceration;  but  the  cartilages  and  the  bones  of  the  nasal  fossae  are  not 
often  involved  till  a  later  period  in  the  disease. 

The  nasal  catarrh  is  associated  with  more  or  less  laryngitis,  causing 
hoarseness  or  aphonia,  and  rarely  there  may  be  laryngeal  stenosis.  Bil- 
lon Brown  has  reported  one  ease  in  an  infant  six  weeks  old,  which  recov- 
ered after  intubation. 

Eruption. — The  early  eruption  usually  appears  after  the  coryza  has 
lasted  about  a  week;  but  the  two  may  come  at  the  same  time;  or  the 


I 


Fig.  182. — Early  Ekuption  of  Hereditary 
Syphilis.  Infant,  two  and  one-half  months 
old. 


Fig.  183. — Syphilitic  Scialing  of  the 
Foot.  From  an  infant  eiffht  weeks 
old. 


coryza  may  be  absent  or  so  slight  that  the  rash  seems  to  be  the  first 
symptom. 

Occasionally  there  is  seen  a  diffuse  blush  or  roseola,  but  usually  the 
eruption  i_s  macular,  occurring  in  small,  dark-red  spots  about  the  size 
of  the  infant's  finger  nails,  usually  circular  and  often  slightly  elevated; 
there  is  no  surrounding  inflammation,  and  no  itcjiing.  It  is  usually  most 
abundant  about  the  center  of  the  face,  the  extensor  surfaces  of  the  upper 
and  lower  extremities  and  especially  the  hands  and  feet.  It  may  extend 
over  the  entire  body,  but  is  generally  absent  over  the  chest  and  abdomen. 
At  iirst  the  color  is  bright,  but  gradually  becomes  of  a  dusky-red  or  cop- 
pery hue.  After  a  little  time  veij  fine  scales  may  be  seen  upon  the- surface 
of  the  red  macules.  The  rash  comes  out  slowly,  usually  requiring  from 
one  to  three  weeks  for  its  full  development.  It  fades  gradually,  leaving 
a  coppery  discoloration  of  the  skin,  which  continues  for  a  long  time.   The 


HEKEDITARY  SYPHILIS  1113 

duration  of  the  eruption  is  from  three  to  eight  weeks;  less  if  active  treat- 
ment is  employed. 

A  papnlar  eruption  is  rarely  seen  alone,  but  is  usually  associated 
with  the  niac-ular  \ariety.  The  papules  are  of  a  brownish  color  and 
arejiiird.    They  are  seen  most  frequently  upon  the  palms  and  soles. 

A  squamous  eruption  is  frequently  seen  upon  the  palms  and  soles,  but 
not  often  elsewhere.  In  a  few  cases  this  scaliness  forms  the  most  dis- 
tinctive feature  of  the  cutaneous  lesion  (see  Fig.  183). 

Fissures  and  Mucous  Patches. — These  are  among  the  most  diagnostic 
features  of  early  hereditary  syphilis.  Fissures  are  most  frequently  seen 
on  the  lips  and  about  the  anus,  but  they  may  occur  about  the  nostrils  and 
occasionally  elsewhere.  The  fissures  of  the  lips  are  really  linear  ulcers, 
and  arc  distinguished  by  their  persistence  in  spite  of  local  treatment. 


Fig.  184. — A  Lateu  Form  of  Eruption  in  Hb:reditary  Syphilis. 
Infant  eight  months  old. 

Tliey  arc  multii)le,  deep,  painful,  and  l)leed  easily.  After  healing, 
these  fissures  may  leave  many  cicatrices  radiating  from  the  mouth, 
tlie  contraction  of  which  produces  the  so-called  "purse-string"  deformity. 

Mucous  patches  may  develop  from  fissures,  but  more  frequently  from 
papules  which  are  situated  in  regions  where  they  are  exposed  to  constant 
moisture  and  friction.  They  are  very  common  upon  the  mucocutaneous 
surfaces  and  wherever  the  skin  is  especially  thin.  They  arc  most  apt 
to  be  seen  al)out  the  lips,  anus,  scrotum,  and  vulva,  but  they  may  also  be 
found  behind  the  ears,  between  the  toes,  in  the  folds  of  the  groin,  axillae, 
or  buttocks.  They  vary  from  an  eighth  to  half  an  inch  in  diameter,  are 
whitish  in  color,  and  are  raised  rather  than  excavated. 

Ulcers  may  be  present  upon  any  of  the  mucous  membranes,  fre- 
quently in  the  mouth  or  on  the  genitals;  they  are  seldom  symmetrical, 
and  wliile  they  may  be  broad  they  are  never  deep. 

Hemorrhages. — They  are  generally  associated  with  the  lesions  of  the 
mucous  membranes,  especially  of  the  nose.    In  young  infants  witli  severe 


1114  THE  SPECIFIC  IXFECTIOUS  DISEASES 

infection,  bleeding  may  occur  from  the  bullous  eruption  upon  the  skin, 
or  from  the  fissures  at  any  of  the  orifices,  particularly  the  mouth  and 
anus.  Fischl  has  reported  seven  cases  of  multiple  hemorrhages  in  the 
newly  bom,  associated  with  other  symptoms  of  congenital  syphilis. 
Mracek  noted  hemorrhages  in  thirty-three  per  cent  of  160  autopsies  on 
syphilitic  still-born  infants  or  those  dying  soon  after  birth.  Examination 
of  the  blood-vessels  in  some  of  these  cases  showed  infiltration  of  their 
walls  and  narrowing  of  their  lumen.  The  vascular  changes  were  thought 
to  be  the  cause  of  the  bleeding. 

Nails. — The  nails  present  several  peculiarities  in  syphilitic  infants. 
There  may  be  a  diseas.e  of  the  matrix  resulting  in  suppuration  and  ex- 
foliation of  the  nail;. frequently  the  dorsum  is  much  arched,  and  the  nail 
appears  as  if  it  had  Ijeen  pinched  by  a  pair  of  forceps — i..  e.,  clajv-shaped ; 
this  is  an  early  symptom  of  some  diagnostic  importance.  The  hjjj  and 
eyebroAvs  frequently  fall  out  completely.  This  symptom  is  not  usually 
present  in  very'early  infancy. 

Pseudoparalysis. — This  is  due  to  acute  epiphysitis,  and  it  may  be 
the  first  symptom  of  hereditary  syphilis  to  attract  attention.  It  is  usu- 
ally noticed  when  the  infant  is  a  few  weeks  old,  that  one  or  more  ex- 
tremities is  not  moved,  and  that  the  parts  are  tender  when  handled. 
The  limb  lies  perfectly  motionless,  and  any  attempt  at  passive  move- 
ment causes  evident  pain.  A  history  Avill  usually  be  obtained  that  the 
loss  of  power  did  not  exist  at  birth  but  developed  subsequently.  If  the 
arm  is  affected  it  is  very  frequently  held  in.  marked  inward  rotation  with 
the  palm  looking  outwards,  resembling  the  position  in  Erb's  palsy.  There 
is  tenderness  on  pressure,  and  soon  swelling  is  seen,  both  being  most 
marked  at  the  epiphyseal  line.  If  the  bone  affected  is  superficially  situ- 
ated, as  the  lower  epiphysis  of  the  humerus,  radius,  or  tibia,  swelling  is 
very  apparent,  while  it  may  be  scarcely  perceptible  at  the  upper  epiphysis 
of  the  humerus.  The  swelling  is  usually  cylindrical  and  moderate  in 
degree,  being  limited  to  the  extremity  of  the  bone.  Separation  of  the 
epiphysis  may  take  place,  so  that  crepitation  is  obtained  by  moving  the 
limb.  With  this  there  is  sometimes  suppuration  due  to-  secondary  in- 
fection. The  X-ray  shows  in  many  instances  an  increase  in  the  -n-idth 
of  the  epiphyseal  line  which  may  be  very  irregular.     (Fig.  185.) 

In  the  milder  cases,  or  those  which  have  been  subjected  to  active 
treatment,  both  the  swelling  and  the  tenderness  subside  rapidly  Avitliout 
suppuration ;  and  CAen  though  the  epiphysis  has  separated  from  the  shaft 
it  speedily  unites.  When  pseudoparalysis  has  been  the  chief  symptom, 
very  rapid  improvement  occurs  under  treatment,  and  usually  there  is 
complete  recovery  of  function  in  two  or  three  weeks.  If  secondary  in- 
fection takes  place  the  condition  is  usually  fatal. 

Syphilitic  Osteoperiostitis. — This  is  usually  found  in  infancy  only 


HEPvEDFJ  ARY  SYPPIILIS 


1115 


as  the  result  of  a  severe  infection.  It  chiefly  affects  the  long  bones, 
especially  the  tibia,  fibula,  radius,  humerus,  plialanges,  and  metacarpal 
and  metatarsal  bones.  The  lesions  are  multiple,  often  symmetrical,  and 
at  this  age  are  principally  periosteal.  They  are  generally  situated  near 
the  ends  of  the  shaft.  The  swellings  caused  by  the  periostitis  can  be 
made  out  readily  when  they  are  but  slightly  covered  by  muscles  or  fat. 
It  may,  however,  be  impossible  to  demonstrate  their  presence  except  by 
means  of  the  X-ray.  The  swellings  are  firm  and  often  distinctly  tender. 
They  are  frequently  associated  with  the  symptoms  of  syphilitic  epiphys- 


FiG.  185. — Hereditary  Syphilis. 
Showing  irregularity  and  exagger- 
ation of  line  A.  Infant  two 
months  old. 


Fig.  186. — Syphilitic  Periostitis  of  the 
Fibula.  Infant  three  months  old. 
Same  patient  as  Figs.  187-190 
Right  side  affected ;  left  side  normal. 


itis.     The  X-ray  picture  shows  a  fusiform  swelling  chiefly  due  to  peri- 
osteal thickening.     (Fig.  186.) 

Syphilitic  Dactylitis. — This  is  found  in  infants  usually  between  the 
third  and  seventh  months.  It  is  not  a  frequent  manifestation  of  syphilis. 
When  present  there  are  usually  other  evidences  of  bone  syphilis,  such  as 
periosteal  swellings,  for  the  dactylitis  is  an  osteoperiostitis  but  usually 
differs  from  that  affecting  other  bones  in  that  the  involvement  of  the 
bone,  even  at  this  early  age,  is  considerable  and  the  periostitis  rather 
slight.  By  means  of  the  X-ray  it  can  be  seen  that  the  phalanx  involved 
is  much  thickened  and  of  denser  structure  than  the  normal.  Except  for 
the  fact  that  more  than  one  and  frequently  several  phalanges  are  in- 


1116 


THE  SPECIFIC  IXFECTIOUS  DISEASES 


^■olved,  the  symptoms  closely  resemble  the  tuhereulons  form.  The  en- 
largement is  spindle-shaped,  involving  the  entire^phalanx.  It  is  usually 
not  painful.  It  slowly  increases  in  size  and  but  rarely  goes  on  to  sup- 
puration or  necrosis.  The  disease  may  he  arrested  and  cured  hy  consti- 
tutional treatment. 

Lympli  iVo^Zes.— These  are  often  palpable.  IMarked.  enlargement  is 
uncommon.  No  aid  in  diagnosis  can  he  obtained  from  any  but  the 
epitrochlear  glands.  If  these  are  considerably  enlarged  in  infancy  with- 
out evident  adequate  explanation,  a  suspicion  of  syphilis  should  always  be 
aroused.    They  may  be  at  times  almost  the  only  evidences  of  the  disease. 

The  only  visceral  symptoms  of  importance  are,  enlargement  of  the 


Fig.  187.  Fiu.  lys. 

Figs.  187,  188. — Syphilitic  Dactylitis.  On  right  hand  first  phalanges  of  forefinger  and 
little  finger  affected;  on  left  hand  first  phalanx  of  thumb  and  second  phalanx  of  second 
finger. 


spleen,  which  is  almost  invariably  present  in  the  active  stage  of  hereditary 
syphilis,  and  jaundice  with  or  without  enlargement  of  \he  liver  (see 
Icterus  of  the  Xewly  Born). 

Late  Hereditary  Syphilis. — Tlie  symptoms  may  come  on  at  any 
period  during  childhood  or  about  the  time  of  pubert)^,  but  rarely  at  a 
later  time  than  this.  •  They  are  seen  both  in  those  who  have  had  the 
usual  symptoms  of  hereditary  syphilis  in  early  infancy,  and  in  others 
where  the  most  careful  examination  into  the  history  fails  to  disclose  any 
symptoms  whatever  of  early  syphilis.  It  is  fair  to  assume  in  such  cases 
either  that  early  S3anptoms  were  absent  or  that  they  Avere  of  trivial 
importance. 

Late  hereditary  syphilis  shows  itself  by  symptoms  which  in  acquired 
disease  would  be  classed  as  tertiary.  The  most  characteristic  are  the  af- 
fections of  tlie  tei'ib.  the  br)iies,  the  eves,  a'umniatoiis  deposits  in  tlie  solid 


HEREDITARY  SYPHILIS 


1117 


viscera,  the  skin  or  mucous  membranes,  the  breaking  down  of  which  may 
lead  to  ulceration,  and,  finally,  symptoms  of  disease  of  the  nervous  sys- 
tem. 

Teeth. — There  are  no  peculiarities  in  the  first  teeth  of  syphilitic  chil- 


FiG.  189.  Fig.  190. 

Figs.  189,  190. — Same  Hands  as  Figs.  187,  188.  Note  that  besides  the  bones  shown  in  the 
other  pictures,  two  metacarpal  bones  (C,  D)  are  affected  in  the  left  hand  and  the 
lower  end  of  the  radius  (G)  in  the  right  hand. 


dren  except  their  proneness  to  early  decay.    They  are  rather  more  likely 
to  appear  early  than  late. 

The  characteristic  teeth  of  syphilis  are  those  of  the  second  set.  In 
estimating  the  diagnostic  value  of  these  changes,  only  the  upper  ceniral 
incisors  are  to  be  relied  upon ;  these  are  the  test  teeth.  Although  changes 
are  frequently  seen  in  other  teeth,  they  are 
not  always  diagnostic.  Typical  syphilitic 
teeth,  according  to  Hutchinson,  have  each  a 
single  notch  in  the  center  of  the  edge  (Fig. 
191).  The  notch  is  usually  shallow  and  more 
or  less  crescentic  in  shape.  The  enamel  is 
generally  deficient  in  the  center  of  the  notch, 

and  the  tooth  here  is  apt  to  be  discolored.  The  teeth  in  other  cases  are 
variously  dwarfed  and  deformed  (Fig.  192).  They  often  taper  regu- 
larly from  the  base  to  the  edge,  giving  rise  to  the  term  "screw-driver 
teeth."  The  teeth  often  are  not  so  flat  as  the  normal  incisors,  but  often 
rounded  and  peg-like.  They  are  not  properly  placed,  but  incline  either 
37 


Fig.  191. — Typical  "Hutch- 
inson's Teeth."  (After 
Fournier.) 


1118 


THE  SPECIFIC  INFECTIOUS  DISEASES 


toward  or  away  from   eacli  other.     They  are  seldom  large  enough  to 
touch  the  adjacent  teeth  on  both  sides. 

Although  Hutchinson's  teeth  may  generally  he  taken  as  conclusive 
evidence  of  syphilis,  they  are  not  invariably  so,  as  Keyes  and  others  have 
shown.  It  is  to  be  remembered  in  this  connection  that  the  absence  of 
changes  in  the  teeth  is  of  no  importance  whatever  as  evidence  that 
syphilis  is  not  i:)resent.  Hutchinson  states  that  they  are  wanting  in  more 
than  half  the  cases. 

Bones. — The  form  of  disease  which  is  usually  seen  at  this  period  is  an 
osteoperiostitis,  affecting  principally  the  shaft  of  the  long  bones  and  the 
cranium.  Chronic  osteoperiostitis  is  more  frequent  after  the  third  year, 
and  most  of  the  cases  occur  between  the  fifth  and  fourteenth  years.    The 

most  common  seat  of  disease  is  the  tibia, 
and  next  to  this  the  bones  of  the 
forearm  and  the  cranium.  The  follow- 
ing is  the  frequency  with  which  the  dif- 
ferent bones  were  affected  in  the  series  of 
cases  reported  by  Fournier:  tibia  in  91 
cases,  ulna  in  22,  radius  in  15,  cranium 
in  16,  humerus  in  12,  all  others  in  37. 
The  process  may  result  either  in  a  diffuse 
or  a  localized  hyperplasia  of  bone  or  in 
necrosis. 

The  typical  changes  are  seen  in  the 
tibia.  The  shaft  of  the  bone  is  princi- 
■pally  or  solely  affected.  There  is  often 
produced  a  very  characteristic  deformity, 
consisting  of  a  forward  curve  of  the  an- 
terior border  of  the  tibia,  which  has  been  compared  to  a  saber  blade 
(Figs.  193,  194).  In  some  cases  the  bone  is  bent  inward  at  its  lower 
third,  resembling  somewhat  a  rachitic  curvature.  Sometimes  the  entire 
shaft  of  the  bone  is  affected,  and  it  may  be  greatly  enlarged.  At  other 
times  the  swelling  is  chiefly  near  the  epii^hysis,  where  large  bosses  may 
form  of  sufficient  size  to  interfere  with  the  fimctions  of  the  joint.  In- 
stead of  affecting  the  bone  uniformly,  the  disease  often  affects  only  cer- 
tain parts,  leading  to  the  formation  of  large  nodes  which  are  more  likely 
to  be  followed  by  necrosis  than  are  the  other  lesions.  In  most  of  the 
cases  the  process  is  purely  a  hyperplastic  one,  leaving  the  bone  perma- 
nently enlarged  and  the  limb  often  lengthened.  Less  frequently,  there 
occur  gummatous  deposits  in  or  beneath  the  periosteum,  which  may 
soften,  suppurate,  and  lead  to  superficial  necrosis,  with  the  formation 
of  sinuses  that  remain  open  until  the  sequestrum  is  exfoliated.  Syphi- 
litic deposits  sometimes  take  place  in  the  interior  of  the  bones,  generally 


t 

^9    1^ 

^ 

riUi 

1 

^^^ 

Fig.  192. — Syphilitic  Teeth.  Boy 
eight  years  old;  under  observa- 
tion several  years  with  various 
syphilitic  manifestations. 


HEREDITARY  SYPHILIS 


1119 


near  the  articular  ends  (Fig.  194)  ;  these  may  soften  and  break  down 
with  abscesses,  sinuses,  etc.,  very  much  after  the  manner  of  a  tubercu- 
lous inflammation. 

The  lesions  of  the  other  long  bones  are  essentially  the  same  as  of 
the  tibia.  They  are  nearly  always  symmetrical  and  often  multiple.  The 
course  of  syphilitic  osteoperiostitis  is  very  chronic,  and  some  permanent 
deformity  is  the  rule,  unless  cases  come  very  early  under  treatment. 

When  affecting  the  bones  of  the  cranium  the  disease  usually  takes  the 
form  of  a  gummatous  periostitis,  which  leads  to  the  formation  of  large 


Fig.  193. — Syphilitic  Osteoperiostitis  of  the  Tibia.  Left  tibia  greatly  enlarged; 
\y^  inches  longer  than  the  right,  and  leg  2  inches  larger  in  circumference;  saber-like 
anterior  border.     Right  tibia  normal;  lesion  of  long  standing.     Patient  13  years  old. 

nodes.  These  may  remain  as  permanent  deformities,  or  they  may  break 
down  and  suppurate,  with  necrosis  of  one  or  both  tables  of  the  skull. 
This  may  be  followed  by  inflammation  of  the  dura,  the  pia,  and  even  of 
the  brain  itself. 

When  the  long  bones  are  affected,  the  symptoms  are  pain,  tenderness, 
and  deformity.  These  come  on  very  gradually,  and  often  the  deformity 
is  noticed  before  either  pain  or  tenderness  is  sufficiently  marked  to  attract 
attention.  The  pain  is  regularly  worse  at  night,  and  often  felt  only  at 
that  time;  it  may  be  mild  and  occasional,  or  so  severe  as  virtually  to 
prevent  sleep.     There  is  tenderness  on  pressure  over  the  bones  affected, 


1120 


THE  SPECIFIC  INFECTIOUS  DISEASES 


the  acuteness  of  which  will  depend  upon  the  activity  of  the  process. 
When  suppuration  occurs,  it  comes  very  slowly,  and  never  with  symptoms 
of  acute  inflammation.  Sinuses  usually  continue  to  discharge  until  a 
sequestrum  is  exfoliated.  The  course  of  the  disease  is  very  tedious,  and 
the  whole  duration  is  usiially  several  years. 


Fig.  194. — Syphilitic  Osteoperiostitis  of  the  Left  Tibia.     Similar  lesion  to  that 
shown  in  Fig.  193;    patient  8  years  old.     The  right  tibia  is  normal. 

When  the  cranium  is  affected,  there  are  seen  irregular  nodes,  espe- 
cially upon  the  frontal  and  parietal  bones.  They  are  from  one  to  two 
inches  in  diameter,  and  project  from  one-eighth  to  one-fourth  of  an  inch 
above  the  general  outline  of  the  skull.  There  may  be  pain,  tenderness, 
softening,  suppuration,  and  necrosis,  as  in  the  long  bones. 

It  is  rare  that  disease  of  the  bones  of  the  cranium  is  due  in  childhood 
to  any  other  cause  than  syphilis,  and  this  disease  may  usually  be  assumed 
to  exist  if  traumatism  can  be  excluded.     The  bosses  upon  the  cranium 


HEREDITARY  SYPHILIS  1121 

in  rickets  are  always  large,  smooth,  and  regular  in  position,  and  belong 
to  infancy. 

Syphilitic  disease  of  the  long  bones  is  recognized  by  the  nociurnal 
pain,  the  tenderness  and  peculiar  deformity,  and  by  the  association  of 
other  late  manifestations  of  syphilis — i.  e.,  the  peculiar  notched  teeth, 
the  interstitial  keratitis,  the  enlarged  epitrochlear  glands,  etc.  Tuber- 
culous disease  generally  affects  the  articular  ends  of  the  bones;  syphilis 
nearly  always  the  shaft.  The  diffuse  hyperplasia  of  the  tibia  and  the 
saber-like  deformity  of  its  anterior  border  are  rarely,  if  ever,  due  to  any 
other  cause  than  syphilis.  The  deformities  of  the  long  bones  have  in 
some  cases  a  certain  resemblance  to  those  due  to  rickets,  but  tlie  two  con- 
ditions can  hardly  be  confused  if  a  careful  examination  is  made. 

Arthritis. — This  may  occur  in  a  subacute  or  even  acute  form.  It  is 
most  common  in  the  knee,  though  any  of  the  large  joints  may  be  in- 
volved. The  lesion  is  chiefly  synovial.  The  onset  may  be  sudden  with 
pain  and  marked  tenderness.  Effusion  into  the  joint  occurs  and  there  is 
local  heat  and  often  a  rise  in  temperature  to  101°  F.  or  more.  The 
process  usually  remains  limited  to  one  joint  and  resists  obstinately  all 
methods  of  treatment  except  antisyphilitic  treatment,  to  which  it  readily 
yields. 

LympJi  Nodes. — They  are  less  frequently  affected  than  in  adults.  In 
most  cases  there  may  be  found  a  moderate  degree  of  enlargement  of  the 
postcervical  and  epitrochlear  glands,  swelling  of  the  latter  having  con- 
siderable diagnostic  value.  Under  normal  conditions  these  can  scarcely 
be  felt;  but  in  syphilitic  children  they  may  be  as  large  as  a  pea  or  a 
small  bean;  sometimes  two  or  three  of  them  can  be  distinguished.  Pro- 
vided no  local  cause  for  the  swelling  exists,  they  should  always  create 
a  suspicion  of  syphilis.  The  postcervical  glands  are  frequently  affected, 
but  are  not  so  diagnostic.  The  degree  of  enlargement  is  rarely  great. 
Occasionally  there  are  seen  in  the  neck  large  masses  of  swollen  lymph 
glands  which  resemble  tuberculous  swellings.  They  are,  however,  very 
rare. 

Special  Senses. — The  most  frequent  affection  of  the  eye  in  late  syph- 
ilis is  interstitial  keratitis,  the  close  connection  of  which  with  hereditary 
syphilis  was  first  pointed  out  by  Hutchinson.  It  is  often  found  asso- 
ciated with  the  typical  notched  teeth.  The  diagnostic  value  of  keratitis 
in  syphilis  is  denied  by  Fournier,  who  states  that,  while  often  syphilitic, 
it  is  not  infrequently  due  simply  to  malnutrition.  We  cannot  subscribe 
to  this  statement.  In  our  experience  it  is  alntost  always  due  to  syphilis. 
Both  eyes  are  usually  affected,  and  in  all  degrees  of  severity,  from  a  slight 
haziness  of  the  cornea  to  complete  opacity.  However,  with  an  early  diag- 
nosis and  prompt  treatment,  a  marked  degree  of .  improvement  may  be 
expected  in  most  cases. 


1122  THE  SPECIFIC  INFECTIOUS  DISEASES 

Chronic  otitis  may  be  a  result  of  tlie  acute  process  seen  in  early 
infancy.  There  is  nothing  peculiar  about  the  inflammation  in  these 
cases.  A  form  of  deafness  occurs  in  older  children,  "which  Hutchinson 
states  is  almost  invariably  due  to  syphilis.  Its  onset  is  quite  sudden, 
without  pain.  The  loss  of  hearing  is  apt  to  be  permanent,  and  if  it 
occurs  early  in  childhood  it  is  a  cause  of  deaf-mutism. 

8Jcin. — The  most  important  of  the  later  manifestations  of  syphilis 
consists  in  the  formation  of  subcutaneous  gummata.  In  the  earh-  stage 
they  are  indurated,  elastic,  of  a  grayish  color,  with  red  borders.  Under 
treatment  they  disappear  quite  rapidly  by  absorption ;  but  when  neglected 
they  break  down,  leaving  large  deep  ulcers.  These  ulcers  are  quite  char- 
acteristic in  appearance,  but  may  be  confounded  with  those  due  to  tuber- 
culosis. The  syphilitic  ulcer  has  rounded,  thickened,  indurated  borders, 
and  a  base  which  is  depressed  and  has  the  appearance  of  being  scooped 
out.  It  is  sometimes  covered  by  hard  crusts  and  is  surrounded  by  a  red 
areola.  It  leaves  a  smooth  white  scar.  The  most  frequent  situation 
is  upon  the  face  and  upper  part  of  the  legs  or  thighs.  Tuberculous 
ulcers  have  usually  soft,  flat  edges,  and  do  not  extend  so  deeply;  they 
are  more  irregular  in  outline;  the  cicatrix  left  is  of  a  purplish  color, 
which  becomes  red  and  slowly  fades;  and  tubercle  bacilli  may  be  found. 

Nose  and  Palate. — Disease  of  these  parts  generally  begins  as  the 
breaking  down  of  gummatous  deposits  in  the  mucous  membrane.  The 
nose  may  in  consequence  be  the  seat  of  a  protracted  fetid  discharge 
(ozena).  The  disease  may  take  on  a  destructive  form  of  ulceration  which 
is  at  times  phagedenic,  and  may  cause  rapid  destruction  of  the  nasal  car- 
tilages and  bones,  perforation  of  the  septum,  and  occasionally  of  the  floor 
of  the  nasal  fossae.  There  may  be  necrosis  of  the  turbinated  bones,  the 
vomer,  or  the  ethmoid.  In  the  most  severe  forms  the  nose  may  be  almost 
destroyed  in  the  course  of  a  few  weeks.  There  may  be  at  the  same  time 
deep  ulceration  of  the  soft  palate,  leading  to  perforation.  In  a  young 
person  this  is  almost  invariably  due  to  syphilis.  In  many  particulars 
these  ulcerations  of  the  nose  and  palate  resemble  lupus;  they  are  dis- 
tinguished by  the  rapidity  of  their  progress,  syphilis  often  doing  as 
much  damage  in  weeks  as  is  done  by  lupus  in  years. 

Other  Symptoms. — Syphilitic  disease  of  the  larynx  and  bronchi  is 
rare  in  childhood.  The  former  may  give  rise  to  hoarseness  or  aphonia 
and  occasionally  to  stenosis ;  the  latter  to  a  chronic  cough  and  asthmatic 
attacks.  There  are  no  characteristic  symptoms  belonging  to  syphilis 
of  the  lungs. 

The  only  visceral  changes  which  aid  much  in  diagnosis  are  those  of 
the  liver'  and  spleen.  The  liver  is  often  enlarged,  sometimes  to  a  marked 
degree,  and  occasionally  there  is  ascites,  but  very  seldom  jaundice. 

Enlargement  of  the  spleen  is  a  very  frequent  symptom — in  fact,  it  is 


HEREDITARY  SYPHILIS  1123 

almost  constant  during  active  syphilitic  disease.  It  is  occasionally  so 
swollen  as  to  form  an  abdominal  tumor  of  considerable  size.  In  one  case 
under  our  observation,  in  a  boy  three  years  old,  the  spleen  extended  five 
inches  below  the  free  border  of  the  ribs,  quite  to  the  crest  of  the  ileum. 
It  was  associated  with  moderate  enlargement  of  the  liver,  as  is  usually 
the  case. 

In  addition  to  the  local  symptoms  of  late  hereditary  syphilis  enu- 
merated, there  are  others  of  a  general  character  which  are  quite  as  im- 
portant. The  body  is  usually  undersized;  the  constitution  is  delicate, 
and  shows  but  little  resistance  to  all  forms  of  disease;  puberty  is  fre- 
quently delayed,  and  the  development  of  the  breasts  and  the  genital 
organs  often  imperfect;  anemia  is  usually  present,  and  the  skin  has  a 
sallow  appearance.  ]\Ientally,  many  of  these  children  are  somewhat  de- 
ficient. 

Syphilis  of  the  Nervous  System. — This  may  show  itself  in  a  great 
variety  of  ways.  There  may  be  a  combination  of  symptoms  giving  rise  to 
a  more  or  less  distinct  clinical  picture,  indicating  diffuse  involvement 
of  one  or  more  parts  of  the  brain  or  cord,  or  the  lesion  may  apparently 
be  limited  to  a  strikingly  small  area. 

Paralysis  of  single  nerves,  particularly  the  cranial  nerves,  is  not  un- 
common. There  may  be  only  failure  of  one  or  both  pupils  to  react  to 
light,  or  there  may  be  strabismus.  Sudden  deafness  may  occur.  There 
may  be  a  gradually  developing  optic  atrophy. 

Mention  has  been  made  of  syphilis  as  a  cause  of  hydrocephalus.  In 
our  experience  the  association  between  the  two  diseases  is  unusual,  but 
many  clinicians  with  large  experience  emphasize  the  fact  that  hydro- 
cephalus may  often  be  due  to  syphilis.  Epilepsy,  also,  may  depend, 
but  in  our  experience  very  infrequently,  upon  syphilis.  Statistics  vary 
much  as  to  the  role  of  syphilis  in  producing  feeblemindedness.  Studies 
upon  inmates  in  institutions  for  the  feebleminded  in  this  country  have 
shown  that  not  more  than  two  or  three  per  cent  have  clear  clinical  evi- 
dences of  syphilis,  while  not  more  than  ten  per  cent  without  physical 
symptoms  of  the  disease  give  a  positive  Wassermann  reaction.  This,  of 
course,  does  not  indicate  that  syphilis  is  in  the  ten  per  cent  the  cause  of 
the  feeblemindedness.  The  association  of  the  two  conditions  may  be 
merely  accidental.  It  is  probable  that  the  part  of  syphilis  in  the  produc- 
tion of  mental  deficiency  has  been  exaggerated.  Lesions  of  the  cord  due 
to  syphilis  are  distinctly  uncommon. 

Juvenile  paresis  is  occasionally  seen,  but  it  is  rare  before  the  fifth 
year.  There  is  no  doubt  of  its  dependence  upon  hereditary  syphilis.  The 
symptoms  usually  appear  shortly  before  or  about  the  time  of  puberty. 
They  are  quite  characteristic.  A  child  that  has  developed  in  a  practically 
normal  way  gradually  begins  to  lose  his  ability  to  do  certain  things. 


1124  TpE  SPECIFIC  INFECTIOUS  DISEASES 

There  is  loss  of  memory  and  a  difficulty  in  speech,  which  consists  in 
dropping  a  syllable  or  a  whole  word.  If  he  has  been  able  to  write,  the 
capacity  to  do  this  is  gradually  lost.  Eventually  speech  is  impossible  and 
the  intelligence  is  reduced  to  a  minimum.  Walking  becomes  difficult 
and  later  almost  impossible.  The  child  loses  all  sense  of  cleanliness  and 
remains  in  a  demented  condition  often  for  years  until  death  occurs  from 
inanition,  bed-sores  or  from  intercurrent  disease.  There  is  usually  loss 
of  reaction  of  the  jDupils  to  light,  irregularity  of  the  pupils,  and  often 
some  degree  of  optic  atrophy.  The  cerebrospinal  fluid  contains  an  excess 
of  cells  and  globulin  and  gives  a  strongly  positive  Wassermann  reaction. 
The  course  is  slowly  but  progressively  downwards. 

It  is  at  times  difficult  to  differentiate  from  Juvenile  paresis  a  form 
of  cerebral  syphilis,  which  in  our  experience  is  more  common  than  the 
paretic  form.  The  history  often  gives  valuable  aid,  showing  that  the 
child  has  ever  appeared  entirely  normal.  There  has  usually  been,  almost 
from  the  beginning,  some,  often  a  marked,  degree  of  mental  impairment 
and  speech  has  been  slowly  and  iiuperfectly  acquired.  .  The  .children  are 
oftentimes  restless  and  disobedient.  They  may  have  screaming  attacks. 
The  reflexes  may  be  exaggerated  or  absent.  Attacks  of  headache  and 
vertigo  with  vomiting  are  not  uncommon.  There  may  be  unequal  pupils 
or  failure  to  react  to  light.  Some  degree  of  optic  atrophy  is  generally 
present.  Hemiplegic  attacks  may  occur  in  the  course  of  the  disease  or 
they  may  appear  as  the  first  evidence  of  cerebral  involvement.  These 
attacks  may  occur  first  on  one  side  and  then  on  the  other,  and  the 
paralysis  often  improves  to  a  marked  degree,  even  without  treatment. 
With  this  form  of  cerebral  syphilis  there  is  not  the  same  tendency  to 
mental  and  physical  deterioration  as  with  paresis.  The  children  may 
live  many  years  in  about  the  same  mental  condition.  Sometimes  with 
treatment,  especially  if  it  is  begun  early,  considerable  improvement  oc- 
curs. The  cerebrospinal  fluid  shows  in  these  cases  also  an  excess  of  cells 
and  globulin  and  always  gives. a  strongly  positive  Wassermann  reaction. 
As  is  the  case  with  paresis,  it  is  exceedingly  difficult  to  diminish  the 
intensity  of  or  to  abolish  the  Wassermann  reaction  in  the  spinal  fluid  by 
antisyphilitic  treatment  of  any  kind,  no  matter  how  vigorously  given  or 
how  often  repeated. 

Tabes  may  be  found  in  childhood  as  the  result  of  hereditary  syphilis 
but  is  very  uncommon.  The  symptoms  are  similar  to  those  of  the  adult 
form  of  the  disease,  but  some  of  them  may  be  absent.  The  Argyll- 
Eobertson  pupil  is  constant,  but  the  patellar  reflexes  may  not  be  lost 
and  Eomberg's  symptom  may  not  be  marked.  Incontinence  of  urine  is 
frequent.  The  course  of  the  disease  is  exceedingly  slow.  It  may  last  for 
fifteen  or  twenty  years  or  even  more. 

Diagnosis. — The  diagnosis  of  early  syphilis  in  most  cases  is  not  diffi- 


HEREDITARY  SYPHILIS  1125 

> 

cult.     The  coryza,  eruption,  labial  fissures,  mucous  patches  about  the 

anus  and  genitals,  enlarged  spleen,  and  later  the  general  cachexia — all 
unite  to  form  a  picture  which  it  is  difficult  to  mistake.  In  irregular 
cases  the  diagnosis  is  easy  just  in  proportion  to  the  number  of  the  fore- 
going symptoms  which  are  present.  Special  care  should  be  taken  not  to 
confound  the  moist  papules  of  simple  intertrigo  upon  the  buttocks  or 
thighs  with  those  of  syphilis.  Much  assistance  may  be  obtained,  espe- 
cially in  early  cases,  from  the  discovery  of  the  spirochetae  in  the  external 
lesions.  This  is  a  means  of  diagnosis  which  is  too  seldom  employed.  In 
a  series  of  34  cases,  mostly  early  ones,  in  the  hospital  service  of  one  of 
us,  there  were  external  lesions  in  22,  in  all  but  one  of  which  the  spiro- 
chetae were  demonstrated.  The  dark  field  is  useful  but  not  essential. 
They  can  easily  be  demonstrated  by  the  India  ink  method.  The  Wasser- 
mann  reaction  has  the  same  value  as  in  adults. 

In  late  syphilis  the  following  symptoms  are  the  most  reliable  for 
diagnosis:  notching  of  the  teeth,  falling  in  of  the  bridge  of  the  nose, 
interstitial  keratitis,  deafness  not  traceable  to  ordinary  otitis,  enlarge- 
ment of  the  spleen  and  epitrochlear  glands,  ulceration  of  the  palate  or 
nose,  the  saber-like  deformity  of  the  tibia,  and  nodes  upon  the  tibia  or 
cranium.  There  are  often  found  in  older  children  indefinite  symptoms 
in  regard  to  which  a  suspicion  of  syphilis  exists.  For  such  cases  the 
Wassermann  test  is  of  very  great  value. 

It  becomes  at  times  important  to  distinguish  hereditary  from  ac- 
quired syphilis.  Visceral  lesions  in  acquired  syphilis  are  not  common 
and  belong  to  the  late  period  of  the  disease ;  in  the  hereditary  form  they 
are  well-nigh  constant  and  occur  early,  often  being  present  at  birth. 
The  acute  epiphysitis,  sometimes  accompanied  by  pseudoparalysis,  sel- 
dom if  ever  occurs  in  acquired  syphilis,  though  frequent  in  the  hereditary 
form.  Symptoms  due  to  defects  in  development,  like  the  misshapen  fin- 
ger-nails, are  seen  only  in  hereditary  syphilis.  The  early  symptoms  ref- 
erable to  the  mucous  membranes  and  mucocutaneous  surfaces — coryza, 
hoarseness,  hemorrhages,  labial  fissures,  etc.— so  characteristic  of  he- 
reditary syphilis,  have  no  place  in  the  acquired  form,  while  the  single 
primary  lesion  sometimes  found  in  the  acquired  form  does  not  exist  in 
the  hereditary  disease. 

The  value  of  Noguchi's  cutaneous  "luetin"  test  has  not  yet  been  finally 
settled.    Considerable  experience  is  needed  to  interpret  results. 

Prognosis. — Generally  speaking,  the  prognosis  is  worse  in  infantile 
syphilis  than  in  that  of  adults.  In  infancy  it  is  much  worse  when  hered- 
itary than  when  acquired,  for  the  reason  that  often  the  child  Avho  is  the 
subject  of  hereditary  syphilis  has  been  affected  by  the  poison  from  the 
very  beginning  of  his  existence,, and  this  has  modified  his  entire  de- 
velopment. 


1126  THE  SPECIFIC  IXFECTIOUS  DISEASES 

The  results  of  206  syphilitic  pregnancies  observed  by  Jiilien  (Paris) 
were  as  follows:  abortion  occnrred  in  36,  stillbirths  in  8,  and  69  chil- 
dren died  soon  after  birth,  making  a  total  mortality  of  55  per  cent; 
50  were  living  and  syphilitic;  only  43  living  and  in  good  health.  Still 
worse  were  the  results  in  cases  observed  by  Le  Pilenr :  of  154  pregnancies 
in  syphilitic  women,  there  were  120  abortions  or  stillbirths,  26  children 
died  soon  after  birth,  and  only  8  survived.  The  statistics  of  the  Found- 
ling Asylum  in  Moscow  for  ten  years  showed  that  of  2,038  syphilitic  in- 
fants the  mortality  was  over  70  per  cent. 

Such  a  mortality  as  that  indicated  in  the  above  statistics  is  seen  only 
in  institutions  where  little  or  no  previous  treatment  has  been  employed. 
In  private  practice  certainly  nothing  approaching  it  occurs. 

In  addition  to  those  who  die  early  as  the  result  of  syphilitic  infection, 
there  must  be  added  many  whose  constitutions  are  so  impaired  by  syphilis 
that  they  fall  an  easy  prey  in  infancy  to  pneumonia,  diarrhea,  or  other 
forms  of  acute  disease.  The  remote  etfects  of  syphilis  in  infancy  it  is 
hard  to  estimate ;  it  may  exert  an  injurious  influence  upon  the  constitu- 
tion in  childhood  and  even  throughout  the  life  of  the  individual. 

The  prognosis  in  an  individual  case  depends  upon  the  age  at  which 
the  symptoms  develop,  the  time  when  treatment  is  begun,  upon  its  thor- 
oughness, and  upon  the  surroundings  and  mode  of  nourishment  of  the 
child.  The  outlook  is  better  the  longer  after  birth  the  first  symptoms 
appear;  it  is  also  very  much  better  in  infants  who  are  nursed  than  in 
those  who  are  artificially  fed. 

As  compared  with  syphilis  of  the  adult,  relapses  are  less  frequent, 
and  when  they  occur  early  they  are  nearly  always  the  result  of  insufficient 
treatment.  If  proper  treatment  is  carried  out,  these  severe  late  symptoms 
are  not  common ;  patients  are  usually  free  from  all  symptoms  until  six  or 
seven  years  old,  or  until  near  the  time  of  puberty — two  periods  when  they 
are  likely  to  develop.  We  must  conclude  that  treatment  persisted  in 
only  for  a  short  time  and  not  energetic  enough  to  influence  in  any  way 
the  Wassermann  reaction  has,  nevertheless,  a  great  influence  in  prevent- 
ing the  further  ravages  of  the  disease.  We  have  observed  children  after 
an  interval  of  several  years  that  had  been  treated  in  this  unsatisfactory 
way  and  could  find  no  evidence  of  the  disease  but  a  positive  Wassermann 
reaction.  It  is  a  fact  also  that  most  of  the  patients  that  apply  for  treat- 
ment for  late  hereditary  syphilis  have  never  received  any  treatment. 

The  prognosis  is  better  in  the  later  children  of  syphilitic  parents  than 
in  the  earlier  ones,  provided  infection  has  preceded  the  birth  of  all  the 
children.  This  fact  illustrates  the  general  tendency  of  the  sj^philitic 
poison  to  diminish  in  virulence  as  time  passes,  even  without  treatment. 
The  following  Instance  cited  by  Bertin  well  illustrates  this  point : 

In  the  first  pregnancy,  the  mother  aborted  with  a  dead  child  at  the 


HEREDITARY  SYPHILIS  1127 

sixth  month ;  in  the  second,  at  the  seventh  month ;  in  the  third,  at  seven 
and  a  half  months ;  in  the  fourth  the  child  was  born  at  term,  and  lived 
eighteen  days ;  in  the  fifth  it  lived  six  weeks ;  in  the  sixth  the  child  lived 
four  months,  without  treatment. 

The  prognosis  of  syphilis  of  the  nervous  system  should  be  considered 
by  itself.  Certain  of  the  manifestations,  such  as  localized  paralyses,  may 
yield  promptly  to  treatment.  It  is  also  reported  that  many  cases  of 
syphilitic  epilepsy  and  hydrocephalus  have  been  greatly  improved  or 
cured.  Gummatous  lesions  usually  disappear  promptly  with  appropriate 
treatment  as  in  acquired  syphilis.  But  the  lesions  of  the  nervous  system 
are  usually  the  result  of  arterial  disease  or  of  meningitis  and  encephalitis. 
These  are  very  little  influenced  by  treatm^ent.  In  cases  of  diffuse  involve- 
ment of  the  brain  and  in  juvenile  paresis,  we  have  not  seen  lasting  benefit 
from  even  the  most  energetic  and  long-continued  treatment  with  salvarsan 
or  with  mercury  and  iodids. 

Prophylaxis. — No  infected  person  should  be  allowed  to  marry  until 
at  least  two  years  have  passed  after  the  initial  sore,  treatment  being  con- 
tinued meanwhile;  nor  if  there  are  any  active  symptoms,  no  matter  how 
long  a  time  has  elapsed  since  infection,  nor  if  the  Wassermann  reaction  is 
positive. 

The  mother  should  be  treated  during  her  pregnancy:  (1)  If  she  is 
syphilitic,  whether  the  disease  was  acquired  at  the  time  of  conception 
or  subsequently;  (2)  if  the  father  is  known  to  be  suffering  from  syphilis, 
whether  the  mother  has  symptoms  or  not;  (3)  if  the  mother  has  ever 
previously  shown  signs  of  syphilis,  even  if  she  has  had  no  active  symptoms 
for  a  considerable  period.  In  all  these  conditions  if  efficient  treatment  is 
carried  on  throughout  pregnancy  there  is  a  strong  probability,  but  in  no 
case  a  certainty,  that  the  child  will  escape.  The  third  condition  men- 
tioned is  the  one  in  which  treatment  is  most  likely  to  be  neglected, 
especially  if  the  mother  has  previously  borne  a  child  who  was  not 
syphilitic.  Syphilis,  however,  shows  a  strong  tendency  to  reappear  and 
become  active  during  pregnancy,  even  though  it  has  been  long  quiescent, 
as   the   following  case   cited  by   Diday  shows: 

A  woman  who  had  lost  seven  children  from  syphilis  was  put  under 
treatment  during  the  eighth  pregnancy;  result — child  born  healthy,  and 
continued  so.  In  the  ninth  pregnancy  treatment  was  continued  with  a 
like  result ;  in  the  tenth  pregnancy,  no  treatment,  child  syphilitic,  dying 
when  six  months  old;  in  the  eleventh  pregnancy,  treatment  repeated, 
child  healthy. 

The  danger  of  infection  during  labor  is  slight.  As  the  greatest 
danger  of  infecting  a  child  after  birth  is  from  his  parents  or  a  wet-nurse, 
syphilitic  parents  should  be  duly  warned  of  the  danger  to  their  children, 
and  especially  should  be  cautioned  against  kissing  them  or  sleeping  in 


1128  THE  SPECIFIC  INFECTIOUS  DISEASES 

the  same  bed  with  them.  The  utmost  care  should  be  exercised  to  pre- 
vent a  healthy  child  from  being  infected  by  a  syphilitic  nurse.  A  nurse 
should  never  be  accepted  without  a  thorough  physical  examination,  no 
matter  how  clear  a  history  may  be  given.  As  a  syphilitic  child, in  the 
household  may  be  the  means  of  infecting  other  children,  the  same  precau- 
tions should  be  taken  as  in  the  case  of  other  contagious  diseases.  The 
chief  danger  to  other  children  comes  from  kissing  or  from  using  bottles, 
spoons,  or  cups  which  have  been  infected;  as  the  syphilitic  infant  is 
chiefly  dangerous  on  account  of  the  lesions  in  the  mouth.  Trouble  most 
frequently  occurs  because  of  ignorance  regarding  the  nature  of  the  dis- 
ease. It  is  possible  for  a  syphilitic  child  to  nurse  a  healthy  woman 
without  communicating  syphilis,  if  the  child's  mouth  contains  no  lesions 
and  the  nipple  not  allowed  to  become  fissured;  but  it  is  an  experiment 
which  should  never  be  tried. 

Treatment. — This  should  always  be  begun  as  soon  as  the  first  posi- 
tive symptoms  of  syphilis  appear.  In  certain  circumstances  it  may  be 
advisable  not  to  wait  for  symptoms;  as,  for  example,  when  both  parents, 
have  recently  suffered  from  active  symptoms,  when  previous  children 
have  died  soon  after  birth,  or  when,  with  marked  symptoms  in  the  par- 
ents, the  child  exhibits  the  cachexia  of  syphilis,  but  no  definite  local 
symptoms.  Such  anticipatory  treatment  need  not  be  continued  after  a 
negative  Wassermann  reaction  is  obtained.  It  sliould  be  remembered, 
however,  that  even  a  syphilitic  infant  may  give  a  negative  Wassermann 
reaction  for  the  first  two  or  three  weeks  of  life. 

The  indirect  treatment,  designed  to  reach  the  child  through  the 
mother's  milk,  has  fallen  into  deserved  disuse,  as  it  is  very  uncertain 
and  altogether  unsatisfactory. 

The  two  drugs  most  useful  in  treatment  are  mercury  and  salvarsan. 
Mercury  is  as  much  a  specific  for  hereditary  as  for  acquired  syphilis. 
There  are  many  ways  of  introducing  it  into  the  system — by  inunctions, 
by  mouth,  by  fumigations,  baths,  or  hypodermically.  In  most  cases,  in- 
unction is  the  manner  to  be  preferred  with  children.  Mercurial  ointment 
in  doses  of  from  ten  to  twenty  grains,  depending  upon  the  size  of  the 
child,  diluted  with  an  equal  amount  of  vaseline  may  be  rubbed  into  the 
abdomen,  axillae,  or  the  inner  surface  of  the  thighs.  It  is  advisable  to 
change  the  place  of  inunction  from  time  to  time  and  if  this  is  done  it  is 
extremely  rare  that  erythema  is  produced.  It  may  advantageously  be 
placed,  with  small  infants,  upon  the  inner  surface  of  an  abdominal  binder. 
If  for  any  reason  inunctions  are  objectionable,  as  they  may  be  when  the 
family  are  to  be  kept  in  ignorance,  either  the  gray  powder  or  the  bichlorid 
may  be  given  by  mouth.  The  usual  dose  of  the  gray  powder  is  gr.  Yz, 
three  times  a  day,  and  that  of  the  bichlorid,  gr.  1-60  three  times  a  day, 
always  well  diluted.    It  is  rare  that  larger  doses  are  advisable.     Calomel 


HEEEDITARY  SYPHILIS  1129 

in  doses  of  1-10  gr.  four  times  a  day  is  oftentimes  a  rapid  method  of 
bringing  the  system  under  the  influence  of  m.ercury.  Other  methods  of 
administration  and  other  preparations  offer  no  advantages  and  have 
some  very  obvious  disadvantages.  The  duration  of  mereuriar treatment 
should  be  at  least  one  year.  The  doses  during  the  last  six  months  may 
be  reduced  to  one  half  or  one  third  of  those  employed  while  active  symp- 
toms were  present.  It  is  well  to  repeat  two  or  three  months  of  mercurial 
treatment  during  the  second  and  third  years,  even  if  no  symptoms  are 
present.  Treatment  should  always  be  employed  longer  than  a  year  if 
symptoms  exist.  It  is  often  better  not  to  give  the  mercury  continuously, 
but  with  short  periods  of  intermission. 

Salvarsan  is  quite  as  efficacious  in  infants  as  in  older  patients.  Single 
doses  of  salvarsan  do  not  cure  syphilis  and  several  doses  may  not  do  so. 
A  repetition  is  always  necessary  and  the  best  results  are  obtained  when 
salvarsan  is  combined  with  the  mercurial  treatment.  In  such  circum- 
stances, it  is  wise  to  omit  the  mercury  for  a  few  days  before  and  after 
the  injection  of  salvarsan.  The  intravenous  method  of  administration 
of  salvarsan  is  altogether  to  be  preferred  on  account  of  its  irritating 
effects  when  injected  into  the  tissues.  The  usual  dose  is  .05  gram  for 
very  young  infants  and  0.1  gram  for  those  who  are  five  or  six  months 
old.  More  exactly  it  may  be  calculated  as  0.01  gram  for  each  kilogram 
(.005  per  pound)  of  body  weight.  With  infants,  the  injection  may  be 
made  into  a  vein  of  the  scalp  or  the  external  jugular  vein.  ISTo  dissec- 
tion is  necessary  but  care  should  be  taken  that  none  of  the  injected  fluid 
is  allowed  to  escape  into  the  surrounding  tissue,  otherwise  sloughing 
may  result.  Neosalvarsan  has  the  advantages  of  being  more  readily 
prepared,  much  less  irritating  in  its  effect  and  consequently  much  less 
likely  to  cause  necrosis  if  any  escapes  into  the  tissues.  It  is,  how- 
ever, less  active  and  the  dose  should  be  one  and  one-half  times  that  of 
salvarsan.  The  usual  doses  of  neosalvarsan  required  by  infants  are 
readily  given  in  5  c.e.  of  freshly  distilled  water.  The  intravenous  use 
of  this  preparation  is  greatly  to  be  preferred.  If,  however,  for  any 
reason  this  is  not  practicable,  neosalvarsan  may  be  given  intramuscularly, 
dissolved  in  some  bland  oil  such  as  benzoinol.  Salvarsan  should  not  be  so 
given. 

Injections  of  salvarsan  should  not  be  made  more  frequently  than 
once  in  two  weeks,  usually  repeated  four  or  five  times  and  controlled  by 
the  Wassermann  reaction.  It  is  uncommon  for  a  negative  reaction  to  be 
obtained  after  less  than  three  injections ;  we  have  used  as  many  as  eight 
and  have  found  at  times  the  reaction  persistently  positive. 

The  iodid  of  potassium  may  be  used  in  combination  with  mercury 
whenever  such  lesions  exist  as  are  classed  among  adults  as  tertiary.  This 
includes  all  the  late  manifestations  and  the  earlier  ones  whenever  the 


1130  THE  SPECIFIC  INFECTIOUS  DISEASES 

bones  or  viscera  are  affected.  The  iodid  is  iisiiall}^  Avell  borne  by  chil- 
dren and  may  be  given  in  almost  any  desired  dosage.  In  infancy,  not 
more  than  gr.  xx  daily  are  required,  but  in  older  children  one  or  two 
drams  daily  ma}'  be  given,  always  largely  diluted^ 

Syphilis  of  the  nervous  system  is  often  but  slightly  affected  by 
treatment,  as  has  been  mentioned  previously.  The  symptoms  of  sharply 
localized  disease,  including  the  gummatous  lesions,  are  usually  promptly 
affected,  but  diffuse  cerebrospinal  syi^hilis,  including  paresis  and  tabes,  is 
hardly  benefited  at  all.  The  AYassermann  reaction  in  the  blood  may  some- 
times be  made  negative,  but  the  Wassermann  reaction  of  the  cerebro- 
spinal fluid  remains  positive  and  the  symptoms  are  in  almost  all  in- 
stances entirely  unaffected. 

The  general  treatment  of  syphilis  is  important  and  should  not  be 
neglected.  After  specific  treatment  has*  been  carried  oh  for  a  time, 
particularly  if  rapidly  pushed,  the  child  often  becomes  anemic  and 
suffers  greatly  from  malnutrition.  In  such  circumstances,  it  is  usu- 
ally wise  to  discontinue  mercury  altogether  for  a  time,  or  at  least  to 
reduce  the  dose  very  much.  Such  a  change  is  frequently  found  to  act 
most  beneficially. 

Local  Treatment. — Ulcerative  lesions  of  the  skin  require  cleanliness, 
dusting  with  calomel  or  iodoform,  or  bathing  with  the  black  wash. 
Mucous  patches  should  be  dusted  with  equal  parts  of  calomel  and  bis- 
muth. Fissures  and  ulcers  of  the  mucous  membranes  should  be  treated 
by  nitrate  of  silver.  Phagedenic  ulcers  of  the  palate  or  nose  should 
be  cauterized  with  nitric  acid  or  the  acid  nitrate  of  mercury.  The  late 
syphilitic  ulcers  of  the  skin,  due  to  the  breaking  down  of  gummata, 
should  be  treated  aseptically. 


CHAPTEE    XII 
INFLUENZA 

In  1892  a  bacillus  was  described  by  Pfeiffer  which  he  believed  to  be 
the  cause  of  epidemic  influenza  or  what  is  commonly  known  as  the  grippe. 
It  seems  evident  by  the  studies  of  the  last  half  dozen  years  that  this  or- 
ganism is  not  the  cause  of  the  grippe,  although  it  is  a  pathogenic  organ- 
ism of  considerable  importance  in  respiratory  diseases,  and  is  associated 
with  a  pretty  definite  group  of  clinical  symptoms.  In  this  chapter  we 
shall  include  under  the  term  Influenza  only  the  disease  or  diseases  due 
to  Pfeiffer's  bacillus. 

Etiology. — Pfeiffer's  bacillus,  or  the  influenza  bacillus  as  it  is  known 


INFLUENZA  1131 

in  literature,  is  chiefly  found  in  the  secretions  of  the  lower  respiratory 
tract ;  less  often  in  those  of  the  upper  tract — the  rhinopharynx  and  dis- 
charges from  the  ears.  As  it  usually  occurs,  it  has  been  shown  by  Woll- 
stein  to  be  an  organism  of  low  virulence.  It  prodiices  few  immune 
bodies  and  consequently  complement  fixation  cannot  be  demonstrated  in 
the  serum  of  these  patients.  It  does  not  agglutinate  except  in  very  low 
dilutions.  No  immunity  is  developed  from  such  attacks  and  hence  pa- 
tients are  continually  liable  to  recurrent  influenza  infection.  Like  the 
pneumococcus,  Pfeiffer's  bacillus  may  be  present  in  the  respiratory  secre- 
tions without  producing  any  symptoms  whatever.  It  may  be  of  no  sig- 
nificance. At  times  very  virulent  strains  of  the  infiuenza  bacillus  are  met 
with.  These  produce  antibodies  and  cause  ^immunity;  but  unfortunately 
because  of  their  virulence  the  patient  is  likely  to  be  overpowered  before 
this  has  occurred.  The  organism  may  quickly  find  its  way  from  the  res- 
piratory tract  into  the  blood  stream,  producing  an  -intense  septicemia  and 
leading  to  the  development  of  a  severe  form  of  pneumonig,,  to  cerebro- 
spinal meningitis,  and  rarely  to  inflammation  of  the  large  joints.  Pfeif- 
fer's bacillus  belongs  to  the  hemoglobinophilic  group,  growing  only  on  a 
medium  containing  hemoglobin.  It  can  be  demonstrated  in  the  sputum 
with  certainty  only  by  cultivation,  smears  being  entirely  unsatisfactory. 
In  acute  cases  it  may  disappear  very  early;  but  in  protracted  cases  its 
presence  can  often  be  demonstrated  for  weeks  or  even  months.  In  the 
respiratory  inflammations  in  which  the  organism  occurs,  although  it  may 
be  found  in  pure  culture,  it  is  usually  associated  with  the  pneumococcus  or 
the  staphylococcus  aureus,  less  frequently  with  the  streptococcus.  In  rou- 
tine cultures  made  from  the  sputum  in  acute  respiratory  infections  in 
the  winter  and  spring  in  the  Babies'  Hospital  during  a  period  of  six  years 
the  influenza  bacillus  was  found  in  different  years  in  from  28  to  43  per 
cent  of  the  cases. 

Influenza  may  be  ranked  among  moderately  contagious  diseases.  It 
is  rather  more  communicable  than  pneumococcus  infections,  but  much 
less  so  than  epidemic  catarrh  or  the  grippe.  The  influenza  bacillus  is 
regularly  found  in  New  York  in  the  cold  season,  beginning  early  in 
November,  but  most  years  is  not  frequently  found  till  after  January.  It 
usually  disappears  completely  about  the  end  of  May  with  the  advent  of 
very  warm  weather.  Its  prevalence  in  the  winter  and  spring  of  some 
seasons  is  so  great  that  it  may  often  be  said  to  be  epidemic.  All  ages 
are  liable  to  the  disease,  infants  especially  so. 

Lesions. — The  influenza  bacillus  is  much  less  frequently  associated 
with  the  inflammations  of  the  upper  than  the  lower  respiratory  tract.  It 
is  found  in  comparatively  few  of  the  cases  of  acute  rhinopharyngitis,  in 
the  severe  inflammations  which  invade  the  antrum,  the  frontal  or  ethmoi- 
dal sinus  or  the  middle  ear.    It  is  much  more  frequently  associated  with 


1132 


THE  SPECIFIC  IXFECTIOUS  DISEASES 


iiijflammations  of  the  trachea,  bronchi,  and  lungs.  There  are  no  charac- 
teristic lesions  of  influenza.  Those  found  in  the  respiratory  tract  differ 
little  from  the  same  inflammations  when  due  to  Qther  organisms.  The 
pneumonia  is  nearly  always  of  the  bronchopneumeiiia  type.  In  certain 
cases  resolution  is  much  delayed  or  is  incomplete  and  the  inflammation 
may  then  develop  into  a  chronic  interstitial  type  which  may  continue 
indefinitely,  with  the  later  development  of  fibrosis  in  the  lung  of  con- 
siderable extent  with  bronchiectasis,  etc. 


Pig.  195. — TEMPEEATtrEE  Chaet  of  Uncomplicated  Influenza.  Infant  fourteen 
months  old.  No  local  signs  of  disease;  repeated  blood  examinations  for  malaria 
negative;  the  wide  fluctuations  of  the  temperature  independent  of  therapeutic  meas- 
ures.    Prompt  cessation  of  fever  on  removal  from  the  city. 


Symptoms. — The  symptoms  of  influenza  are  in  part  due  to  the  gen- 
eral infection  and  in  part  to  the  local  inflammations  which  are  excited. 
These  may  be  regarded  either  in  the  light  of  manifestations  or  possibly 
as  complications.  The  clinical  manifestations  of  influenza  are  numerous 
and  often  exceedingly  puzzling  in  diagnosis.  Those  most  frequently  met 
with  are  the  following: 

1.  There  may  be  only  symptoms  of  a  general  infection  of  moderate 
severity,  often  with  a  high  temperature  but  with  few  or  no  respiratory 
symptoms. 

2.  There  are  cases  with  symptoms  of  niild  respiratory  infections — ■ 
bronchitis,  otitis,  etc. — or  others  with  severe  bronchitis  or  bronchopneu- 


INFLUENZA 


1133 


monia  which,  present  little  unusual  in  their  symptoms  except  quite  ex- 
traordinary fluctuations  of  temperature. 

3.  A  protracted  form  of  bronchopneumonia  or  recurring  attacks  of 
acute  bronchopneumonia  with  incomplete  resolution,  often  mistaken  for 
tuberculosis. 

4.  A  protracted  mild  respiratory  catarrh  with  little  fever  but  with 
a  paroxysmal  cough  which  is  almost  indistinguishable  from  whooping- 
cough. 

5.  An  especially  severe  form  of  infection  with  general  blood  infec- 
tion often  terminating  in  meningitis. 

The  chart  (Fig.  195)  well  illus- 
trates the  first  group  of  cases.  There 
are  often  no  local  symptoms  of  im- 
portance to  be  found  on  the  most 
careful  examination;  there  is  a  high 
and  widely-fluctuating  temperature 
which  is  quite  out  of  proportion  to 
the  other  symptoms.  The  child  does 
not  appear  to  be  seriously  ill,  yet  the 
height  of  the  temperature  and  its 
wide  fluctuations  are  most  alarming. 
Sometimes  at  the  height  of  the  fever 
there  may  be  marked  nervous  symp- 
toms —  irritability,  hj^peresthesia, 
rigidity,  stupor,  etc.,  strongly  sug- 
gestive of  cerebrospinal  meningitis; 
but  with  the  fall  in  the  temperature 
all  these  symptoms  pass  off  in  a  few 
hours.  In  most  of  the  cases  the 
only  symptoms  present  are  such  as 

accompany  high  temperature  from  any  cause.  In  some  there  is  an  acute 
erythematous  blush  of  the  fauces  and  in  many  there  is  a  slight  cough. 
Often  such  a  temperature  as  that  shown  in  the  chart  may  continue  for 
several  days,  subside  without  treatment,  and  all  symptoms  recur  after 
an  interval  of  a  few  days  or  one  or  two  weeks;  finally  a  small  area  of 
j)neumonia  may  be  discovered,  or  perhaps  otitis  may  develop  as  a  later 
complication.  The  improvement  in  symptoms  by  change  in  climate  is 
sometimes  most  surprising  and  occasionally  an  equally  abrupt  ending  of 
the  attack  may  occur  without  it.  More  frequently,  however,  tl^e  symp- 
toms subside  gradually.  Malaria  or  some  hidden  focus  of  suppuration  are 
most  frequently  diagnosticated. 

The  cases  of  pneumonia  associated  with  influenza  are  sometimes  of 
such  brief  duration  as  to  be  classed  as  abortive  (Fig.  196).     The  attack 


DAY 

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102° 
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98° 

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Fig.  196. — Acute  Bronchopneumonia, 
Abortive  Type,  Complicating  In- 
fluenza IN  an  Infant  Six  Months 
Old.  The  entire  left  lung  posteriorly 
was  involved. 


1134 


THE  SPECIFIC  INFECTIOUS  DISEASES 


begins  like  au  ordinary  pneumonia  of  perhaps  more  than  usual  severity; 
but  after  two  or  three  days,  generally  before  signs  of  complete  consolida- 
tion have  appeared,  a  rapid  subsidence  of  symj^toms  and  signs  takes  place 
with  a  speedy  convalescence.  In  other  casesi  of  pneumonia  more  often 
seen  the  physical  signs  and  general  symptoms  do  not  differ  essentially 
from  those  of  an  ordinary  pneumonia,  but  the  temperature  shows  the 
same  tendency  to  high  and  irregular  fluctuations  without  evident  reason, 
similar  to  those  seen  in  the  first  group  considered  (see  Fig.  62,  Chapter 
on  Pneumonia). 

Influenza  complicated  by  otitis  often  presents  a  most  difficult  problem 
in  diagnosis.     The  early  part  of  the  attack  may  be  with  general  svmp- 


DAY 

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2 

3 

4 

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8 

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12 

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17 

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23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

34 

35 

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105° 
104° 
103° 
102° 
101° 
100° 
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— 

Fig.  197. — Influenza-bronchitis;  Double  Otitis;  Late  Bronchopneumonia;  Au- 
topsy. Infant,  nine  months  old,  admitted  with  influenza-bronchitis;  double  para- 
centesis fourth  day,  repeated  on  tenth  day;  the  left  ear  opened  again  on  twelfth  and 
twenty-fourth  days.  The  only  signs  in  the  chest  were  those  of  bronchitis  until  the 
eighteenth  day,  then  bronchopneumonia  which  persisted  until  death.  On  account 
of  the  wide  fluctuations  in  temperature  from  the  eighth  to  the  eighteenth  day,  mas- 
toiditis and  sinus  thrombosis  suspected.  Operation  not  permitted,  partly  because 
of  the  child's  poor  condition,  but  chiefly  because  the  bacillus  influenzae  was  con- 
stantly present  in  the  bronchial  secretion  and  this  was  regarded  as  a  sufficient  ex- 
planation of  the  temperature.  Autopsy. — Moderate  bronchopneumonia;  cultuies 
from  the  lungs  showed  the  influenza  bacillus  and  pneumococcus.  Careful  examina- 
tion of  the  mastoid  and  sinus  showed  no  trace  of  disease. 


toms  which  are  not  particularly  characteristic.  Otitis  develops  after  a 
time  as  a  complication;  the  ears  are  opened,  the  temperature  does  not 
subside,  however,  but  assumes  the  widely  fluctuating  character  seen  in 
many  cases  of  influenza.  It  is  often  assumed  that  the  continuance  of  the 
temperature  is  due  to  some  grave  condition  associated  with  the  otitis 
— mastoiditis,  sinus  thrombosis,  etc. — and  serious  operations  have  often 
been  performed  in  these  circumstances;  whereas  the  fever  was  simply 
a  manifestation  of  the  general  influenza  infection  upon  which  the  para- 
centesis has  of  course  had  no  effect  (Fig.  197).  Intercurrent  attacks 
of  influenza  occurring  in  surgical  cases  with  few  or  no  respiratory  symp- 
toms may  also  be  very  puzzling. 

The  most  characteristic  forms  of  pneumonia  accompanying  influenza 
are  the  cases  which  in  the  early  part  of  the  attack  may  show  little  that 


INFLUENZA    '  1135 

is  untisual  except  the  very  irregular  temperature  curve.  The  signs  are 
like  those  of  ordinary  bronchopneumonia,  often  with  a  lobar  type  of  con- 
solidation. The  course  is  a  very  protracted  one.  The  signs  clear  up  very 
slowly  and  imperfectly.  The  children  get  better,  but  they  do  not  get 
well.  One  attack  often  succeeds  another,  separated  sometimes  by  an 
interval  of  only  a  few  days,  and  sometimes  of  several  weeks,  and  so  a 
patient  may  go  on  for  the  greater  part  of  a  season.  Tuberculosis  is 
usually  suspected,  and  no  doubt  it  is  frequently  the  explanation  of  similar 
symptoms.  But  we  see  many  cases  which  are  not  tuberculous;  the  von 
Pirquet  test  is  negative  and  tubercle  bacilli  are  not  found  in  the  spu- 
tum, but  the  influenza  bacillus  is  often  regularly  found  for  months. 
The  persistence  of  the  organism  in  the  lungs  and  smaller  bronchi  is  ex- 
ceeded only  by  that  of  the  tubercle  bacillus.  Many  of  these  cases  re- 
cover slowly  and  recover  completely  so  far  as  can  be  determined  clinically. 
There  are  some,  however,  which  go  on  to  chronic  interstitial  pneumonia 
and  a  few  which  develop  bronchiectasis. 

Influenza  may  be  accompanied  by  a  paroxysmal  cough  which  is  hard 
to  distinguish  from  pertussis.  There  is  a  mild  degree  of  laryngotracheitis 
or  tracheobronchitis  with  few  constitutional  symptoms.  Such  a  cough  we 
have  seen  continue  for  from  four  to -six  weeks  with  paroxysms  so  severe 
as  to  excite  vomiting.  We  have  observed  it  in  families  of  children  who 
had  previously  had  pertussis.  Bordet's  bacillus  could  not  be  discovered  in 
the  sputum  but  the  influenza  bacillus  was  present.  There  was  no  lympho- 
cytosis but  only  a  moderate  polymorphonuclear  leucocytosis.  We  believe 
.that  many  of  the  reported  instances  of  second  attacks  of  pertussis  are 
of  this  nature. 

The  very  virulent  forms  of  influenza  are  not  common.  It  is  usually 
only  on  account  of  the  pulmonary  complications  that  the  attacks  are 
serious.  Every  now  and  then,  however,  one  encounters  the  especially 
severe  type.  The  early  symptoms  often  are  not  grave  and  for  two  or 
three  days  the  patient's  condition  may  excite  no  apprehension,  when 
there  develops,  often  quite  rapidly,  a  state  of  profound  general  septice- 
mia with  great  prostration  and  a  severe  pneumonia ;  or  there  are  seen 
(Convulsions,  drowsiness  and  stupor,-  hyperesthesia  and  rigidity;  in  short 
the  symptoms  of  an  acute  meningitis  which  in  our  experience  has  been 
invariably  fatal.  The  blood  cultures  in  these  cases  regularly  show  the 
presence  of  the  influenza  bacillus. 

Suppuration  in  the  large  joints  we  have  in  a  few  instances  seen  in 
influenza,  in  which  this  organism  was  found  in  the  pus  in  pure  culture. 
Usually  this  occurs  as  a  late  symptom.  We  have  in  one  case  seen  it  as 
the  first  definite  local  symptom.  A  boy  of  eight  months  after  five  days 
of  general  febrile  symptoms  developed  swelling  of  an  elbow  and  ankle. 
When  first  seen  one  week  later  there  was  general  prostration,  and  the  in- 


1136  THE  SPECIFIC  INFECTIOUS  DISEASES 

fluenza  bacillus  was  grown  from  pus  aspirated  from  both  joints.  The  fol- 
lowing day  convulsions  occurred  and  the  cerebrospinal  fluid  was  turbid 
and  contained  the  same  organism.  It  was  also  found  in  the  blood  culture. 
Death  from  meningitis  occurred  three  days  later  and  at  autopsy  the 
influenza  bacillus  was  obtained  from  brain,  lungs,  and  blood.  This 
proved  to  be  one  of  the  most  virulent  strains  of  the  influenza  bacillus 
ever  tested  in  the  hospital  laboratory.  ~^ 

The  influenza  bacillus  is  associated  chiefly  with  inflammations  of- 
the  lower  respiratory  tract;  in  which  respect  it  closely  resembles  the 
pneumococcus.  The  two  organisms  are  often  associated  in  inflamma- 
tions of  the  lungs  and  l)rohchi.  It  has  also  the  same  tendency  as  the 
pneumococcus  when  in  virulent  form  to  excite  a  general  septicemia, 
cerebrospinal  meningitis  and  occasionally  joint  suppuration.  It  differs 
from  it  in  being  much  less  frequently  associated  with  inflammations  of 
the  upper  respiratory  tract,  and  in  occurring  almost  solely  in  the  cold 
season,  while  pneumococcus  infections  prevail  throughout  the  entire 
year. 

Gastro-intestinal  symptoms  associated  with  the  influenza  bacillus  we 
have  not  seen  other  than  those  that  may  occur  with  any  form  of  acute 
febrile  illness. 

Complications  and  Sequelae. — The  most  frequent  complications  are 
bronchitis,  pneumonia,  otitis,  and  adenitis.  In  most  of  the  cases  with 
high  temperature  the  urine  contains  albumin,  and  acute  nephritis  is  oc- 
casionally seen.  We  have  seen  three  cases  of  hemorrhagic  ne]3hritis  in  a 
single  season.  All  recovered  promptly.  In  one  case  the  influenza  bacillus 
was  obtained  from  the  urine  by  culture.  One  of  the  most  frequent 
sequelae  is  anemia;  this  may  be  severe.  Following  the  inflammation 
of  the  mucous  membranes,  there  may  be  chronic  enlargement  of  the 
cervical  lymph  glands.  Attacks  of  influenza  bear  the  same  relation  to 
the  development  of  tuberculosis  as  do  those  of  .measles. 

Convalescence  after  influenza  is  often  very  slow,  and  it  may  be  months 
before  the  full  effects  of  a  severe  attack  have  disappeared.  For  a  long 
time  the  mucous  membranes  are  in  an  extremely  sensitive  condition. 
Eelapses  are  often  brought  about  by  slight  exposure  before  the  symptoms 
have  quite  disappeared. 

Diagnosis. — The  ordinary  head  colds  even  when  severe  and  epidemic 
are  very  rarely  due  to  influenza  infection.  The  features  which  distinguish 
influenza  infections  of  the  respiratory  tract  from  those  due  to  other  causes 
are,  the  peculiar  range  of  temperature,  the  tendency  to  chronicity,  to  re- 
lapses, and  to  recurrences.  A  very  'high  and  widely-fluctuating  tempera- 
ture accompanied  by  few  constitutional  symijtoms  in  the  winter  season  is 
always  suggestive.  Influenza  can  be  diagnosticated  with  certainty  only 
by  cultures  which  should  be  made  upon  blood  agar.     These  should  be 


INFLUENZA  1137 

made  from  the  bronchial  secretion  which  is  obtained  as  in  cases  of 
tuberculosis  (q.  v.).  Cultures  from  the  pharyngeal  secretion  are  not  to 
be  depended  upon.  It  is  somewhat  difficult  to  obtain  the  organism  from 
the  bronchial  secretion  and  repeated  examinations  are  usually  necessary. 
In  some  typical  cases  we  have  been  unable  to  find  it  at  all  during  life, 
though  it  was  found  in  the  lungs  at  autopsy.  Influenza  may  be  con- 
founded with  malaria  or  cerebrospinal  meningitis;  from  both  of  these 
it  is  distinguished  by  the  methods  of  diagnosis  used  to  identify  these  dis- 
eases. In  the  absence  of  cultures  the  diagnosis  in  many  cases  must  be 
made  by  exclusion. 

Prognosis. — Uncomplicated  cases  are  seldom  fatal,  even  in  infants. 
Though  the  temperature  is  very  high,  recovery  may  be  predicted  as  long 
as  there  is  no  evidence  of  important  complications.  The  prognosis  of 
the  pneumonia  of  influenza  is  rather  worse  than  that  of  simple  broncho- 
j)neumonia.  In  a  word,  influenza  is  serious  when  there  are  pulmonary 
complications,  but  rarely  otherwise,  except  in  its  virulent  form,  which, 
however,  is  infrequent.  In  this,  general  blood  infection  and  meningitis 
are  likely  to  occur. 

Treatment. — The  communicability  of  the  disease  makes  it  desirable 
that  cases  of  influenza  should  be  isolated  whenever  practicable,  and  par- 
ticularly that  delicate  children,  or  those  prone  to  pulmonary  disease, 
should  not  be  exposed.  As  there  is  no  specific  for  influenza,  the  treat- 
ment is  symptomatic  and  conducted  along  the  same  general  lines  as  in 
other  respiratory  infections.  The  temperature  rarely  calls  for  anti- 
pyretic measures ;  for,  although  very  high  at  times,  there  is  very  rarely  a 
sustained  high  temperature.  In  our  experience  patients  with  influenza 
infections  are  not  benefited  by  very  cold  air,  but  on  the  contrary  are  not 
infrequently  made  worse  by  it.  Fresh  air  is,  however,  indispensable  in 
the  treatment  of  these  cases,  but  at  a  moderate  temperature,  i.  e.,  60°  to 
65°  F.  The  cough  which  so  often  persists  after  influenza  is  best  con- 
trolled by  cod-liver  oil  and  creosote,  used  as  after  acute  bronchitis.  With 
persistent  bronchitis  which  resists  ordinary  remedies,  a  patient  should 
be  sent  to  a  warm,  dry  climate. 

The  complications  of  influenza  are  to  be  treated  as  they  arise,  in 
the  same  manner  as  when  they  occur  under  other  conditions.  Especial 
care  should  be  exercised  to  avoid  exposure  during  convalescence.  One 
should  be  particularly  anxious  about  patients  who  have  a  strong  ten- 
dency to  tuberculosis,  and  such  cases  should  be  watched  with  the  greatest 
care.  In  prolonged  or  constantly  recurring  attacks  nothing  is  of  much 
avail  except  a  removal  to  a  warm  climate.  If  this  is  impossible,  a 
young  or  delicate  child  should  be  kept  indoors  during  the  cold  season, 
but. frequently  moved  from  one  apartment  to  another. 


1138  THE  .SPECIFIC  IXFECTIOUS  DISEASES 


EPIDEMIC   CATARRH— LA   GRIPPE 

To  this  disease  the  term  Influenza  has  often  heen  given.  With  our 
present  knowledge  it  seems  to  us  hest  to  restrict  the  latter  term  to  the 
disease  or  diseases  just  described  with  which  Pfeiffer's  bacillus  is  asso- 
ciated, instead  of  using  it  as  a  general  name  to  cover  contagious  epidemic 
catarrh.  Pfeif!er's  bacillus  was  originally  put  forward  as  the  cause  of 
epidemic  catarrh.  Studies  of  the  last  few  years  have  made  this  extremely 
doubtful.  It  is  evident,  however,  that  it  is  found  in  a  certain  proportion 
of  cases ;  l)ut  it  seems  to  play  the  role  rather  of  an  associated  organism, 
exactly  as,  under  the  same  circumstances,  do  the  pneumococcus  and  the 
staphylococcus.  But  all  these  organisms  are  frequently  found  when  no 
epidemic  exists.  The  final  solution  of  this  question  must  wait  on  the 
discovery  of  the  actual  cause  of  the  grippe.  Meanwhile,  there  are  many 
important  reasons  for  believing  that  Pfeilfer's  bacillus  is  not  its  cause: 

(1)  The  highly  contagious  character  of  the  disease,  in  which  respect 
it  is  comparable  to  measles.  The  disease  due  to  Pfeiffer's  bacillus  is  only, 
moderately  communicable.  (2)  "When  the  grippe  is  prevailing  epidem- 
ically, Pfeiffer's  bacillus  is  found  in  only  a  small  proportion  of  the  cases ; 
and,  per  contra,  Pfeiffer's- bacillus  is  often  found  in  groups  of  cases  when 
the  grippe  is  not  prevalent.  ( 3 )  The  most  striking  clinical  symptom  of  the 
disease  induced  by  Pfeiffer's  bacillus  is  a  very  high  temperature  without 
other  general  or  local  symptoms  of  corresponding  severity;  while  in  the 
grippe  exactly  the  opposite  is  often  the  case,  i.  e.,  severe  general  symptoms 
with  only  a  moderate  elevation  of  temperature.  (I)  The  intense  general 
prostration,  especially  s3'mptoms  relating  to  the  heart  and  nervous  system, 
so  common  in  the  grippe,  are  not  found  in  the  disease  due  to  Pfeiffer's 
bacillus,  except  in  those  rare  cases  of  bacteriemia  and  meningitis.  (5) 
Although  a  prolonged  convalescence  due  to  general  prostration  is  not  un- 
common, the  grippe  is  usually  a  short  acute  infection  with  little  tendency 
to  become  protracted  as  are  the  inflammations  due  to  Pfeiffer's  bacillus. 
(6)  With  either  form  of  infection  any  part  of  the  respiratory  tract  may 
be  involved  in  inflammation ;  but  it  is  characteristic  of  the  grippe  that 
it  is  so  often  complicated  by  inflammations  of  the  upper  respiratory 
tract — rhinopharyngitis  with  extension  to  the  adjacent  sinuses,  otitis, 
mastoiditis,  adenitis,  etc. — complications  which  are  relatively  infrequent 
with  infections  due  to  Pfeiffer's  bacillus,  whose  complications  are  rather 
those  of  the  lower  respiratory  tract — ^bronchitis  and  bronchopneumonia. 

Clinically  the  grippe  is  manifested  in  children  as  in  adults  by  two 
main  groups  of  symptoms.  In  one  there  are  quite  marked  symptoms  of 
general  prostration,  chilly  sensations,  general  aching  pains  in  the  muscles 
and  sometimes  in  the  joints,  with  only  a  moderate  elevation  of  tempera- 


EPIDEMIC  CATARRH  1139 

ture — 101°  to  103°  F.  A  few  respiratory  symptoms  are  usually  pres- 
ent, but  in  most  cases  there  is  only  a  moderate  cough  and  perhaps 
coarse  rales  in  the  chest.  In  infants  and  young  children  gastro-intestinal 
symptoms  are  frequently  seen  accompanying  these  symptoms.  There 
may  be  vomiting  or  acute  diarrhea  or  marked  indigestion  with  quite  a 
prolonged  loss  in  weight  without  either  vomitiDg  or  diarrhea. 

In  the  second  group  of  cases  the  respiratory  symptoms  are  especially 
pronounced.  In  many  these  are  only  of  the  upper  respiratory  tract; 
there  is  a  severe  inflammation  of  the  rhinopharynx,  with  sneezing,  copious 
discharge  from  nose  and  eyes,  followed  by  the  development  of  hoarseness 
and  cough.  The  inflammation  does  not  extend  beyond  the  trachea  or 
possibly  the  larger  bronchi.  The  chief  complications  of  these  cases  are 
adenitis,  otitis  frequently  followed  by  mastoiditis,  extension  from  the  nose 
to  the  neighboring  sinuses,  etc.  These  cases  seldom  have  high  tempera- 
ture except  when  complicated.  In  others  the  temperature  is  higher  and 
acute  bronchitis  or  bronchopneumonia  develops  early.  Although  at  the 
onset  the  pneumonia  often  seems  particularly  severe,  it  is  not  infrequently 
of  short  duration,  resolution  taking  place  before  complete  consolidation 
of  the  lungs  has  occurred.  In  other  cases  the  type  of  pneumonia  is  of 
special  severity,  spreads  rapidly,  usually  with  a  fatal  outcome. 

The  treatment  of  the  grippe  is  the  treatment  of  its  special  symptoms 
and  complications,  which  should  be  managed  along  the  same  general 
lines  as  when  these  occur  under  other  conditions. 


CHAPTEE   XIII 

MALARIA 

Malaeia  is  an  infectious  disease  due  to  the  presence  in  the  blood  of 
a  specific  organism  often  called  the  Plasmodium,  but  more  exactly  the 
hematocytozoon  malariae.  It  manifests  itself  in  children  by  the  ordinary 
acute  febrile  attacks  which  are  seen  in  adults  and  by  chronic  malarial 
poisoning.  Both  of  these  forms  may  present  certain  peculiar  symptoms 
dependent  upon  the  age  of  the  patient. 

Etiology. — The  malarial  organism  was  discovered  by  Laveran  in 
1881 ;  it  is  a  parasite  of  the  blood  and  belongs  to  the  group  of  protozoa. 
It  is  now  well  established  that  the  parasite  enters  the  blood  through  the 
bite  of  certain  forms  of  mosquito,  those  belonging  to  the  genus  Anopheles, 
and  probably  in  no  other  way.  For  this  knowledge  we  are  indebted 
chiefly  to  the  work  of  Eonald  Eoss,  in  India,  in  1897.     For  a  general 


1140  THE  SPECIFIC  INFECTIOUS  DISEASES 

discussion  of  the  malarial  parasite,  its  methods  of  staining,  etc.,  the 
reader  is  referred  to  works  on  clinical  medicine. 

Malaria  affects  all  ages,  even  the  newly-born  infant.  We  must  accept 
with  some  allowance  the  statements  made  by  the  older  writers  upon  the 
subject  of  intra-uterine  infection,  but  in  the  following  case  reported  by 
Crandall,  there  seems  little  doubt  that  the  disease  was  contracted  in 
utero :  For  ten  days  before  delivery  the  mother  had  suffered  from  a  ter- 
tian intermittent  of  moderate  severity.  Eighteen  hours  after  birth  the 
child  was  noticed  to  have  cold  hands  and  feet,  blue  lips  and  nails,  and 
a  pinched  face.  These  symjjtoms  lasted  about  half  an  hour  and  were 
followed  by  a  distinct  fever.  Upon  the  following  day  the  paroxysm  was 
repeated.  Examination  of  the  blood  of  the  mother  and  the  child  revealed 
the  malarial  organisms  in  both  cases. 

Malaria  is  more  frequently  overlooked  in  young  children  than  in  later 
life,  from  the  fact  that  its  forms  are  more  irregular,  and  this  has  led  to 
the  belief  that  young  children  are  less  liable  than  adults  to  the  disease. 
"We  believe,  however,  the  opposite  to  be  the  case.  In  a  large  number  of  in- 
stances where  families  have  been  exjDosed  to  malarial  poisoning  we  have 
noted  that  the  young  children  were  frequently  the  first  to  show  the 
symptoms  of  the  disease. 

Malaria  is  an  endemic  disease  prevailing  in  certain  localities.  Exact 
knowledge  regarding  the  mode  of  infection  has  cleared  up  many  obscure 
points  in  its  etiology.  The  role  of  the  mosquito  explains  the  greater 
liability  to  contract  malaria  after  sunset  and  during  the  night,  the 
danger  from  stagnant  ponds  and  pools  of  water,  the  peculiar  suscepti- 
bility of  infants  and  young  children,  and  the  greater  frequency  of  the 
disease  in  the  spring  and  summer.  IMalarial  attacks  may,  however,  occur 
at  any  season,  since  the  organism  may  be  latent  in  the  body,  for  an 
indefinite  time;  how  long  it  is  impossible  to  say,  but  there  seems  to  be 
conclusive  proof  that  it  may  be  for  many  months.  Attacks  of  malaria 
very  often  occur  when  the  general  health  has  been  reduced  by  some 
other  cause,  particularly  by  disturbances  of  digestion. 

Lesions. — Opportunities  for  a  study  of  the  peculiarities  of  the  lesions 
of  malaria  in  children  are  infrequent,  especially  in  N"ew  York,  as  fatal 
cases  are  extremely  rare.  We  have  seen  but  two.  As  observed  by  others, 
the  lesions  do  not  differ  in  any  marked  Vay  from  those  of  the  adult 
form  of  the  disease.  The  most  important  changes  are  the  destruc- 
tion of  the  red  corpuscles  of  the  blood,  enlargement,  and  in  chronic 
cases  hyperplasia  with  pigmentation  of  the  spleen;  less  frequently  pig- 
mentation of  the  liver,  kidneys,  and  brain.  Pneumonia  and  gastro- 
enteritis are  occasional  complications. 

Symptoms. — The  clinical  forms  of  malarial  fever  in  children  from  six 
to  ten  years  old,  do  not  differ  essentially  from  the  same  disease  in  adults. 


MALARIA 


1141 


Both  tertian  (Fig.  199)  and  estivo-autumnal  (Fig.  200)  attacks  occur 
with  considerable  frequency,  the  former  being  the  type  most  often  seen. 
Double  tertian  infection  (Fig.  198)  is  not  uncommon  but  along  the 
middle  Atlantic  coast  the  quartan  type,  unless  imported,  is  unknown. 
The  stages  of  the  paroxysm  are  generally  well  marked.  The  cold  stage 
begins  with  a  chill  or  vomiting,  with  headache,  lassitude,  and  general 


DAY 

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Fig.  198. — Typical  Malarial  Temperature,  Double  Tertian  Type,  in  a  Boy  Six 
Years  Old.  Each  paroxysm  preceded  by  a  chill.  It  will  be  noticed  that  the  tem- 
perature rose  higher  with  each  succeeding  paroxysm ;  X  marks  the  time  when  quinin 
was  begun. 


pains.  The  hot  stage  is  usually  characterized  by  a  higher  temperature 
than  in  adults,  and  this  is  followed  by  the  sweating  stage,  which  is  gen- 
erally marked.  The  paroxysm  may  be  repeated  ever}'-  other  day  or  every 
day,  depending  upon  whether  there  is  a  single  or  double  tertian  infection, 
until  controlled  by  quinin.  Less  frequently  there  is  an  estivo-autumnal 
infection  and  the  fever  is  remittent  from  the  beginning  and  the  con- 
stitutional symptoms   are   of   greater  severity.      In   tliis   form  there   is 


1142 


THE  SPECIFIC  INFECTIOUS  DISEASES 


marked  prostration,  the  tongue  is  thickly  coated,  there  are  often  tender- 
ness and  pain  in  the  region  of  the  liver,  and  occasionally  there  is  slight 
jaundice. 

In  infants  and  very  young  children  peculiar  types  of  malaria  are 
seen.  A  well-marked  intermittent  fever  with  distinct  stages  is  often 
absent,  many  cases  assuming  more  of  a  remittent  type  or  an  irregular 


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Fig.  199. — Typical  Malarial  Temperatuhe,  Tertian  Type,  in  a  Boy  Five  Years  Old. 
Onset  with  vomiting  and  drowsiness,  but  no  chill.  This  was  an  anticipating  tertian, 
the  first  paroxysm  occurring  at  3  p.m.,  the  Second  at  12  m.,  the  third  at  10  a.m.;  X 
marks  the  time  when  quinin  was  begun. 


form  of  intermittent  (Fig.  200).  The  onset  is  usually  abruj^t  with 
vomiting,  a  well-marked  chill  being  rare.  Malarial  chills  are  not  often 
witnessed  in  children  under  five  years  old.  They  are  replaced  in  infants 
by  cold  hands  and  feet,  blue  lips  and  nails,  sometimes  slight  general 
cyanosis,  pallor,  drowsiness,  and  prostration.  Vomiting  has  been  present 
in  two-thirds  of  our  own  cases.  Several  times  we  have  seen  a  malarial 
attack  ushered  in  by  convulsions. 

The  fever  is  relatively  higher  than  in  adults,  rising  rapidly  to  104° 
or  105°  F.,  occasionally  to  106°  or  106.5°  F.    This  continues  from  four 


MALARIA 


1143 


to  twelve  hours  and  graduall^y  falls^  usually  to  normal.  The  other  con- 
stitutional symptoms  of  the  febrile  stage  are  much  less  severe  than  in 
most  diseases  with  the  same  elevation  of  temperature.  The  sweating 
stage  is  only  slightly  marked  and  is  often  absent  altogether.  With  the 
fall  in  the  temperature  there  is  a  gradual  subsidence  of  all  the  other 
symptoms  of  the  febrile  stage. 

After  the  first  paroxysm  the  patient  may  be  quite  well  for  several 


DAY                         1 

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Fig.  200. — An  Irregular  Malarial  Temperature  (due  to  Estivo-Autumnal  Infec- 
tion) IN  A  Child  Nine  Month.s  Old.  The  paroxysm  on  the  fourth  day  was  accom- 
panied by  an  attack  of  acute  pulmonary  congestion  which  came  near  being  fatal; 
X  marks  the  time  when  quinin  was  begun.  Although  the  course  of  the  temperature 
ia  irregular,  it  touched  the  normal  line  both  on  the  second  and  fourth  days. 


hours  or  even  for  a  day,  wlien  the  second  paroxysm  occurs.  Hi  is  is 
generally  not  so  well  marked  as  the  first  one,  the  third  may  be  even 
less  so,  and  the  case  may  resemble  more  and  more  one  of  continuous 
fever  with  wide  oscillations  in  the  temperature.  .In  some  cases  it  is 
remittent  at  first  and  later  becomes  intermittent,  but  it  is  very  rare 
in  any  circumstances  that  the  temperature  does  not  touch  the  normal 
point  at  some  time  in  the  twenty-four  hours. 

Enlargement  of  the  spleen  is  present  in  the  great  majority  of  cases, 
and  usually  to  a  sufficient  degree  to  be  readily  appreciated  by  examina- 
tion.    The  most  satisfactory  method  of  examination  is  by  palpation. 


1144  THE  SPECIFTC  IXFECTIOUS  DISEASES 

A  spleen  which  can  be  easily  felt  below  the  ribs  (except  in  the  rare 
cases  in  which  the  organ  is ' displaced  downward  by  some  condition  in 
tlie  thorax)  is  enlarged.  When  it  is  not  sufficiently  enlarged  to  be 
readily  felt  by  a  practiced  observer  under  favorable  conditions  for  ex- 
amination, it  is  not  large  enough  to  be  of  any  diagnostic  importance, 
None  of  the  other  symptoms  occurring  in  malarial  fever  are  character- 
istic ;  they  are  quite  similar  to  those  which  are  seen  in  almost  all  febrile 
attacks.  They  are  anorexia,  coated  tongue,  constipation,  and  rest- 
lessness. 

Masked  or  Irregular  Forms  of  Malaria. — These  are  quite  frequent  in 
young  children,  and  are  due  to  the  presence  of  certain  special  or  uncom- 
mon s}Tnptoms  which  may  readily  lead  to  a  mistake  in  diagnosis.  They 
are  more  often  seen  than  cases  of  true  malarial  cachexia. 

Among  the  most  frequent  of  the  irregular  forms  are  those  relating 
to  the  nervous  system.  Headache  is  exceedingly  common  and  is  usually 
frontal.  "When  severe  and  associated  with  continuous  drowsiness,  vomit- 
ing, and  constipation,  it  may  lead  to  a  strong  suspicion  of  tuberculous 
meningitis.  Yertigo  is  not  a  frequent  symptom,  but  it  is  sometimes  very 
prominent.  Pains  in  various  parts  of  the  body  are  very  common.  A 
sharp,  severe  pain  at  the  epigastrium  is  frequent  at  the  beginning  of  a 
paroxysm.  It  is  often  associated  with  tenderness,  but  has  no  relation 
to  meals.  Less  frequently,  pain  is  localized  in  the  region  of  the  spleen 
or  liver.  Aching  or  dragging  pains  in  the  muscles  of  the  lower  ex- 
tremities are  frequent  symj)toms  during  acute  attacks,  but  may  be  of 
short  duration,  disappearing  with  the  fever.  The  pain  is  accompanied 
by  tenderness  of  the  muscles  and  nerve  trunks,  and  by  loss  of  power, 
which  is  usually  partial. 

Accompanying  the  paroxysm  of  malaria  there  is  occasionally  seen, 
more  often  in  infants  than  in  older  children,  acute  pulmonary  congestion 
(Fig.  200),  which  may  give  rise  to  obscure  and  often  very  alarming 
symptoms.  There  is  an  acute  onset  with  vomiting  and  prostration,  high 
temperature,  cough,  rapid  respiration,  and  often  slight  cyanosis.  On 
examination  of  the  chest  there  is  found  feeble  or  rude  respiration  over 
one  lung,  or  over  both  lungs  behind,  and  sometimes  coarse  moist  rales ; 
tliese  signs  and  symptoms  may  disappear  in  the  course  of  a  few  hours 
with  the  fall  in  temperature,  to  return  with  the  next  paroxysm,  or  if 
quinin  is  given  they  may  disappear  entirely.^     This  group  of  symptoms 

^The  following  case  is  a  good  example  of  this  condition  in  its  more  severe 
form,  and  illustrates  the  difficulties  in  the  diagnosis  of  malaria  in  infancy:  A 
fairly  nourished  child,  nine  months  old,  who  had  been  under  observation  in  an 
institution  for  two  weeks,  was  suddenly  taken  with  vomiting  and  fever  (Fig. 
200).  A  cathartic  was  followed  by  a  large  undigested  stool,  and  as  the  tem- 
perature then  fell  to  normal,  the  attack  was  regarded  as  one  of  indigestion.     On 


MALARIA  1145 

has  sometimes  led  to  the  mistaken  opinion  that  the  disease  was  pneu- 
monia, which  had  been  aborted  by  the  administration  of  quiuin. 

Subacute  or  Chronic  Perms  of  Malaria. — The  most  constant  symp- 
toms are  anemia,  enlargement  of  the  spleen,  and  slight  fever.  The 
anemia  is  usually  marked,  often  being  extreme.  The  enlargement  of  the 
spleen  is  distinct,  easily  made  out  by  palpation,  and  sometimes  is  very 
great.  The  fever  is  often  so  slight  as  to  be  discovered  only  when  the 
temperature  is  taken  five  or  six  times  in  the  twenty-four  hours.  The 
other  symptoms  are  of  a  very  indefinite  character;  there  may  be  slight 
edema  of  the  lower  extremities,  general  muscular  weakness,  so  that  the 
child  is  easily  fatigued,  loss  of  appetite,  coated  tongue,  constipation,  head- 
ache, muscular  pains,  and  often  cough  from  a  slight  bronchitis.  These 
symptoms  may  depend  upon  many  conditions  other  than  malaria,  even 
when  they  are  seen  in  a  malarial  district.  The  only  positive  evidence  of 
malaria  in  such  cases  is  the  presence  of  the  malarial  organisms  in  the 
blood.  Even  the  swollen  spleen,  anemia,  and  slight  fever,  which  are 
often  looked  upon  as  diagnostic,  may  be  present  in  cases  of  anemia  with 
which  malaria  has  nothing  whatever  to  do. 

Diagnosis. — The  positive  diagnosis  of  malaria  rests  upon  the  demon- 
stration of  the  malarial  organisms  in  the  blood.  They  will  be  found  in 
nearly  all  the  cases  provided  a  careful  examination  is  made  a  few  hours 
before  the  j^aroxysm,  and  also  that  no  quinin  has  been  administered. 
When  their  number  is  small  they  may  be  missed  at  the  height  of  the 
fever,  although  they  may  readily  be  found  just  before  the  temperature 
begins  to  rise.  While  a  positive  result  is  conclusive,  a  negative  one  is  not 
always  so  because  of  the  impossibility  of  fulfilling  all  the  above  condi- 
tions. This  fact  and  lack  of  experience  in  blood  examinations  make  it 
necessary  for  a  large  part  of  the  profession  to  make  the  diagnosis  by  the 

the  third  day  the  temperature  was  again  high  and  accompanied  by  cough;  coarse 
rales  were  found  throughout  the  chest,  and  fine  rales  at  the  right  base;  it  was 
then  thought  that  pneumonia  was  developing.  On  the  fourth  day  all  the  symp- 
toms were  so  much  improved  that  the  infant  was  regarded  as  convalescent.  At 
6  P.M.  the  temperature  was  normal,  and  the-  infant  went  to  sleep  quietly.  At 
9.30  P.M.  he  awoke  with  a  temperature  of  104°  F.,  extreme  restlessness,  and 
marked  dyspnea.  In  half  an  hour  his  symptoms  had  increased  to  a  point  where 
he  seemed  likely  to  die.  He  became  cyanotic,  the  respirations  were  of  a  panting 
character  and  rose  nearly  to  one  hundred  a  minute,  and  he  coughed  with  almost 
every  breath;  the  pulse  was  scarcely  perceptible.  The  severe  symptoms  con- 
tinued for  about  an  hour,  then  passed  away  gradually,  and  at  the  end  of  two 
and  a  half  hours  they  had  completely  disappeared,  and  the  child  was  in  a  quiet 
sleep  which  continued  until  morning.  Malaria  was  now  suspected,  and  the  diag- 
nosis established  by  the  discovery  of  the  organisms  in  the  blood.  The  spleen 
was  at  this  time  much  enlarged;  the  signs  in  the  chest  were  those  only  of  bron- 
chitis of  the  large  tubes.  Quinin  was  given  in  full  doses,  and  immediately  con- 
trolled the  temperature  and  the  pulmonary  symptoms: 


1146  THE  SPECIFIC  INFECTIOUS  DISEASES 

other  symptoms.  These,  in  the  order  of  their  importance,  we  would 
place  as  follows:  Prompt  curability  (especially  in  cases  of  fever)  by 
c[uinin;  distinct  periodicity  in  the  symptoms;  enlargement  of  the  spleen; 
and  a  history  of  an  exposure  in  a  district  known  to  be  malarial.  Particular 
importance  is  to  be  attached  to  the  therapeutic  test.  Eecent  experience 
emphasizes  more  and  more  strongly  the  fact  that  quinin  has  very  little 
influence  upon  fevers  which  are  not  malarial,  and,  conversely,  that  a 
fever  immediately  and  permanently  controlled  by  quinin  is  pretty  certain 
to  be  malarial. 

The  fever  and  recurring  chills  of  pyelitis  are  often  attributed  to 
malaria.  ]\Iany  conditions  accompanied  by  an  enlarged  spleen  may  be 
confounded  with  malaria,  especially  simple  anemia,  leukemia,  rickets, 
and  syphilis.  While  malaria  may  be  multiform  in  its  manifestations, 
the  physician  can  fall  into  no  more  serious  error,  even  in  a  malarial  dis- 
trict, than  to  regard  all  ailments  with  obscure  or  indefinite  symptoms  as 
malarial,  neglecting  careful  physical  and  blood  examinations,  by  which 
means  alone  an  accurate  diagnosis  is  reached. 

Prognosis. — Although  it  is  seldom  fatal  in  itself,  an  attack  of  malaria 
in  a  young  child  may  so  undermine  his  constitution  that  he  may  suc- 
cumb to  some  other  acute  disease.  Cases  are  often  difficult  to  cure 
while  the  patient  remains  in  the  malarial  district,  and  when  frequent 
re-infection  occurs.  In  other  circumstances  and  with  proper  treat- 
ment the  prognosis  of  malaria  is  good. 

Treatment. — FropJiylaxis. — ]\Iore  exact  knowledge  regarding  the  eti- 
ology of  malaria  makes  it  possible  for  much  to  be  done  in  the  way  of 
prevention.  Besides  the  general  measures  proposed  for  the  extermina- 
tion of  the  mosquitoes  concerned,  emphasis  sliould  be  laid  upon  the  neces- 
sity, in  the  case  of  young  children,  of  protecting  them  against  the  bites 
of  mosquitoes  in  localities  which  are  or  which  may  possibly  be  malarial. 
This  can  be  done  by  a  more  thorough  use  of  mosquito  netting  and  by 
using  upon  exposed  parts  of  the  body  lotions  or  ointments  containing 
menthol,  pennyroyal,  turpentine,  or  other  substances  which  keep  these 
pests  away.  The  general  treatment  is  symptomatic,  and  is  to  be  con- 
ducted as  in  all  acute  febrile  diseases.  In  the  cold  stage,  stimulants  or  a 
hot  bath  may  be  required ;  in  the  hot  stage,  ice  to  the  head  and  frequent 
sponging. 

Methods  of  Administraiion  of  Quinin. — For  infants  our  own  prefer- 
ence is  to  give  the  sulphate  in  an  aqueous  solution,  two  or  five  grains 
to  the  teaspoonful,  according  to  the  age  of  the  patient.  Most  infants 
take  such  a  solution  with  less  difficulty  and  vomit  it  less  frequently  than 
the  combinations  Avith  the  various  vehicles  supposed  to  cover  its  taste. 
If  the  quinin  is  given  at  night  upon  an  empty  stomach,  vomiting  seldom 
occurs.      If  repeated  vomiting  makes  it  impossible   to   give   quiuin   by 


MALARIA  1147 

mouth  it  may  be  given  hypodermically.  For  this  purpose  the  bimuriate 
of  quinin  and  urea  is  perhaps  tlie  most  satisfactory  preparation;  but 
the  bisulphate  may  be  used.  Both  are  more  or  less  irritating  and  there 
usually  follows  some  induration  at  the  site  of  the  injection,  which  may 
last  a  long  time.  While  the  hypodermic  use  of  quinin  is  sometimes 
invaluable  it  should  not  be  employed  in  infants  except  in  serious  attacks 
and  when  the  diagnosis  has  been  established.  The  frequent  repetition 
of  the  hypodermic  injections  should  be  avoided;  in  most  cases,  two  or 
three  good  doses  are  sufficient,  the  effect  being  continued  by  quinin  given 
by  other  methods. 

For  children  from  two  to  seven  years  old  the  taste  of  quinin  must 
be  concealed.  An  aqueous  solution  of  the  bisulphate  may  be  mixed  with 
the  syrup  of  sarsaparilla,  orange,  or  yerba  santa ;  or  the  sulphate  may  be 
given  in  suspension  in  one  of  the  same  vehicles,  the  mixture  being  made 
Just  before  the  dose  is  taken;  otherwise  the  partial  solution  of  the  drug 
will  render  the  whole  dose  exceedingly  bitter.  When  the  dose  required  is 
not  large,  as  in  the  milder  cases,  the  lozenges  of  the  tannate  of  quinin 
combined  with  chocolate  answer  the  purpose  admirably,  for  these  are  so 
nearly  tasteless  that  children  will  take  them  without  difficulty.  Each 
lozenge  usually  contains  one  grain  of  -the  tannate,  which  is  equivalent  to 
about  one-third  of  a  grain  of  the  sulphate  of  quinin.  A  similar  lozenge 
containing  one  grain  of  the  sulphate  may  be  made,  which  is  often  taken 
by  children  without  the  slightest  objection. 

For  children  over  seven  years  old,  the  same  methods  of  administra- 
tion may  usually  be  employed  as  in  adults.  It  is  always  preferable  to 
give  quinin  in  solution,  or  if  not  so,  in  capsule,  but  not  in  pill  form. 

In  a  case  with  well-marked  paroxysms  the  quinin  should  if  possible 
be  given  in  the  interval,  with  the  largest  dose  about  four  hours  before 
the  expected  paroxysm.  With  infants  this  plan  is  sometimes  imprac- 
ticable, as  frequent  small  doses  are  usually  better  borne  by  the  stomach 
than  a  few  large  ones.  In  them  also  vomiting  seems  less  likely  to  occur 
when  it  is  given  on  an  empty  stomach.  For  this  reason  it  is  advantageous 
to  give  the  drug  at  regular  two-  or  three-hour  intervals  during  the  night, 
and  omit  all  medication  during  the  day. 

Dosage. — Relatively  much  larger  doses  of  quinin  are  required  for 
young  children  than  for  adults.  Except  for  its  tendency  to  disturb  the 
stomach,  quinin  is  borne  remarkably  well  by  little  patients.  Generally 
too  small  doses  are  given.  An  infant  of  a  year  with  a  sharp  attack  of 
malarial  fever  will  usually  require  from  eight  to  twelve  grains  of  the 
sulphate  (ten  to  fourteen  grains  of  the  bisulphate)  daily.  Occasionally 
we  have  found  it  necessary  to  give  double  the  quantity  referred  to.  It 
is  useless  to  expect  to  control  an  acute  attack  of  malaria  by  such  doses 
as  one  grain  three  or  four  times  a  day.     Children  from  five  to  ten  years 


1148  THE  SPECIFIC  IXFECTIOUS  DISEASES 

old  require  almost  as  large  doses  as  do  adults.  None  of  the  substitutes 
for  quinin  are  to  be  relied  upon  in  acute  cases. 

In  chronic  cases,  arsenic  and  iron  are  usually  required  in  combination 
with  smaller  doses  of  the  quinin  than  those  mentioned.  For  children 
over  seven  years  old;,  Warburg's  tincture  may  be  employed.  In  most 
chronic  cases  a  cure  can  be  effected  only  by  a  change  of  climate. 

The  masked  and  irregular  manifestations  of  malaria  are  to  be 
treated  in  the  same  manner  as  cases  of  malarial  fever. 


SECTION  X 
OTHER  GENERAL  DISEASES 

CHAPTER    I 
RHEUMATISM 

Rheumatism  manifests  itself  in  children  by  quite  a  different  group 
of  symptoms  from  those  seen  in  adults;  for  this  reason  the  disease  was 
formerly  supposed  to  be  a  rare  one  in  early  life.  It  is  only  within  recent 
years  that  its  frequency  and  its  peculiarities  have  come  to  be  appre- 
ciated. For  our  present  understanding  of  the  subject  we  are  indebted 
largely  to  the  Avork  of  English  physicians,  especially  Cheadle,  who  has 
brought  out  more  fully  than  any  one  else  the  close  connection  existing 
between  many  conditions  formerly  not  regarded  as  rheumatic.  One 
who  has  in  mind  only  the  adult  types  of  articular  rheumatism,  and 
regards  arthritis  as  a  necessary  symptom  for  a  diagnosis,  will  overlook 
in  early  life  many  manifestations  which  are  clearly  the  result  of  the 
rheumatic  poison.  There  is  seen  at  this  period  a  group  of  clinical  phe- 
nomena, which  often  occur  in  combination  or  in  succession,  whose  asso- 
ciation was  not  understood  until  they  were  all  discovered  to  be  related 
to  rheumatism.  Sometimes  one  member  of  the  group  and  sometimes 
another  is  fir&t  seen,  but  when  one  has  appeared  others  are  likely  soon 
to  follow. 

Rheumatism  in  childhood,  then,  is  manifested  not  alone  by  arthritis 
with  acute  or  subacute  symptoms,  but  by  a  large  number  of  other  condi- 
tions which  are  not  to  be  regarded  in  the  light  of  complications,  but  rather 
as  forms  of  the  disease. 

Etiolo^. — It  is  not  in  the  province  of  this  work  to  discuss  the  vari- 
ous theories  regarding  the  nature  of  rheumatism  and  its  exciting  cause. 
The  drift  of  medical  opinion  to-day  is  strongly  toward  the  view  that 
acute  rheumatism  is  an  infectious  disease,  probably  of  microbic  origin. 
Although  the  character  of  the  microorganism  is  not  yet  satisfactorily 
determined,  the  observations  of  Poynton  and  Paine,  Wassermann  and 
others  point  to  a  diplococcus.  Under  five  years  of  age  articular  rheu- 
matism is  not  common,  and  in  infancy  it  is  extremely  rare.  We  once  saw, 
however,  in  a  nursing  infant,  a  typical  attack  of  rheumatic  fever  with 
38  1149 


1150  OTHER  GENERAL  DISEASES 

multiple  joint  lesions.  The  condition  is,  however,  so  exceptional  that 
one  should  be  cautious  in  making  the  diagnosis  of  rheumatism  in  infancy. 
Most  of  the  cases  so  regarded  are  examples  of  scurvy.  After  the  fifth 
year  both  the  articular  and  the  other  manifestations  of  rheumatism 
become  very  common,  and  occur  with  increasing  frequency  up  to  the 
time  of  puberty. 

Heredity  is  a  very  important  etiological  factor,  and  in  fully  two- 
thirds  of  the  cases  that  have  come  under  our  care,  a  rheumatic  family 
history  was  obtained.  Of  the  other  important  causes,  the  most  frequent 
are  living  in  damp  dwellings,  direct  exposure  to  cold  and  wet,  poor 
hygienic  surroundings,  and  insufficient  food.  While  seen  among  all 
classes,  rheumatism  is  more  common  among  those  who  are  badly  housed. 
Attacks  of  rheumatism  occur  at  all  seasons,  but  are  much  more  frequent 
in  the  spring  months.  One  attack  strongly  predisposes  to  a  second,  and 
in  most  cases  there  is  a  history  of  a  large  number  of  attacks  of  greater 
or  less  severity.  Among  our  own  patients,  girls  have  been  afEected  with 
greater  frequency  than  boys. 

Symptoms. — The  General  and  Articular  Manifestations. — The  clini- 
cal types  of  rheumatism  in  children  present  very  notable  contrasts  to  those 
seen  in  adults.  A  typical  attack  of  acute  articular  rheumatism  such 
as  is  seen  in  adult  life,  with  a  sudden  onset,  high  temperature,  severe  in- 
flammation of  several  joints,  profuse  acid  perspiration,  and  occasional 
delirium,  is  rarely  seen  in  a  child  under  eight  or  ten  years  old.  In  most 
of  the  attacks  in  childhood  the  onset  is  not  very  acute,  the  temperature 
is  but  slightly  elevated — only  100°  or  101.5°  F. — the  swelling  and  pain 
are  moderate,  and  the  redness  is  often  absent.  The  number  of  joints 
involved  is  generally  small,  those  most  frequently  affected  being  the 
ankles,  the  knees,  the  small  joints  of  the  foot,  the  wrists,  or  the  elbows. 
These  symptoms  are  often  not  severe  enough  to  keep  the  patient  in  bed, 
and  only  the  pain  in  the  joints  of  the  lower  extremities  prevents  him 
from  walking.  The  duration  of  these  attacks  is  from  one  to  three  weeks, 
and  in  the  course  of  a  month  most  of  them  recover  even  without 
treatment. 

Not  infrequently  the  symptoms  are  limited  to  a  single  joint,  usually 
the  hip,  knee,  or  ankle.  Possibly  the  joints  of  the  upper  extremity  are 
affected  oftener  than  would  appear,  but  disease  here  is  much  more  likely 
to  be  overlooked  than  when  lameness  is  present.  The  swelling  is  moderate 
and  may  not  be  evident  except  on  a  close  examination ;  in  some  cases 
there  is  none.  There  is  stiffness  of  the  joint,  as  shown  by  lameness,  and 
there  may  be  so  much  pain  and  soreness  that  the  child  refuses  to  walk 
altogether.  Muscular  spasm  about  the  affected  joint  is  often  marked, 
and  may  be  the  most  striking  objective  symptom.  The  tenderness  is 
sometimes  localized,  but  it  may  affect  the  ligaments,  tendons,  and  even 


RHEUMATISM  1151 

the  muscles.  These  symptoms  may  persist  for  two  or  three  M-eeks  and 
lead  to  a  suspicion  of  incipient  tuberculous  disease  of  the  joint.  Eheuma- 
tism  is  distinguished  by  its  more  acute  onset  and  usually  by  the  presence 
of  slight  fever ;  some  elevation  of  temperature  being  the  rule,  though  it  is 
not  often  much  over  100°  F.  A  family  history  of  rheumatism,  or  a 
history  of  previous  similar  attacks  in  the  patient  affecting  the  same  or 
other  joints,  or  other  manifestations  of  rheumatism,  are  also  of  assistance 
in  the  diagnosis.  Occasionally  all  doubt  is  removed  by  the  disease 
extending  to  other  joints,  or  by  the  development  of  endocarditis.  In 
some  cases  the  symptoms  are  less  in  the  joints  themselves  than  in  the 
muscles,  and  they  are  frequently  dismissed  as  simply  "growing  pains," 
having  nothing  characteristic  about  them  except  their  occurrence  in 
damp  weather. 

Cardiac  Manifestations. — 'These  may  occur  when  the  articular  symp- 
toms are  very  mild,  and  in  some  cases  when  they  are  entirely  absent. 
The  most  frequent  is  endocarditis.  This  is  much  more  often  seen  in  the 
acute  rheumatism  of  children  than  of  adults,  and  probably  occurs  in  the 
majority  of  all  severe  cases;  if  it  does  not  come  in  the  first  attack,  it  is 
likely  to  be  seen  in  the  later  ones.  It  frequently  occurs  with  a  mild 
rheumatic  arthritis,  often  being  unnoticed  until  valvular  disease  of  con- 
siderable severity  has  developed.  Sometimes  there  is  only  high  fever 
with  severe  constitutional  symptoms  of  an  indefinite  character,  but  no 
arthritis,  and  no  suspicion  that  the  attack  is  rheumatic  until  endocar- 
ditis is  discovered.  Such  cases  are  not  infrequent.  If  the  patients  are 
kept  under  observation,  articular  symptoms  are  almost  certain  to  develop 
later,  and  often  there  are  other  manifestations  of  rheumatism,  especially 
chorea. 

Pericarditis  is  much  less  frequent  than  endocarditis,  and  usually 
occurs  in  children  over  seven  years  old.  It  is  often  associated  with  en- 
docarditis. The  most  characteristic  form  of  inflammation  in  early  life  is 
a  sub-acute,  dry,  fibrous  form,  often  resulting  in  great  thickening  with 
extensive  adhesions,  and  frequently  in  obliteration  of  the  pericardial 
sac.  When  once  started  it  shows  a  strong  tendency  to  recurrence  and 
persistence. 

The  heart  is  so  frequently  affected  in  the  rheumatism  of  childhood 
that  it  should  be  closely  watched  whenever  articular  symptoms  are  pres- 
ent, no  matter  how  mild  they  may  be ;  and  not  only  in  these  cases,  but  in 
all  the  conditions  hereafter  enumerated  with  which  rheumatism  is  likely 
to  be  associated. 

Inflammations  of  other  serous  membranes — the  pleura,  peritoneum, 
and  pia  mater — were  much  more  frequently  ascribed  to  rheumatism  in 
the  past  than  now.  There  is  reason  for  believing  that  on  rare  occasions 
the  pleura  may  be  involved,  but  very  exceptionally  in  young  children. 


1152  OTHEK  GENERAL  DISEASES 

There  is  no  evidence  that  the  peritoneum  and  meninges  are  directly 
affected  by  rheumatism. 

Torticollis  when  it  occurs  acutely  is  frequently  rheumatic.  This 
form  is  characterized  by  its  sudden  development,  continuous  spasm,  the 
great  amount  of  muscular  soreness,  the  moderate  pain,  and  the  fact  that 
it  usually  disappears  spontaneously  after  a  few  days.  Other  manifesta- 
tions of  muscular  rheumatism  are  less  characteristic  and  usually  affect  the 
muscles  of  the  extremities. 

Anemia  is  almost  invariably  seen  in  rheumatic  patients,  both  during 
and  between  the  attacks.  The  effect  of  the  rheumatic  poison  upon  the 
blood  resembles  that  of  malaria.  A  secondary  anemia  develops,  often 
of   considerable   severity. 

Chorea. — In  the  chapter  upon  Chorea  we  have  already  discussed  the 
association  of  that  disease  with  rheumatism  and  expressed  our  belief 
in  a  very  close  relationship  existing  between  them.  Not  infrequently 
chorea  is  the  first  manifestation  of  a  rheumatic  diathesis,  to  be  fol- 
lowed soon  by  articular  symptoms  or  by  endocarditis  without  such  symp- 
toms. In  other  cases  chorea  and  acute  endocarditis  occur  together  with- 
out articular  symptoms,  or  all  three  may  be  associated.  Whichever  of 
the  three  conditions  is  first  seen,  the  physician  should  always  be  on  the 
lookout  for  the  others.  The  frequency  of  rheum;atism  in  choreic  patients 
has  been  variously  estimated  by  different  observers;  in  our  own  cases 
over  fifty  per  cent  have  given  unmistakable  evidence  of  a  rheumatic 
diathesis. 

Tonsillitis. — The  association  of  tonsillitis  and  pharyngitis  with  rheu- 
matism appears  in  many  ciases  to  be  a  close  one.  Children  who  are  the 
subjects  of  frequent  attacks  should  be  regarded  as  probably  rheumatic, 
and  closely  watched  for  other  signs  of  that  disease.  Acute  tonsillitis 
often  ushers  in  an  attack  of  rheumatic  arthritis,  and  occasionally  acute 
endocarditis  without  articular  symptoms.  The  nature  of  the  relationship 
is  not  yet  fully  explained ;  by  many  the  tonsils  are  regarded  as  the  struc- 
tures in  which  the  organisms  of  rheumatism  first  obtain  a  foothold. 

Subcutaneous  Tendinous  Nodules. — General  attention  was  first  drawn 
to  these  as  a  manifestation  of  rheumatism  by  Barlow  and  Warner,  in 
1881,  who  described  them  as  "oval,  semi-transparent,  fibrous  bodies  like 
boiled  sago  grains."  They  are  most  frequently  found  at  the  back  of  the 
elbow,  over  the  malleoli,  at  the  margin  of  the  patella ;  occasionally  on 
the  extensor  tendons  of  the  hands,  fingers,  or  toes,  or  over  the  spinous 
processes  of  the  vertebrae  or  the  scapulae.  They  are  composed  of  fibrin, 
cells,  and  fibrous  tissue,  and  vary  in  size  from  a  large  pin's  head  to  a 
small  bean,  sometimes  being  as  large  as  an  almond.  The  nodules  may 
come  in  crops,  lasting  for  a  few  weeks  and  then  disappear,  or  they  may 
last  for  months.    An  eruption  of  nodules  is  u.sually  coincident  with  other 


EHEUMATISM  1153 

rheumatic  manifestations.  These  nodules  are  better  felt  than  seen, 
although  they  may  be  visible  if  the  skin  is  tightly  drawn.  They  are 
certainly  not  common  in  this  country;  and  although  we  have  made  i^a 
rule  to  examine  rheumatic  patients  for  them,  we  have  seen  them'  "but 
seldoniij,  and  they  have  been  prominent  in  only  eight  or  ten  casts.,  This 
has  also  been  the  experience  of  most  observers  in  this  country.  From 
published  reports,  however,  they  appear  to  be  much  more  frequent  in 
England.  There  can  be  no  doubt  regarding  the  connection  of  these 
nodules  with  rheumatism. 

Erythema. — The  connection  between  rheumatism  and  the  various 
forms  of  erythema — marginatum,  papulatum,  and  nodosum — has  been 
very  clearly  shown  by  Cheadle.  None  of  these  is  a  frequent  condition 
in  childhood,  but  when  seen  it  should  always  suggest  rheumatism. 

Purpura. — The  association  of  purpura  with  rheumatism  is  at  times  so 
close  that  there  can  be  little  doubt  of  the  close  connection  between  the  two 
conditions.  Eheumatic  purpura,  however,  is  quite  distinct  from  the 
other  forms  of  purpura,  and  is  a  much  less  frequent  disease. 

Diagnosis. — In  order  to  recognize  rheumatism  in  a  child,  one  must 
free  his  mind  from  preconceived  notions  of  the  disease  drawn  from  its 
manifestations  in  adults,  as  very  few_cases  correspond  to  the  adult  type 
of  acute  rheumatism.  In  early  life  the  disease  is  recognized  not  by  any 
one  or  two  special  symptoms,  but  by  the  association  oi:  combination  of  a 
number  of  conditions  which  may  appear  unrelated.  In  determining 
whether  or  not  any  given  set  of  symptoms  is  due  to  rheumatism,  one 
should  consider:  (1)  the  family  history,  since  in  early  life  heredity  is 
so  important  an  etiological  factor;  (2)  the  previous  history  of  the  patient, 
not  only  as  regards  articular  pains  and  swellings,  the  slight  joint-stiffness 
without  swelling,  the  indefinite  wandering  pains  in  damp  weather,  and 
the  so-called  growing  pains,  but  also  the  previous  existence  of  chorea, 
frequent  attacks  of  tonsillitis,  torticollis,  or  erythema;  (3)  the  examina- 
tion of  the  patient,  which  should  include  a  careful  search  for  tendinous 
nodules,  as  well  as  a  thorough  examination  of  the  heart  for  signs  of 
endocarditis  or  pericarditis,  and,  in  cases  which  are  at  all  acute,  the 
temperature.  In  doubtful  cases  with  monarticular  symptoms  much  im- 
portance is  to  be  attached,  to  the  presence  of  slight  fever,  the  abrupt 
onset,  and  tenderness  of  the  neighboring  muscles  and  tendons — all 
occurring  without  a  history  of  traumatism.  Eheumatism  is  more  often 
overlooked  than  confounded  with  other  diseases;  although  in  childhood 
multiple  neuritis  and  tuberculous  and  syphilitic  bone  disease  are  often 
mistaken  for  it,  and  in  infancy  the  same  is  true  of  scurvy.  The  extreme 
infrequency  of  rheumatism  during  the  first  two  years  of  life  should 
always  make  one  sceptical  regarding  it.  In  an  infant,  when  the  symp- 
toms are  confined  to  the  legs  and  are  not  accompanied  by  fever,  they 


1154  OTHER  GENERAL  DISEASES 

are  almost  certain  to  be  due  to  scurvy,  even  though  the  gums  are  normal 
and  ecchymoses  have  not  appeared.  Multiple  gonococcus  arthritis  has 
(M^^  heen  diagnosticated  rheumatism.  Many  cases  of  general  sepsis, 
especial U  such  as  originate  from  the  tonsils  or  the  teeth,  may  be  accom- 
panied lyjf  'joint  swellings  resembling  rheumatism. 

Pro^osis. — Eheumatism  in  a  child  is  in  itself  seldom  if  ever  danger- 
ous to  life.  In  the  great  majority  of  cases  the  articular  symptoms  soon 
disappear,  even  without  special  treatment.  The  danger  from  the  disease 
consists  in  its  cardiac  complications.  One  attack  of  rheumatism  is  almost 
certain  to  be  followed  by  others,  and  when  once  the  heart  has  been 
affected  it"  lesions  are  likely  to  increase  with  each  recurrence  of  the 
disease. 

Treatment.— Eheumatism  in  children  derives  its  chief  importance 
from  its  relation  to  cardiac  disease.  Cardiac  complications  are  so  fre- 
quent and  so  serious  that  everything  possible  should  be  done  to  avert 
rheumatism  from  those  who  by  inheritance  are  especially  predisposed  to 
it,  to  prevent  its  recurrence  in  a  child  who  has  once  had  the  disease,  and 
during  an  attack  to  prevent  the  heart  from  becoming  involved.  The 
relation  of  diet  to  rheumatism  is  very  imperfectly  understood.  Our  own 
opinion  is  that  there  is  no  close  connection  between  the  two.  The  under- 
clothing should  be  of  wool  during  the  entire  year,  in  summer  the  lightest 
weight  being  worn.  The  feet  should  be  carefully  protected,  and  exposure 
in  damp  weather  avoided.  Indoor  occupations  should  be  chosen  for 
rheumatic  boys. 

The  tendency  to  recurrence  is  so  strong  in  this  disease  that  a  child  of 
rheumatic  antecedents,  who  has  shown  in  the  various  ways  mentioned  a 
marked  predisposition  to  rheumatism,  and  who  has  had  an  attack,  even 
though  a  mild  one,  should,  if  possible,  spend  the  winter  and  spring  in 
some  warm,  dry  climate,  or  even  remain  there  permanently.  Otherwise 
in  most  such  children,  it  is  only  a  question  of  time  when,  with  the  re- 
peated attacks,  the  heart  will  become  involved. 

To  avert  the  danger  of  cardiac  complications  during  an  attack  of 
rheumatism,  or  to  limit  their  extent,  there  are  two  things  which  should 
invariably  be  insisted  on :  first,  to  confine  to  the  house  and  in  a  warm 
room  every  child  with  rheumatic  pains,  no  matter  how  mild;  secondly, 
if  fever  is  also  j^resent,  to  keep  the  child  in  bed  while  it  continues,  even 
though  it  may  not  be  above  100.5°  F.  Absolute  rest  aiid  the  equable 
temperature  thus  secured  are  unquestionably  of  more  importance  than 
anything  else  in  protecting  the  heart  during  a  rheumatic  attack.  With 
these  precautions  must  be  combined  an  early  diagnosis.  In  very  many, 
perhaps  in  most  cases,  the  harm  is  done  before  the  true  nature  of  the 
disease  is  suspected,  the  symptoms  being  dismissed  as  of  slight  impor- 
tance because  the  articular  manifestations  are  not  very  severe.     Children 


DIABETES  MELLITUS  1155 

who  have  once  had  rheumatism  should  be  closely  watched  during  chorea 
and  other  diseases  related  to  rheumatism,  the  heart  should  be  frequently 
examined,  and  the  physician  should  be  on  the  alert  for  the  first  articuJ^ 
symptoms.  ^^^^^^ 

Aside  from  the  measures  just  mentioned,  the  treatment  ^^B^ma- 
tism  in  childhood  is  to  be  conducted  very  much  like  that  oifflrclult  life. 
In  most  acute  attacks  either  salicylate  of  soda  (gr.  v  every  three  hours 
to  a  child  of  five  years),  aspirin,  oil  of  wintergreen,  or  salicin  should 
be  given;  as  the  majority  of  cases  are  not  very  acute,  marked  improve- 
ment is  by  no  means  always  obtained  by  these  drugs.  Alkalis  should  be 
given  in  all  cases  in  combination  with  the  salicylates,  but  particularly 
in  those  in  which  there  is  hyperacidity  of  the  urine.  Either  the  acetate 
or  citrate  of  potassium  or  the  bicarbonate  of  sodium  may  be  used,  a  suffi- 
cient quantity  being  administered  to  render  the  urine  alkaline. 

Quite  as  necessary  as  these  drugs  is  the  use  of  general  tonics,  par- 
ticularly iron  and  cod-liver  oil.  These  should  be  given  not  only  between 
attacks  to  fortify  patients  against  their  recurrence,  but  also  in  subacute 
cases  which  are  sometimes  influenced  very  little  or  not  at  all  either  by 
salicylates  or  alkalis. 

The  importance  of  attention  to  pathological  conditions  in  the  tonsils 
and  mouth  in  all  children  with  recurring  rheumatic  attacks  should  not 
be  overlooked;  especially  should  diseased  tonsils  be  removed  and  carious 
teeth  and  diseased  gums  receive  appropriate  treatment. 


CHAPTEE   II 

DIABETES  MELLITUS 

In  this  chapter  will  be  attempted  only  a  description  of  the  peculiar 
features  which  diabetes  presents  when  affecting  young  patients.  It  is 
a  rather  infrequent  disease  in  children.  Of  1,360  cases  of  diabetes  col- 
lected by  Pavy,  only  eight  were  under  ten  years  of  age.  In  a  series  of 
700  cases  collected  by  Prout,  only  one  case  was  under  ten  years.  In  a 
series  of  380  cases  collected  by  Meyer,  only  one  case  was  under  ten  years 
of  age.  More  recent  statistics  have  shown  that  the  proportion  of  children 
under  ten  among  diabetics  is  not  so  small  as  would  be  indicated  by  these 
figures.  Von  Noorden  has  reported  84  cases  in  children  under  ten  in 
about  3,000  cases  of  diabetes.  We  have  ourselves  seen  more  than  thirty 
cases. 

Etiology. — Stern,  in  a  series  of  IIT  collected  cases  of  diabetes  in 
children,  states  that  47  were  females  and  31  niivles,  the  sex  in  the  other 


1156  OTHER  GENEEAL  DISEASES 

cases  not  being  given.  Of  26  of  tlie  cases  observed  by  us,  16  were  in 
females  and  10  in  males.  It  seems  that  females  are  rather  more  fre- 
^^ntly  affected,  in  contrast  with  the  marked  preponderance  of  eases  in 
li^Muiadiilt  life.  Although  extremely  rare,  cases  have  been  observed 
durmg^^  first  year  of  life.  Statistics  on  this  point  are  not  altogether 
trustworni}^,  since  some  cases  of  temporary  glycosuria  have  certainly 
been  included.  The  yoimgest  case  that  has  come  under  our  observation 
was  in  a  boy  of  twenty-six  months. 

Among  the  etiological  factors  heredity  is  one  of  the  most  important. 
Pavy  reports  the  case  of  a  child  dying  of  diabetes  at  two  years  in  whose 
family  the  disease  had  existed  for  three  generations.  Instances  have 
been  recorded  of  the  occurrence  of  diabetes  in  four  or  five  children  of 
the  same  family.  There  was  a  family  history  of  the  disease  in  11  out  of 
26  patients  under  our  care.  Several  of  the  cases  reported  in  children 
have  been  preceded  by  injuries  received  upon  the  head.  In  a  number 
of  our  own  cases  the  disease  has  followed  the  consumption  of  large 
quantities  of  sugar  for  a  long  time.  Often  no  adequate  cause  can  be 
found. 

Symptoms. — The  most  important  early  symptoms  are  thirst,  polyuria, 
and  wasting;  their  development  is  often  quite  rapid.  The  thirst  is  in- 
tense, often  leading  children  to  drink  four  or  five  pints  of  fluid  a  day, 
or  even  more.  The  amount  of  urine  passed  varies  from  one  to  eight  quarts 
daily.  The  specific  gravity  is  from  1.026  to  1.010,  and  the  amount  of 
sugar  usually  large.  Acetone,  diacetic  and  /8-oxybutyric  acids  are  also 
present  in  greater  or  less  amount.  Albumin  is  not  infrequently  found. 
Incontinence  of  urine  is  an  important  symptom,  and  often  one  of  the 
earliest  to  be  noticed.  The  wasting  is  usually  quite  rapid,  so  that  a  child 
may  lose  as  much  as  six  or  eight  pounds  in  a  month.  It  is  generally 
accompanied  by  anemia.  The  appetite  may  be  poor;  at  times,  however, 
it  is  voracious.  Other  symptoms  of  less  importance  are  a  dry  mouth, 
scanty  perspiration,  irregular  sleep,  occasional  epistaxis,  furuncles  and 
abscesses,  decayed  teeth,  and  genital  irritation. 

The  course  of  the  disease  is  much  more  rapid  in  children  than  in 
adults,  and,  as  a  rule,  the  younger  the  child  the  more  rapid  its  progress. 
Without  proper  treatment,  the  great  majority  of  the  cases  prove  fatal 
in  from  three  to  six  months  from  the  time  the  symptoms  are  sufficiently 
marked  to  make  the  diagnosis  possible.  Occasionall3%  however,  one  of 
the  milder  type  may  be  prolonged  from  one  to  two  years. 

The  progress  of  the  disease  is  marked  by  continuous  wasting,  which 
may  result  in  a  striking  degree  of  malnutrition  and  prove  fatal.  Some 
are  carried  off  by  intercurrent  pneumonia  or  tuberculosis,  but  the  ma- 
jority die  comatose.  When  coma  develops,  the  case  may  be  considered 
hopeless,  and  death  is  likely  to  be  postponed  but  a  few  days.    The  cause 


DIABETES  MELLITUS  llfj? 

of  diabetic  coma  has  not  been  explained  with  entire  satisfaction.     It 
occurs  when  there  has  been  a   j^rolonged  and  severe   drain  upon   th^ 
alkaline  defenses  of  the  body  by  the  abnormal  acids  which  are  n^^^H 
themselveS;,  directly  poisonous.     Acidosis  is  a  regular  accompa^^^^^of 
coma.     Whether  it  is  the  sole  cause  is  at  the  present  time  n^^ntirely 
clear.    ^ 

Diagnosis. — Diabetes  is  apt  to  be  overlooked,  because  of  the  com- 
mon neglect  of  urinary  examinations  in  children.  The  prominent  symp- 
toms,— thirst,  polyuria,  and  wasting — when  associated,  should  always 
attract  attention.  Enuresis,  accompanied  by  marked  wasting,  is  always 
suspicious.  In  some  cases  genital  irritation  may  be  the  most  prominent 
early  symptom.  A  positive  diagnosis  is  made  only  by  an  examination 
of  the  urine. 

Prognosis. — In  few  diseases  has  the  prognosis  been  so  bad  as  in 
diabetes  in  children.  Senator  has  declared  that  diabetes  in  childhood 
is  hopeless  and  all  treatment  useless.  Von  IS^oorden  has  said  that  with 
rare  exceptions  diabetes  of  childhood  allows  no  respite.  Such  has  also 
been  our  experience.  From  the  more  recent  methods  of  treatment,  espe- 
cially that  recommended  and  elaborated  by  Allen,  much  more  is  to  be 
expected.  It  has  been  sufficiently  demonstrated  that  children  can  be 
maintained  in  a  satisfactory  condition,  free  from  sugar  and  gaining 
gradually  in  weight  for  many  months.  We  have  now  under  observation 
five  children  who  are  doing  well.  Whether  it  will  be  possible  for  them 
to  continue  in  this  way  and  to  reach  adult  life  properly  developed  is  a 
matter  which  only  the  future  can  decide.  The  outlook  is,  however,  not 
so  immediately  dark  as  it  has  been.  Intelligent  observation  and  unremit- 
ting care  are  required  both  by  the  physician  and  parents.  Without  them 
good  results  are  impossible. 

Treatment. — The  indications  for  treatment  are  the  same  in  children 
as  in  adults.  Nothing  more  can  be  indicated  here  than  the  principles  to 
be  followed.  In  diabetes  the  carbohydrate  tolerance  is  always  very 
greatly  diminished  but  usually  not  entirely  lost.  The  purpose  is  to 
increase  this  tolerance.  It  can  only  be  accomplished  by  protecting  the 
carbohydrate  mechanism  from  overstrain.  If  the  tolerance  is  exceeded 
and  sugar  is  excreted  in  the  urine,  the  carbohydrate  mechanism  becomes 
less  and  less  capa1)le  and  the  tolerance  sinks.  By  preventing  sugar 
excretion  the  mechanism  improves  and  the  tolerance  rises.  Patients 
should  therefore  be  rendered  sugar  free  at  the  earliest  possible  moment 
and  constantly  maintained  sugar-free.  This  may  be  accomplished  b}^  tem- 
porary starvation  until  no  sugar  appears  in  the  urine.  Nothing  what- 
ever by  mouth  should  be  allowed  but  clear  broth  and  water.  When 
there  is  no  sugar  excreted,  well-cooked  vegetables  may  be  given,  at  first 
those  containing  but   little   carbohydrate,   such   as   asparagus,   spinach, 


1158  OTHEE  GENERAL  DISEASES 

cabbage,  onions  and  celery.  After  two  or  three  days,  nitrogenous  foods, 
meat  or  fish  may  be  allowed  and  later  bacon,  butter,  olive  oil  and 
^ats.  All  of  these  are  to  be  given  in  small  amount  at  first  and 
gxcivAci^^— increased  until  the  nitrogenous  and  caloric  needs  of  the  body 
are  satiSRl.  Loss  of  weight  at  first  is  to  be  expected  and  is  not  to  be 
feared.  Carbohydrate  tolerance  and  not  the  weight  curve  is  the  index 
of  progress.  It  is  important  that  a  record  should  be  kept  of  the  amount 
of  carbohydrate  taken  and  of  the  amount  of  sugar  and  acetone  bodies 
excreted  in  the  urine.  Xot  more  than  10  grams  of  carbohydrate  a  day 
should  be  given  at  first  and  any  increase  should  be  slowly  made.  Even 
if  no  sugar  appears  in  the  urine,  it  is  advisable  in  severe  cases  to  intro- 
duce a  day  of  only  broth  feeding  every  ten  days  or  two  weeks,  after 
which  a  low  carbohydrate  diet  should  be  instituted  and  the  carbohydrates 
again  gradually  increased.  From  time  to  time  an  attempt  should  be 
made  to  introduce  articles  of  food  such  as  oatmeal  and  milk  in  small 
quantities  but  never  in  amount  sufficient  to  cause  glycosuria.  If  sugar 
appears,  a  rapid  and  great  reduction  in  the  carbohydrates  of  the  food  is 
to  be  made  and  any  increase  should  be  instituted  with  caution,  and  not 
for  several  weeks  should  the  amount  be  reached  which  was  formerly 
followed  Ijy  glycosuria. 


CHAPTEE   III 

PELLAGRA 

Although  it  is  only  recently  that  pellagra  has  attracted  much  atten- 
tion in  this  country,  it  is  not  likely  that  it  has  existed  here  for  only  a 
few  years,  but  rather  that  it  has  not  been  recognized.  At  the  present  time 
its  etiology  is  not  understood.  Three  theories  as  to  its  cause  have  been 
advanced.  The  first  and  the  one  longest  held  is  that  it  is  due  to  the 
eating  of  spoiled  corn  (maize).  In  this,  toxic  products  are  supposed 
to  be  produced  by  the  growth  of  fungi  or  of  bacteria.  The  second  is 
that  it  is  a  parasitic  disease  transmitted  by  the  bite  of  an  insect  (the 
gnat).  The  third,  and  the  view  which  is  becoming  more  and  more 
widely  accepted,  is  that  it  is  due  to  a  diet  deficient  in  certain  important 
constituents  (vitamins),  which  places  it  in  the  same  group  as  scurvy 
and  beriberi.  The  recent  observations  of  Goldberger  have  shown  that 
recurrences  of  the  disease  may  be  prevented  by  a  reduction  in  the  amount 
of  carbohydrate  food,  and  by  considerable  increase  in  vegetable  and  ani- 
mal proteins,  especially  fresh  milk,  eggs,  meat  and  leguminous  vege- 
tables. His  observations  indicate  that  pellagra  may  l)e  produced  by  giv- 
ing a  diet  which,  thous^h  abundant,  may  consist  chieflv  of  carbohvdrates 


vr 


PELLAGEA  1159 

and  from  which  fresh  animal  and  vegetable  proteins  have  been  excluded. 

Pellagi'a  is  seen  at  all  ages  although  it  is  comparatively  rare  in 
very  young  infants.  After  two  years  of  age  it  is  much  more  common..^ 
It  is  found  with  greatest  frequency  in  the  states  of  the  South  Atlanlie 
Coast,  although  cases  have  been  reported  from  almost  every  state  in  the 
Union  and  even  from  Canada.  Pellagra  is  a  disease  preeminently  of 
the  warm  months, — spring,  summer  and  autumn.  As  soon  as.  cool 
weatlier  comes  it  usually  diminishes  much  in  severity  and  in  frequency, 
but  cases  sometimes  develop  even  during  the  winter.  It  is  found  chiefly 
among  the  poor  living  in  unsanitary  surroundings,  but  no  class  is  entirely 
exempt.  While  it  is  found  in  cities  as  well  as  towns,  it  occurs  more  often 
in  country  districts. 

There  are  no  characteristic  anatomical  lesions  in  pellagra.  Cellular 
change  in  the  brain  is  common.  In  the  cord  degeneration  of  the  lateral 
and  posterior  columns  is  frequently  found,  but  usually  only  in  cases  that 
have  existed  for  many  months  or  years. 

Symptoms. — The  symptoms  in  a  well-marked  case  are  easy  to  recog- 
nize, but  in  the  mild  form  the  disease  may  be  almost  impossible  to  detect, 
and  it  may  be  a  long  time  before  a  definite  conclusion  as  to  the  diagnosis 
can  be  reached.  There  are  three  chief  symptoms — the  cutaneous  lesions, 
the  gastro-intestinal  symptoms  and  those  of  the  nervous  system.  The 
cutaneous  or  the  gastro-intestinal  symptoms  are  those  first  in  evidence. 
The  eruption  is  found  chiefly  on  exposed  surfaces  and  for  this  reason  and 
because  it  often  begins  with  the  advent  of  warm  weather,  it  is  frequently 
mistaken  for  sunburn.  The  eruption  begins  as  an  erythema,  but  after  a 
variable  length  of  time  exfoliation  takes  place,  desquamation  being  in 
some  cases  very  marked.  The  skin  is  thickened,  rough  and  dry,  although 
in  exceptional  circumstances  vesicles  and  bullae  may  be  found  and 
ulceration  even  may  take  place.  The  eruption  (Fig.  201)  is  found 
upon  the  hands,  neck,  face  and  feet,  although  it  may  spread  far  up  the 
arms  and  legs  and  involve  even  portions  of  the  trunk  as  well.  It  is 
strikingly  symmetrical  and  the  lesions  are  sharply  outlined;  when  they 
are  not  so  it  usually  indicates  that  the  eruption  is  receding.  There  is  a 
certain  amount  of  brownish  discoloration,  its  intensity  depending  some- 
what upon  the  complexion  of  the  person  affected.  Xo  itching  is  com- 
plained of,  but  a  slight  burning  or  tingling  sensation.  The  nails  are 
unaffected.  The  tongme  is  oftentimes  red;  it  may  be  coated,  with  clear 
edges,  or  it  may  be  dry  and  glazed.  The  papillae  are  often  somewhat 
enlarged.  The  tongue  may  be  swollen.  In  addition  to  the  glossitis  there 
may  be  also  stomatitis  and  gingivitis.  Burning  in  the  mouth  is  an  occa- 
sional complaint. 

The  gastric  symptoms  are  few.  Vomiting  is  rare.  Anorexia  may  be 
marked  but  at  times  there  is  a  craving  for  unusual  food.     Diarrhea  is 


1160 


OTHER  GEXERAL  DISEASES 


the  rule.     The  stools  are  from  two  or  three  to  as  many  as  fifteen  a  day. 
They  may  be  watery,  but  at  times  mucus  and  even  blood  are  present. 
^Prolonged  constipation  is  rare,  but  the  diarrhea  often  alternates  with 
periods  of  constipation. 

The  n^ental  symptoms  are  not  so  marked  in  children  as  in  adults. 


Fig.  201. — Pellagra.     Boy,  five  years  old;  died  of  the  disease  five  months  later. 


Depression  is  often  present.  There  is  frequently  a  change  in  disposition, 
the  children  becoming  dull,  morose  and  peevish.  An  anxious,  distressed 
facial  expression  is  characteristic  of  marked  cases.  The  reflexes  are 
usually  exaggerated.  Ankle  clonus  is  frequently  present  and  there  may 
be  a  decided  tremor  upon  exertion.  If  the  intestinal  symptoms  are 
marked,  there  may  be  great  loss  of  weight.  The  progress  of  the  symptoms 
is  not  usually  continuous,  but  there  are  marked  remissions  and  exacerba- 
tions.    The  disease  often  disappears  in  the  fall  and  winter  to  return 


PELLAGRA  1161 

again  the  following  spring  and  this  may  he  repeated  many  times.  It  is 
for  this  reason  difficult  to  say  when  tlie  disease  is  really  cured.  The 
prognosis  in  children  is  better  than  that  in  adults  but  death  may  occur 
from  a  continuance  of  the  diarrhea,  from  the  development  of  marked 
malnutrition  or  from  intercurrent  infections. 

Treatment. — Xo  speciiic  remedy  for  the  disease  has  yet  been  discov- 
ered. The  gastro-intestinal  condition  should  be  treated  symptomatically. 
Pellagrous  mothers  should  not  nurse  their  infants.  They  should  be 
artificially  fed  or  a  wet-nurse  should  be  secured.  In  children  beyond 
the  nursing  age  the  diet  should  be  a  mixed  one,  suited  to  the  age  of  the 
child  so  far  as  the  gastro-intestinal  symptoms  will  allow.  Following  the 
suggestions  derived  from  Goldberger's  observations,  careful  attention 
should  be  given  to  the  food.  A  faulty  diet  in  which  carbohydrates,  espe- 
cially corn  meal,  have  been  excessive  should  be  replaced  by  one  with  an 
abundance  of  milk,  eggs,  fresh  meat,  peas  and  beans.  The  patient  should 
be  put  in  the  best  hygienic  surroundings  possible.  Arsenic  is  believed  to 
be  of  special  value.  It  may  be  given  by  mouth  in  the  form  of  Fowler's 
solution,  but  it  is  thought  by  many  to  be  more  effective  when  given  hypo- 
dermatically.  Sodium  cacodylate  may  be  used  in  doses  of  1/13  to  ^4 
grain  repeated  two  or  three  times  at  -intervals  of  several  days. 


INDEX 


Abdomen,  examination  of,  39  ;  growth  of, 

25  ;  in  rickets,  254. 
Abscess,  alveolar,  273 ;  cerebral,  759 ; 
cerebral,  in  acute  otitis,  943 ;  hepatic, 
439  ;  ischiorectal,  434  ;  mammary,  117  ; 
multiple,  in  newly  born,  86  ;  peritoneal, 
445  ;  peritonsillar,  307  ;  psoas,  in  spinal 
caries,  911  ;  retro-esophageal,  312 ;  re- 
tro-pharyngeal,  in  Pott's  disease,  293, 
908  ;  subphrenic,  455. 

Acid,  h.vdrochloric,  Increased  by  lavage, 
340  ;  hydrochloric,  in  stomach  digestion, 
317  ;  in  chronic  gastric  digestion.  341. 

Acidosis,   217.  365  ;  treatment  of,   372. 

Adenitis,  simple,  acute,  862 ;  simpli', 
chronic,  865. 

Adenoid  vegetations  of  pharynx,  294 ; 
asthma  from.  488 ;  causing  chronic 
nasal  catarrh,  460 ;  chronic  laryngitis 
with,  472  ;  in  rickets,  255  ;  with  adeni- 
tis,   865, 

Adenoma,    of  umbilicus,    114, 

Agenesis,    cortical,    779. 

Airing,    when    allowed    out   of   doors,    8. 

Air-space   required    by   infants,    10. 

Alalia,   711. 

Albumin   water,   preparation  of,   164. 

Albuminuria,  orthostatic  or  cyclic,  617  ; 
in  chronic  cardiac  disease,  598 ;  in 
chronic  nephritis,  637  ;  in  measles,  986  ; 
in  scarlet  fever,  966. 

Alcohol,  as  stimulant,  54 ;  as  tonic,  55  ; 
effect  of,  on  breast  milk,  175  ;  use  of, 
in  diet  of  nurse,   143. 

Amaurotic   family   idiocy,   788. 

Amebic  colitis,  390. 

Amyloid  degeneration,  441 ;  in  chronic 
bone  disease,  907  ;  of  the  intestines, 
391 ;  of  the  liver,  391  ;  of  the  .spleen, 
391. 

Anemia,  cardiac  murmurs  in,  607  ;  perni- 
cious, 846 ;  pseudoleukemic,  of  infan- 
cy, 844 ;  secondary,  841  ;  treatment, 
847. 

Anesthetics,  66. 

Aneurism,  612. 

Antipyretic  drugs,  53. 

Antipyretics,  51. 

Antitoxin,  in  tetanus,  92;  eliminated  by 
human  milk,  143. 

Anuria,  621. 

Anus,  fissure  of  the,  431  ;  imperforate, 
118. 


Aorta,  abnormal  origin  ot  582  ;  aneurism 
of,    612 ;   atheroma   of,    612 ;   hypoplasia 
of,   611  ;  thrombosis  of,   611. 
Aortic  insufficiency,  600  ;  stenosis,  COO. 
Aphasia,     functional,     711  ;     in     acquired 
cerebral    paralysis,    786 ;    after    typhoid 
fever,    1064. 
Appendicitis,     418 ;     diagnosis     of,     421  ; 

treatment    of,    422. 
Arm,    paralysis  of,   at  birth.    111. 
Arsenic,    as    a    tonic,    55  ;    dosage    of,    in 

chorea,    699. 
Arteries,     hypogastric,     in     fetal     circula- 
tion,   575  ;    hypoplasia   of,    611 ;    umbili- 
cal,   in    fetal    circulation,    575. 

Arthritis,  acute,  of  infants,  900 ;  atro- 
phic, 902 :  chronic,  902 ;  gonococcus, 
('.53,    659,   900 ;   rheumatic,    1150. 

Arthrogryposis    (see   Tetany),    677. 

Artificial    feeding,    179 ;    versus    wet-nurs- 
~  ing,  168. 

Ascaris  lumbricoides  (see  Worms,  Intes- 
tinal), 425. 

Ascites,  454  ;  chylous,  455;  in  acute  dif- 
fuse nephritis,  631  ;  in  cirrhosis  of  liver, 
440  ;  with  chronic  peritonitis,  448  ;  with 
tuberculosis  of  the  peritoneum.  450. 

Asphyxia,  death  from,  in  young  children, 
46  ;  from  overlying,  48  ;  from  aspiration 
of  food,  48 ;  from  enlarged  thymus, 
49  ;  in  convulsions,  675  ;  in  retropharyn- 
geal abscess,  292 ;  in  the  newly  born, 
69 ;  from  tuberculous  bronchial  lymph 
nodes,  1098  ;  methods  of  resuscitation, 
72 ;  sudden,  in  retro-esophageal  ab- 
scess,  313, 

Aspiration,  of  chest,  in  empyema,  570. 

Asthma,  487 ;  with  adenoids,  297 ;  simu- 
lated by  tuberculous  bronchial  glands, 
1096  ;   treatment,   491. 

Ataxia,  Friedreich's,  820 ;  in  multiple 
neuritis,   831. 

Atelectasis,  acquired,  553  :  in  delicate  in- 
fants, 554 ;  causing  sudden  death,  49 ; 
congenital,   74. 

Atheroma,   612. 

Athetoid  movements,  701  ;  in  acquired 
cerebral  paralysis,  786  ;  in  birth  paral- 
ysis,  783. 

Athetosis,    701. 

Atrophy,  infantile  (see  MARASMrs),  227; 
muscular  spinal,  types  of,  822 ;  mus- 
cular neural,  types  of,  822. 


1163 


1164 


INDEX 


Babcock's    centrifugal    machine,    149. 

Bacillus,  of  diphtheria,  1020,  1041  ;  dis- 
tribution of,  in  the  body,  1023 ;  in 
milk,  146 ;  in  healthy  throats,  1041 : 
in  laryngeal  diphtheria,  1041  ;  non- 
virulent,  1041;  of  dysentery  (Shiga), 
in  ileocolitis,  acute,  374 ;  in  gastro- 
intestinal intoxication,  acute,  374 ;  of 
Eberth,  in  typhoid  fever,  1058 ;  Klebs- 
Loeffler  (see  B.  Diphtherie),  1020; 
lactis  aerogenes,  319 ;  of  Pfeiflfer,  in 
influenza,  1130  ;  pseudodiphtheria.  301  ; 
of  tuberculosis,  1067  ;  in  acute  broncho- 
pneumonia,   495. 

Backwardness,   792. 

Bacterium  coli  communis,  319  ;  in  appen- 
dicitis,   419 ;   in    peritonitis,    445. 

Bacterium  lactis  aerogenes,  319. 

Balanitis,  653. 

Band,    abdominal,    1,    3. 

Barley  water,  directions  for  making,  164  ; 
use  of,  during  first  year,  198. 

Barlow's  disease  (see  Scorbutus)  231. 

Bath,  at  birth,  1,  2 ;  cold,  53 ;  in  acute 
bronchopneumonia,  524 ;  in  asphyxia, 
of  newly  born,  72 ;  evaporation,  53 ; 
hot,  59 ;  hot  air,  59 ;  vapor,  56 ;  mus- 
tard, 59  ;  bran,  60  ;  tepid,  60  ;  shower, 
60 ;  cold  sponge,  60 ;  hot,  in  asphyxia 
of  newly  born,  72 ;  in  typhoid  fever, 
1067. 

Bed-wetting,    662. 

Beef,   raw  scraped,  163. 

Beef  broth,  163. 

Beef  extracts,   163. 

Beef  juice,   159. 

Beef   preparations,   159. 

Belladonna,  56 ;  elimination  of,  in  milk, 
143  ;  scarlatiniform  rash  from,  970. 

Bile,   physiological  action  of,   318. 

Bile  ducts,  congenital  malformations  of, 
78. 

Birth   paralyses,   106. 

Bladder,  control  of,  acquired,  663 ;  ex- 
strophy of,  651  ;  hemorrhage  from,  in 
newly  born,  105  ;  stone  in,  667  ;  train- 
ing  to    control,    4. 

Bleeders,    852. 

Blindness,  hysterical,  705 ;  transient,  in 
pertussis,    1010. 

Blood,  circulation  of,  in  early  life,  575 ; 
diseases  of,  839 ;  in  chlorosis,  843 ;  in 
leukemia,  849 ;  in  pernicious  anemia, 
846 ;  in  pseudoleukemic  anemia,  844 ; 
in  secondary  anemia,  841  ;  transfusion 
of,   68. 

Blood  vessels,  diseases  of,  611 ;  aneurism, 
612 ;  coarctation  of  the  arch  of  the 
aorta,   611. 

Boil   (see  Furunculosis),  930. 

Bones,  diseases  of,  895  ;  in  hereditary 
syphilis,  1115  ;  in  late  syphilis,  1118 ; 
lesions  of.  in  rickets,  244  ;  microscop- 
ical changes  of,   in  rickets,   245  ;   syphi- 


litic diseases  of,  1118  ;  tuberculous  dis- 
eases of,  905. 

Bothriocephalus    latus,    424. 

Bottles,  nursing,   choice  and  care  of,   196. 

Bow-legs,  in  rickets,  253. 

Bradycardia,  609. 

Brain,  diseases  of,  719  ;  abscess  of,  759 ; 
atrophy  and  sclerosis  of,  780,  784 ; 
atrophy  and  sclerosis  of,  in  acquired 
cerebral  paralysis,  780  ;  cysts  of,  in  in- 
fantile cerebral  paralysis,  781  ;  malfor- 
mations of,  719;  tuberculosis  of,  1080  ; 
tumor   of,    762 ;    weight   of,    669. 

Bran    bath,    60. 

Breast,   abscess   of,  in  newly  born,  117. 

Breast-feeding,  166  ;  schedule  for,  171. 

Breast  milk    (see  Milk,   Woman's). 

Breath,  offensive,  in  ulcerative  stomatitis, 
279. 

Breathing,  noisy,  with  adenoids,  296 ; 
stridulous,  in  diseases  of  the  larynx, 
463,  469,  473 ;  in  retro-esophageal  ab- 
scess,   314. 

Bright's    disease    (see    Nephritis),    629. 

Bromids,   elimination  of,   in  milk,   143. 

Bronchi,  catarrhal  spasm  of,  489  ;■  diph- 
theria of,  1026  ;  foreign  bodies  in,  475  ; 
lesions  of,  in  acute  bronchopneumo- 
nia, 498 ;  lymph  nodes  of,  in  tubercu- 
losis, 1073,  1078 ;  tube  casts  from, 
486. 

Bronchial  glands  (see  also  Lymph  Nodes, 
Bronchial),  1095;  enlarged,  cause  of 
asthma,  488 ;  in  acute  bronchopneu- 
monia,  509. 

Bronchitis,  acute  catarrhal,  479 ;  symp- 
toms of,  480,  483;  treatment  of,  4.E3, 
485  ;  capillary  (see  Bronchopneumonia, 
Acute),  497,  506;  attacks  of  asthma 
resembling,  489  ;  chronic,  486  ;  chronic, 
in  rickets,  246 ;  diphtheritic,  broncho- 
pneumonia in,  517  ;  fibrinous,  485 ; 
treatment,  486 ;  in  pertussis,  1008 ;  in 
typhoid  fever,  1063 ;  spasmodic  (see 
Asthma),   489;  tuberculous,  1087. 

Bronchiectasis,  in  chronic  bronchitis,  487; 
in  bronchopneumonia,  chronic,  547. 

Bronchopneumonia,  acute,  497 ;  bacteri- 
ology of,  495,  490 ;  complications  in, 
518  ;  complicating  influenza,  517  ;  com- 
plicating diphthei'ia,  517  ;  complicating 
measles,  517  ;  complicating  pertussis, 
515  ;  complicating  rickets,  246 ;  diag- 
nosis of,  519  ;  etiology  of,  497  ;  lesionu 
in,  498 ;  associated  in  the  lung,  504 ; 
physical  signs  of,  illustrated,  513  ;  pro- 
tracted or  persistent  form  of,  515  ;  sec- 
ondary pneumonia  with  measles,  984  ; 
ileocolitis,  associated  with,  381  ;  influ- 
enza, associated  with,  1136 ;  pertussis, 
associated  with,  1008  ;  diphtheria,  asso- 
ciated with,  1036  ;  prognosis  of,  520  ; 
protracted  cases  of,  51."  ;  symptoms  of, 
505  ;  temperature  charts  of,  510  ;  termi- 


INDEX 


1165 


nations  of,  503 ;  treatment  of,  523 ; 
prophylaxis    in,    523. 

Bronchopneumonia,  chronic,  540,  542. 

Bronchopneumonia,  tuberculous,  1086 ; 
rapid  cases,  1087 ;  protracted  cases, 
1088;  (see  also  Tuberculods  Pneu- 
monia), 1086,  1092. 

Broths,  directions  for  making,   163. 

Buhl's   disease,   93. 

Buttermilk,   159,   207,    388. 

Calamine  lotion,  929. 

Calculi,  biliary,  443 ;  renal,  646  ;  pyelitis 
with,   647  ;   vesical,   667, 

Calories,  required  daily  by  healthy  in- 
fants, 180  ;  method  of  calculating,  181  ; 
value  of  different  foodstuffs  in,  .129, 
181. 

Cancrum  oris  (see  Stomatitis  Gan- 
grenous), 285. 

Carbohydrates,  function  of,  in  diet,  131. 

Carcinoma,  of  brain,  762 ;  of  stomach, 
345. 

Casein,  150,  183. 

Caseinogen,  150. 

Casts,  in  urine,  of  chronic  nephritis,  637. 

Catarrh,  of  eustachian  tube,  in  hyper- 
trophy of  tonsils,  308 ;  gastric,  337 ; 
nasal  acute,  457  ;  prophylaxis  in,  459  ; 
chronic,  460 ;  with  adenoid  growths, 
296  ;  foreign  bodies  in  nose,  460  ;  nasal 
polypi,  461 ;  rhinitis,  simple  chronic, 
461  ;  epidemic,  1138  ;  syphilitic,  462 ; 
rhinopharyngeal,   with    adenoids,   296. 

Catheters,  sizes  required  for  infants,  615. 

Cellulitis,  of  abdominal  wall  with  peri- 
tonitis, 445  ;  of  neck,  in  scarlet  fever, 
964. 

Cephalhematoma,  97. 

Cereals,  164  ;  allowed  from  third  to  sixth 
year,  212. 

Cerebral  abscess,    761. 

Cerebral  tumor,  762. 

Cerebral  paralysis,  infantile,  779 ;  from 
hemorrhage,  106  ;  etiology  of,  106. 

Cerebrospinal  meningitis  (see  Meningitis, 
Acute  Cerebrospinal),  727. 

Chest,  circumference  of,  24  ;  development 
of,  24;  "funnel"  chest,  24;  lateral  de- 
pressions of,  in  adenoids,  296. 

Chicken-pox    (see  Varicella),   994. 

Chloral,  dosage  and  administration  of,  50. 

Chlorosis,  843  ;  treatment  of,  847. 

Cholera  infantum,  363  ;  treatment  of,  367, 
373. 

Chondrodystrophy,  897. 

Chorea,  694 ;  endocarditis  in,  596,  697 ; 
diagnosis  of,  698  ;  etiology  of,  694  ;  fol- 
lowing birth  paralysis,  783  ;  typhoid  fe- 
ver, associated  with,  1064  ;  heart  mur- 
murs in,  697 ;  prognosis  of,  698 ;  hys- 
terical, 707 ;  with  adenoids,  297 ;  in 
rheumatism,  695,  1152 ;  pathology  of, 
696 ;    posthemiplegic,    701  ;    in    cerebral 


palsy,  783  ;  prognosis  of,  698  ;  relation 
of,  to  rheumatism,  695  ;  speech  in,  697, 
711  ;  symptoms  of,  696 ;  treatment  of, 
698. 

Circulation,  changes  in,  at  birth,  575 ; 
fetal,  575  ;  in  early  life,  575. 

Circulatory  system,  diseases  of,  575. 

Cleft  palate,  265. 

Clothing,  at  birth,  2 ;  in  summer,  3 ;  at 
night,  3  ;  in  summer  diarrhea,   368. 

Club-foot,    with   spina   bifida,    799. 

Codein,   dosage  of,   56. 

Cod  liver  oil,   as  tonic,   54. 

Cold,  antipyretic  methods  in  use  of : — 
ice  cap,  52 ;  sponging,  52 ;  pack,  50 ; 
bath,   53 ;   colon  irrigation,  53. 

Cold  sores,  269. 

Colic,  habitual,  194 ;  intestinal,  401 ; 
renal,  647. 

Colitis,  acute  (see  Ileocolitis,  Acute), 
373  ;  amebic,  390  ;  membranous,  379  ; 
membranous  gastritis,  with,  338. 

Collapse,  in  acute  bron<:hopneumonia, 
treatment  of,  525  ;  in  acute  peritonitis, 
447  ;   in   ulcer  of  stomach,   343. 

Collapse,  pulmonary  (see  Atelectasis, 
Acquired),  553. 

Colles's  law,   1105. 

Colon,  abnormal  position  of,  350  ;  dilata- 
tion of,  408  ;  in  rickets,  254  ;  follicular 
ulcer  of,  377 ;  hypertrophy  of,  408 ; 
irrigation  of,  53,  64 ;  gastro-enteric 
intoxication,  371 ;  in  acute  ileocolitis, 
388  ;  membranous  inflammation  of,  385. 

Colostrum,  134. 

Coma,   in   diabetes   mellitus,   1156. 

Compression-myelitis   (see  Myelitis),  804. 

Condensed  milk,  as  a  cause  of  rickets, 
241  ;  composition  of,  158 ;  dilution  of, 
for  infants,  158  ;  fresh,   158. 

Congenital  diseases,  ichthyosis,  875  ;  my- 
atonia,  827 ;  myotonia,  702  ;  rickets, 
256  ;   syphilis,  1104  ;   tuberculosis,  1069. 

Conjunctiva,  catarrhal  inflammation  of, 
in  measles,  986 ;  hemorrhage  from,  in 
newly  born,   105. 

Constipation,  in  rickets,  254 ;  chronic, 
403 ;  treatment  of,  405  ;  dilatation  of 
colon  in,  408  ;  anal  fissure  from,  431 ; 
early  symptom  of  rickets,  248;  from 
deficient  fat  in  food,  241  ;  in  intussus- 
ception, 416. 

Contractures,    hysterical,    706. 

Convulsions,  671  ;  symptoms  of,  672 ; 
treatment  of,  675  ;  causing  death  with- 
out other  symptoms,  47  ;  epileptic,  687  ; 
hysterical,  707  ;  in  acquired  cerebral 
paralysis,^785  ;  in  cerebral  hemorrhages, 
109 ;  in  congenital  atelectasis,  75 ;  in 
pertussis,    1009 ;    in    rickets,    248. 

Cord,  spinal,  diseases  of,  796 ;  malforma- 
tions of,  796  ;  meningitis,  802  ;  myelitis, 
803  ;  pressure-paralysis  of,  808  ;  tumors 
of,    819 ;   weight  of,   669. 


1166 


INDEX 


Cord,  umbilical,  care  of,  1  ;  separation  of, 
2. 

Corpuscles,  of  blood,  S30. 

Coryza,  457  ;  early  symptoms  of  measles, 
978;   syphilitic,   462,    1111. 

Cough,  hysterical.  707  ;  from  tuberculous 
bronchial  glands,  1096 ;  whooping  (see 
Pertussis),  1003. 

Counterirritants,  57. 

Cow's  milk   (see  Milk),  144. 

Craniotabes,  early  symptom  in  rickets, 
248. 

Cranium,    syphilitic    nodes    on,    1119. 

Cream,  151 ;  to  secure  different  percent- 
ages   of,    151,    152. 

Cream-gauge,    139,    149. 

Credo's  method  of  preventing  ophthalmia 
neonatorum,  1  ;  treatment  of  ophthal- 
mia. 90. 

Cretinism   sporadic,    881. 

Croup,  bronchial,  485  ;  catarrhal,  465  ; 
spasmodic,  4(55. 

Croupous  tonsillitis,   300. 

Cry,  causes  and  varieties  of,  34  ;  in  dis- 
eases,  35  ;  in  colic,  402. 

Cryptorchidism,    652. 

Cups,   dry,  indications   for,   58. 

Cyanosis,  in  acute  bronchopneumonia,  506, 
508  ;  in  acute  inanition,  220  ;  in  chron- 
ic cardiac  disease,  598 ;  in  congenital 
atelectasis,  74 ;  in  congenital  disease 
of  heart,  583 ;  in  diphtheritic  pa- 
ralysis, 834 ;  in  malaria,  1142,  1144 ; 
of  face,  from  pressure  at  root  of  lung, 
1097. 

Cyclic   vomiting,    331. 

Cyst,  of  brain,  762  ;  of  brain,  in  infantile 
cerebral  paralysis,  781. 

Cysticerci,   423. 

Dactylitis,  syphilitic,  1116 ;  tuberculous, 
918. 

Deaf-mutism,  795. 

Deafness,  following  mumps,  1019 ;  with 
adenoids,  296  ;  with  hypertrophy  of  ton- 
sils, 309  ;  sudden,  in  late  syphilis,  1122. 

Death,  most  frequent  causes  of,  at  differ- 
ent ages,  46  ;   sudden,  causes  of,   48. 

Deformities,  hysterical,  706 ;  in  rickets, 
248. 

Dental  caries,   272. 

Dentition,  28  ;  eruption  of  first  teeth,  28  ; 
eruption  of  permanent  teeth.  29.  30 ; 
delayed,  29  ;  before  birth,  28 ;  difBcult, 
273  ;  in  rickets,  254. 

Development,  conditions  interfering  with, 
30 ;   muscular,   25  ;   of  body,   15. 

Dew's  method  of  inducing  artificial  respi- 
ration, 73. 

Diabetes  insipidus,  621. 

Diabetes  mellitus,  1155. 

Diagnosis,  general  considerations  in,  31. 

Diapers,    3. 

Diarrhea,    general    consideration    of,    350; 


deaths  from,  in  New  York  in  five  years, 
350  ;  prevalence  of,  during  summer,  351 ; 
impure  milk  as  a  cause  of,  352  ;  observa- 
tions of  the  Rockefeller  Institute,  on 
association  of  feeding  impure  milk  and 
diarrheal  disease,  343  et  seq.  ;  inflam- 
matory (see  Ileocolitis,  Acute),  373; 
with  acute  intestinal  indigestion,  357 ; 
with  chronic  intestinal  indigestion,  395  ; 
summer,   357. 

Diathesis,  exudative,  261  ;  neuropathic,  262. 

Diet  (see  also  Feeding),  as  cause  of 
chronic  constipation,  403 ;  as  cause  of 
rickets,  241  ;  in  acute  gastric-enteric 
infection,  368  ;  in  acute  gastric  indiges- 
tion, 328  ;  in  chronic  constipation,  405  ; 
in  chronic  gastric  indigestion,  340 ;  in 
dental  caries,  272  ;  in  eczema,  928  ;  in 
intestinal  indigestion,  388  ;  in  malnutri- 
tion, 230 ;  in  I'ickets,  258 ;  in  scurvy, 
239 ;    of  nurse,    effect  of,    on   milk,    142. 

Digestion,  gastric,  315  ;  duration  of,  317  ; 
in  infancy,  315  ;  intestinal,  318. 

Digestive  s,ystem,  diseases  of,  267. 

Digitalis,  dosage  of,  54 ;  in  cardiac  dis- 
ease.  593,   604. 

Dilatation,    of    stomach,    341. 

Diphtheria,  1020  ;  bacillus  (see  Bacillus 
OF  Diphtheria),  1020;  bronchopneu- 
monia in,  517,  1028,  1036;  blood  in, 
1028  ;  cardiac  failure  in,  1038  ;  cardiac 
thrombi  in,  1028  ;  catarrhal,  1024, 
1030  ;  complications  and  sequelae,  1036  ; 
diagnosis,  1038  ;  bacteriological,  1041 ; 
clinical,    1039 ;    from    pseudodiphtheria, 

1041  ;  distribution  and  mode  of  com- 
munication of,  1021  ;  etiology  of,  1020  ; 
fibrinous  bronchitis  in,  485  ;  immunity 
to,  1022 ;  immunization  from,  1044 ; 
ileocolitis  in,  1037  ;  incubation,  1023 ; 
lesions,  1023 ;  membrane,  973 ;  proc- 
titis in,  432 ;  myocarditis  in,  605, 
1038 ;  nasal  syringing  in,  1046 ;  ne- 
phritis in,  1027,  1037 ;  of  esophagus, 
311  ;  otitis  in,  1036 ;  paralysis  after, 
1037 ;    paralysis   in,    832 ;    prognosis   of, 

1042  ;  prophylaxis  in,  1043  ;  quarantine 
in,  1043  ;  simulated  after  tonsillotomy, 
310  ;  symptoms  of,  1029  ;  thrombosis  in, 
1036 ;  toxins  of,  1024 ;  treatment  of, 
1045;  local  treatment  of.  1040;  serum 
treatment  of,  1047  :  treatment  of  chil- 
dren exposed  to,  1044 ;  treatment  of 
suspected  cases  of,  1043 ;  laryngeal, 
1029,  1033,  1052 ;  nasal.  1030,  1031  ; 
pseudo-  (see  Pseudo-diphtheria),  300; 
scarlatiniform  erythema  in,  970 ;  ton- 
sillar,  1030. 

Diphtheria  antitoxin,  dosage  of,  1048 ; 
immunizing  dose  of,  1044  ;  local  and 
general  effects  of,  1049 ;  other  treat- 
ment with,  1045,  1046 ;  real  and  al- 
leged dangers  from,  1050  :  strength  of, 
1048  ;   time   of  administration   of,   1048. 


INDEX 


1167 


Diplegia,  in  birth  paralysis,  783 ;  from 
meningeal  hemorrhage,  109 ;  spastic, 
779. 

Disease,  peculiarities  of,  in  children,  30  : 
etiology  of,  o<» ;  symptomatology  and 
diagnosis  of,  '.i^  :  imthology  of,  41  ; 
prognosis  of,  4;>  ;  prophylaxis  in,  00  ; 
therapeutics  in.   '>1. 

Dover's   po^Yder,   dosage  of,  5G. 

Dropsy  (see  also  Edema),  in  acute  dif- 
fuse nephritis,  6.32  ;  in  chronic  cardiac 
disease,  591  ;  in  chronic  nephritis,  630  : 
in  tuberculosis,  1091  ;  without  renal 
disease,   224. 

Drugs,  administration  of,  51  ;  antipyretics, 
51  ;  sedatives,  dosage  of,  56 ;  stimu- 
lants, dosage  of,  55  ;  elimination  of,  in 
breast  milk,  143  ;  well  borne  by  chil- 
dren, 57  ;  not  well  borne  by  children,  57. 

Duodenum,  congenital  atresia  of,  118. 

Dura  mater,  hematoma  of,  724 ;  throm- 
bosis of  the  sinuses  of,  757. 

Dysentery   (see  Ileocolitis,  Acute),  373. 

Dysphagia,  hysterical,  708 ;  in  retro- 
pharyngeal abscess,  291. 

Dyspnea,  evidence  of,  34 ;  from  tuber- 
culous bronchial  lymph  nodes,  1096  ;  in 
acute  catarrhal  laryngitis,  469 ;  in  ca- 
tarrhal spasm  of  larynx,  466  ;  in  chronic 
cardiac  disease,  597  ;  inspiratory,  in 
retro-esophageal  abscess,  313 ;  from 
pressure  of  abscess  on  pneumogastric, 
314  ;   spasmodic,  in  asthma,   489. 

Dystrophy,  muscular,  824. 

Ear,  middle,  inflammation  of  (see  Otitis), 
938  ;  in  measles,  986 ;  in  scarlet  fever, 
965. 

Ecchymoses,  on  purpura,  857  ;  in  scurvy, 
235  ;  in  leukemia.  851. 

Echinococcus,   of   liver,    443.     , 

Eclampsia  (see  Convulsions),  671. 

p]cthyma  gangrenosa,  932. 

Ectocardia,    582. 

Eczema,  923 ;  etiology  of,  924  ;  diagnosis 
of,  926  ;  treatment  of,  927  ;  intertrigo, 
926. 

Edema,  in  acute  diffuse  nephritis,  632  ;  in 
anemia,  842  ;  in  chronic  nephritis,  636  ; 
in  cardiac  disease,  584  ;  in  leukemia, 
851  ;  of  face,  from  pressure  at  root  of 
lung,   1097  ;  general,  in   marasmus,  224. 

Edema  glottidis.  441  ;  in  corrosive  esoph- 
agitis.    312 ;   in   quinsy,   308. 

Emboli,  infections,  in  malignant  endo- 
carditis, 604. 

Embolism,  612;  in  diphtheria,  1036. 

Emphysema,  555  ;  symptoms,  557  ;  acute, 
in  bronchitis  of  infants,  478  ;  in  acute 
bronchopneumonia,  505  ;  in  pertussis, 
1009. 

Empyema,  563 ;  lesions,  563 ;  symptoms, 
566  ;  diagnosis,  567  ;  treatment,  570  ;  in 
acute   bronchopneumonia,    504. 


Encephalocele,  720  ;  symptoms  of,  721  ; 
treatment  of,  722. 

Endarteritis,  syphilitic,  of  brain,  1108 ; 
tuberculous,  748. 

Endocarditis,  acute  simple,  594 ;  lesions, 
595  ;  symptoms,  596  ;  treatment  of,  602  ; 
in  chorea,  595  ;  chronic  (see  also 
Heart,  Valvular  Disea.se),  597;  fetal, 
579 ;  in  chorea,  697  ;  in  rheumatism, 
1152  ;    malignant,    604. 

Enemata,  65  ;  nutrient,  66  ;  drugs  by,  60  ; 
astringent,  in  chronic  ileocolitis,  38!)  ; 
in  chronic  constipation,  407  ;  in  colic, 
402  ;  injuries  to  rectum  from,  431. 

Enuresis,   662. 

Epilepsy,  686  ;  diagnosis  of,  691  ;  hyster- 
ical, 707  ;  in  acquired  cerebral  paralysis, 
786;  in  birth  paralysis,  783;  Jack- 
sonian,  in  cerebral  tumor,  7(i5  ;  mental 
condition  in,  690 ;  prognosis  of,  692  ; 
status  epilepticus,  691  ;  types  of  symp- 
toms, 688  ;  treatment  of,  692. 

Epiphyseal  separation,  in  acute  arthritis, 
900  ;  in  scurvy,  237  ;  in  syphilis,  867. 

Epiphyses,  enlargement  of,  in  rickets,  253  ; 
in  syphilis,   HOG. 

Epiphysitis  (see  Arthritis  Acute),  900; 
syphilitic,    1106,    1118. 

Epispadias,    651. 

Epistaxis,  463 ;  in  anemia,  842  ;  in  per- 
tussis,  1008  ;   in   purpura,   857. 

Epitrochlear  lymph  nodes,  in  syphilis, 
1125. 

Erb's  paralysis.  111. 

Erysipelas,   in   newly  Ijorn,    86. 

Erythema,  following  diphtheria  antitoxin, 
1050 ;  intertrigo,  926  ;  in  intestinal  in- 
digestion, 397  ;  in  rheumatism,  1153  ; 
scarlatiniform  causes,  970. 

Esophagitis,  acute,  311  ;  catarrhal,  311  ; 
corrosive,  312. 

PIsophagus,  diseases  of,  311  ;  abscess  be- 
hind, 312 ;  congenital  narrowing  of, 
311  ;  congenital  obstruction  in,  311  ; 
diphtheria  of,  1026 ;  malformation 
of,  311 ;  stricture  of,  311  ;  thrush  in, 
311. 

Examination,  of  sick  child,  34. 

Exercise,    importance    of,    7  ;    caution    re- 
garding, in  heart  disease,  603  ;   in  ane- 
mia, 848. 
Exstrophy     of     )>]adder,     651  ;     exudative 

diathesis,  261. 
Ivve,  keratitis,  interstitial,  in  syphilis, 
1121  ;  care  of,  at  birth,  1.  3  ;  diph- 
theritic paralysis  of,  834  ;  early  use  of, 
26  ;  ectropion  of,  in  congenital  ichthy- 
osis, 920 ;  inflammation  of,  in  newly 
born,  89  ;  in  measles,  986 ;  nystagmus, 
701. 

Face,  expression  of,  in  disease,  34  ;  cyan- 
osis and  odema  of,  from  pressure  at 
root  of  lung,  1097. 


1168 


INDEX 


Facial   paralysis   at   birth,    110 ;    acquired. 

peripheral,  836  ;  in  otitis,  944. 
Feces,    319 ;    of  milk   diet,    319 ;    of   mixed 

diet,  320  ;  incontinence  of,  43-5. 
Fat,  determination  of,  in  milk,  140 ;  in 
the  feces,  319 ;  lack  of,  a  cause  of 
rickets,  241 ;  in  woman's  milk,  135  ; 
percentage  of,  in  modification  of  cow's 
milk,'  184,  187,  188 ;  sj-mptoms  from 
deficiency  of,  in  food,  193 ;  symptoms 
from  excess  in  food,  192,  194  ;  function 
of,  in  diet,  131. 
Fatty  degeneration,  of  the  newly  born,  93. 
Feeding,  artificial,  principles  of,  181  ; 
rules  for,  189,  197  ;  indications  for 
special  variations  in,  192.  195  ;  sched- 
ule for  first  year,  189  ;  versus  wet  nurs- 
ing, 168 ;  breast,  schedule,  for,  171  ; 
other  'than  milk,  first  year,  198  ;  daily 
dietary  from  fifteen  to  twenty  months, 
211 ;  for  healthy  infants,  second  year. 
209  et  seq.;  difficult  cases,  200  et  seq.; 
from  third  to  sixth  year,  211 ;  articles 
allowed,  211  ;  articles  forbidden.  213 ; 
during  acute  illness,  214 ;  in  infants, 
214  ;  older  children,  214  ;  during  periods 
of  excessive  heat,  367  ;  by  gavage,  in 
acute  illness.  214 ;  nasal,  64 ;  in  acute 
intestinal  indigestion  and  diarrhea,  357  ; 
methods  of,  in  etiology  of  diarrhea, 
351 ;  mixed  indications  for,  179  ;  simple 
rules  in,  214. 
Fever  from  insufficient  nourishment,  172  ; 
inanition,  122  (see  also  Temperature). 
Finger  (see  Dactylitis). 
Fingers,    clubbing   of,   in    congenital  heart 

disease,    584 ;    food   intoxication,    365. 
Fissure  of  the  anus,  431. 
Flatulence,    cause   of  colic,   402  ;   in  intes- 
tinal indigestion,   397. 
Flexner's   serum   for   cerebrospinal   menin- 
gitis,   738. 
Fetal   circulation,   575  ;   endocarditis,   579. 
Fetus,  evidences  of  syphilis  in,   1106. 
Follicular  ulceration,    of  intestine,    377. 
Fontanel,     bulging     of,     in     cerebrospinal 
meningitis.    735 ;    bulging   of,   in   menin- 
geal   hemorrhage,    109 ;    bulging    of,    in 
tuberculous     meningitis,     751 ;     closure 
of.    22 ;    in    cretinism,    883 ;    in    rickets, 
250. 
Food,     constituents,     128 ;     protein,     129 ; 
fats,   131 ;   carbohydrates,    131  ;   mineral 
salts,    132 ;    water,    133 ;    farinaceous,    a 
cause  of  eczema,   928 ;   in   chronic  indi- 
gestion,    340 ;     second    year,     209 :    im- 
proper, in  etiology  of  diarrhea.  351  ;  of 
dental     caries,     272 ;     regurgitation    of, 
causes   and    treatment,    193. 
Foods,  infant,  165  ;  cause  of  rickets,  241  ; 
cause     of     scurvy,     232 ;     indicated,     in 
chronic  constipation,  405. 
Foreign    bodies,    swallowing    of,    339 ;    in 
the  larynx,   47^ 


Fractures,     green-stick,     in     rickets,     244, 

252. 
Freeman's    pasteurizer.    155. 
Friedreich's   ataxia,    820. 
Frohlich's  syndrome,  767. 
Fruit,    best   time    for   giving.   211  ;   during 

second  year,  211;  during  third  to  sixth 

year,  211. 
Furunculosis,    887. 

Gangrene,  of  the.  face  in  noma,  286  ;  of 
intestine,  in  intussusception,  413 ;  of 
lung,  552  :  in  acute  bronchopneumonia, 
505  ;  in  lobar  pneumonia,  528  ;  in  scar- 
let fever.  909  ;  in  measles,  985. 

Gangrenous   stomatitis,   285. 

Gastritis,  acute,  335 ;  symptoms,  337 ; 
treatment,  338  ;  chronic,  339  ;  ulcers  in, 
342;  toxic  (see  Gastritis  Corrosive), 
338. 

Gastro-enteritis  (see  Acute  Intestinal 
Indigestion  and  Diarrhea),  357;  in 
newly  born,  85. 

Gavage,  63 ;  in  acute  illness,  215 ;  In 
acute  inanition,  221  ;  in  diphtheria, 
1046  ;  in  premature  infants,   13. 

Genital  organs,  diseases  of,  650  ;  care  of, 
in  newly  born,  4 ;  malformations  of, 
650  ;  female,  gangrene  of,  285  ;  females, 
diseases  of,  655  ;  hemorrhage  from,  in 
newly  born,  105 ;  males,  diseases  of, 
653. 

Gingivitis,  in  dental  caries,  272 ;  in 
scurvy,   234,    235. 

Glands,  bronchial  (see  Lymph  Nodes, 
Bronchial),  1095. 

Glands,  lymphatic  (see  Lymph  Nodes), 
860. 

Glioma  of  brain,  762  ;  of  spinal  cord,  819. 

Gliosarcoma  of   brain,   763. 

Glossitis,   270. 

Glottis,    edema    of   the,    471. 

Gonococcus,  differentiation  of,  658 ;  in 
gonorrheal  stomatitis,  284 ;  in  specific 
urethritis,    653 ;    vaginitis,    056. 

Grippe,  1138. 

Growing  pains,   rheumatic,   1151. 

Growth,  conditions  interfering  with, 
31 ;  of  body,  15  ;  extremities,  21  :  trunk, 
21. 

Gumma,  syphilitic  (see  Syphilis  Le- 
sions), 1100:  in  syphilitic  bone  disease, 
1118  ;  of  brain,  762. 

Gums,  abscess  of,  272  ;  bleeding  in  ulcer- 
ative stomatitis,  279  ;  inspection  of,  38 ; 
lancing,  275  ;  spongy  and  bleeding,  in 
scurvy,  234,  235  ;  in  ulcerative  stomat- 
itis, 279. 

Habit-spasm,    700. 

Habits,  injurious,  714. 

Hematemesis,    345. 

Hematoma   of  the   sternomastoid,   94. 

Hematuria,   619  ;   in   newly   born,   194 ;   In 


INDEX 


1169 


purpura,  856 ;  in  pyelitis,  645 ; 
in  scurvy,  237  :  in  tumors  of  kidney, 
641. 

Hemoglobinuria,  619  ;  epidemic,  92  ;  par- 
oxysmal,  620. 

Hemophilia,   852. 

Hemorrhage,  from  stomach,  345  ;  in 
hemophilia,  852 ;  intra-alveolar,  in 
acute  bronchopneumonia,  500  ;  internal, 
causing  sudden  death,  46 ;  intestinal, 
from  tuberculous  ulcer,  394  ;  in  typhoid 
fever,  1063 ;  meningeal,  causing  birth 
paralysis,  779 ;  in  acquired  cerebral 
paralysis.  781 ;  in  acute  bronchopneu- 
monia, 519  ;  in  convulsions,  672  ;  men- 
ingeal, in  pertussis,  1008 ;  meningeal, 
in  purpura,  855  ;  nasal,  in  diphtheria, 
1037  ;  pulmonary,  in  cardiac  cases,  597  ; 
rectal,  from  ulcer,  433 ;  in  leukemia, 
850 ;  in  measles,  986 ;  in  pertussis, 
1008  ;  in  pernicious  anemia,  847  ;  in 
purpura,  855  ;  in  the  newly  born,  96 ; 
visceral,  100;  in  scurvy,  237;  in  syph- 
ilis,   1113. 

Hemorrhagic  disease  of  the  newly  born, 
98. 

Hemorrhoids,  435  ;  in  chronic  constipa- 
tion,  404. 

Harelip,    266. 

Hay    fever,    490. 

Head,  circumference  of,  22 ;  closure  of 
sutures,  22 ;  closure  of  fontanels,  22  ; 
shape  of,  23 ;  in  rickets,  248 ;  exami- 
nation of,  35  ;  hydrocephalic,  charac- 
teristics of,  772 ;  nodding  spasm  of, 
701. 

Headache,  varieties,  709  ;   treatment,   710. 

Head-banging,   719. 

Hearing,    when    developed,    26. 

Heart,  diseases  of,  575  ;  aneurism  of, 
612 ;  aortic  disease,  congenital,  581 
auscultation  of,  39,  578 ;  diphtheritic 
paralysis  of,  835  ;  examination  of,  577 
hypertrophy  of,  in  valvular  diseases 
596  ;  in  measles,  986  ;  in  scarlet  fever 
967 ;  malformations  of,  579 ;  peculiari- 
ties of,  in  early  life,  575  ;  persistent 
fetal  conditions,  580  ;  position  of  apex 
beat,  577 ;  in  infancy,  577 ;  size 
and  growth  of,  577  ;  sounds  of  redupli- 
cation, 578  ;  sudden  failure  of,  in  diph- 
theria, 1038  ;  thrombus  of,  ante-mortem, 
612 ;  transposition  of,  583 ;  congen- 
ital anomalies  of,  579  ;  functional  dis- 
turbances of,  608 ;  murmurs  of,  598 ; 
differential  diagnosis  of,  586 ;  acci- 
dental, 606  ;  in  congenital  diseases,  585  ; 
in  chorea,  697  ;  in  marasmus,  224  ; 
valves,  aortic  insufficiency,  600 ;  aortic 
stenosis,  600  ;  mitral  insufficiency,  599  ; 
mitral  stenosis,  599 ;  valvular  diseases 
of  (see  also  Endocarditis),  594; 
chronic  valvular  disease  of,  597 ;  ven- 
tricle,   left,    signs    of    dilatation,    599 ; 


signs  of  hypertrophy,   600  ;  right,  signs 
of  hypertrophy,  599. 

Heart  block,  in  diphtheritic  paralysis, 
835. 

Height,  19  ;  from  birth  to  sixteenth  year, 
20. 

Heliotherapy,  in  tuberculous  peritonitis, 
453. 

Hemichorea,  696. 

Hemiplegia,  in  acquired  cerebral  paral- 
ysis, 782 ;  in  birth  paralysis,  779 ;  in 
meningeal  hemorrhage,  109  ;  in  cerebral 
tumor,   766 ;   spastic,    781. 

Hepatitis,  interstitial,  77 ;  suppurative, 
439. 

Hermaphroditism,    false,    651. 

Hernia,  cerebri,  720  ;  diaphragmatic,  119  ; 
umbilical,   116. 

Herpes   labialis,    269. 

Herpetic   stomatitis,   277. 

Hiccough,  702  ;  in  acute  peritonitis,  447  ; 
in   hysteria,   707. 

Hip-joint  disease,   912. 

History-taking,   32. 

Hives    (see   Urticaria),   933. 

Ilodgkin's  disease,  874. 

Holding-breath    spells,    681. 

Home    modification    of    milk,    196. 

Hookworm,   429. 
-Hutchinson's  teeth,  in  syphilis,   1117. 

Hydatids,  of  liver,  443. 

Hydrencephalocele,    719. 

Hydrocele,   654. 

Hydrocephalus,  769 ;  in  chronic  basilar 
meningitis,  755  ;  with  spina  bifida,  799, 
801 ;  acute  (see  Meningitis,  Tuber- 
culous), 747,  754;  chronic  external, 
769 ;  internal,  770 ;  congenital,  723 ; 
intra-uterine,    721 ;    syphilitic,    1108. 

Hydronephrosis,  624  ;  with  malforma- 
tions of  kidney,  623  ;  with  renal  calculi, 
647. 

Hygiene,    of   infancy,    1. 

Hyperesthesia,  general,  in  cerebrospinal 
meningitis,  733  ;  in  acute  poliomyelitis, 
811  ;  hysterical.  705  ;  in  multiple  neu- 
ritis, 831 ;  in  scurvy,  236 ;  in  spinal 
meningitis,    802. 

Hypertrophy,  muscular  pseudo-,  824. 

Hypodermic  medication,  66 ;  dosage  for, 
55. 

Hypodermoolysis.    indications    for,    66. 

Hypospadias,    651. 

Hysteria,  705  ;  symptoms,  705  ;  diagnosis, 
707 ;    treatment,    708. 

Hystero-epilepsy,  707. 

Ice  bag,  59. 

Ice   cap,    52,   59. 

Ice  coil,  59. 

Ichthyosis,  congenital,  920. 

Icterus,  438  ;  in  epidemic  hemoglobinuria, 
92  ;  varieties  in  newly  born,  77 ;  in 
malformation    of    the    bile    ducts,    78 ; 


1170 


INDEX 


interstitial  hepatitis.  78 ;  physiological 
or  idiopathic,  78  ;  differential  diagnosis, 
81. 

Idiocy,  789 ;  Mongolian,  793 ;  amaurotic 
family,    788. 

Idiosyncrasies  to  foodstuffs,   216. 

Ileocolitis,  acute,  373  ;  catarrhal,  375  ;  fol- 
licular, 377  ;  membranous,  385  ;  associ- 
ated lesions,  381  ;  with  follicular  ulcer- 
ation, 377 ;  membranous  form.  378 ; 
treatment,  378,  et  seq. ;  bronchopneu- 
monia complicating.  518  ;  in  diphtheria, 
1037  ;  In  measles.   985. 

Ileum,    congenital    atresia    of,    118. 

Imbecility,   789. 

Impetigo,  bullous.  94  ;  in  newly  born,  94  ; 
contagiosa,  932. 

Inanition,   acute,    219. 

Inanition  fever,   122. 

Incubators,    12. 

Indican,  in  urine  of  chronic  constipation, 
404 ;  of  chronic  intestinal  indigestion, 
398. 

Indigestion,  chronic  gastric,  339 ;  treat- 
ment, 340 ;  acute  intestinal,  and  diar- 
rhea, 357 ;  diagnosis,  366 ;  treatment, 
367 ;  Finkelstein"s  "food  intoxication," 
365. 

Indigestion,  chronic  intestinal,  395  ;  treat- 
ment,   399. 

Infant,  care  of  newly  born,  1  ;  when 
premature  or  delicate,   11. 

Infant   feeding,    167. 

Infant  foods.  165. 

Infantilism,   intestinal.   398. 

Infarctions,   uric  acid,   in   kidney.    627. 

Infectious   diseases,    specific.    949. 

Influenza,  1130 ;  etiology.  1130 ;  lesions, 
1131  ;  symptoms,  1132  :  bronchopulmo- 
nary complications,  lt^55  ;  protracted 
cases,  1133  ;  complications  and  sequela?, 
1136  ;  anemia  in,  1136  ;  diagnosis,  1136  ; 
prognosis,  1137 ;  treatment,  1137 ; 
bronchopneumonia  in,  517,  1134 ;  epi- 
demic, acute  otitis  in,  938 ;  scarlatini- 
form  erythema  in,  970 ;  nephritis  in, 
1136. 

Inhalations,  62  ;  in  bronchitis,   484. 

Inheritance,   a    factor   in   disease,    30. 

Injections,  rectal,  in  ileocolitis.  388  :  sub- 
cutaneous, of  saline  solution  in  cholera 
infantum.    373. 

Intertrigo,    926. 

Intestinal  obstruction  in  newly  born,  118  ; 
acute,   from  intussusception,  410. 

Intestines,  diseases  of,  348 ;  amyloid  de- 
generation of,  391  ;  bacteria  of,  318 ; 
digestion  in,  317 ;  hemorrhage  from, 
in  newly  born,  104 ;  in  typhoid,  1063  ; 
in  tuberculosis,  393 ;  length,  318  ;  mal- 
formations of.  348 ;  obstruction,  con- 
genital of,  118 ;  perforation  of,  in  tu- 
berculous ulcers,  393  ;  in  typhoid  fever. 
1063 ;    tuberculosis    of,    391,    1082 ;    eti- 


ology, 392 ;  lesions,  392 ;  symptoms, 
393  ;  treatment,  394. 

Intoxication,  acute  intestinal  and  diar- 
rhea, 357  ;  etiology,  357  ;  lesions,  358  ; 
symptoms,  mild  form,  359 ;  relapses, 
360 ;  cases  without  diarrhea,  362  ;  di- 
agnosis, 366 ;  prognosis,  366 ;  prophy- 
laxis, 366  ;  treatment,  367,  372  ;  cholera 
infantum,  363  ;  treatment,  367  ;  acidosis 
in,   372. 

Intubation,  in  acute  catarrhal  laryngitis, 
468 ;  in  syphilitic  laryngitis,  474 ;  in 
pertussis,   1013. 

Intussusception,  410 ;  etiology,  412 ;  le- 
sions and  mechanism,  412 ;  symptoms, 
414  ;  diagnosis,  417  ;  treatment,  41S ; 
laparotomy,  418  ;  in  the  dying,  411. 

lodids,    elimination   of,   in   milk,    143. 

Iritis,    syphilitic,    1109. 

Iron,  preparations  of,  55. 

Irrigation,  intestinal,  in  chronic  indiges- 
tion, 400 ;  as  antipyretic,  53 ;  of  the 
colon,    method   of,    64. 

Ischiorectal  abscess,  434. 

Jaundice  (see  also  Icterus),  77;  catar- 
rhal,  437. 

Jaw,  necrosis  of,  from  alveolar  abscess, 
273  ;  in  gangrenous  stomatitis,  286  ;  in 
ulcerative  stomatitis,  279. 

Je.iunum,   congenital  atresia  of,   118. 

Joints,  diseases  of,  895 ;  hysterical  af- 
fections of,  706  ;  in  scarlet  fever,  967  ; 
rheumatism  of,  1150 ;  suppuration  of. 
in  newly  born,  85 ;  swelling  of,  in 
scurvy.  236 ;  ecchymoses  about,  in 
scurvy,  235  ;  tuberculous  diseases  of, 
905. 

Junket,   162. 

Kcrnig's    sign,    733. 

Keratitis,  interstitial,  in  late  syphilis, 
1109,    1121. 

Kidney,  diseases  of,  623  ;  acute  degenera- 
tion of,  628 ;  calculi  in,  646 ;  chronic 
congestion  of,  628 ;  cystic,  624 ;  mov- . 
able,  627 ;  granular  (see  Nephritis, 
Chronic),  636;  horseshoe,  623;  hydro- 
nephrosis, 624  ;  malformations  and  mal- 
positions of,  623  ;  malignant  tumors  of, 
639  ;  nephritis,  acute  diffuse,  628 : 
acute  exudative.  629 ;  chronic,  635  ; 
perinephritis,  648 ;  pyelitis,  642  ;  pyo- 
nephrosis, 645  ;  tuberculosis  of,  639. 
1081  ;  uric-acid  infarction  in,  627 ; 
in  diphtheria,  1027 ;  in  scarlet  fever, 
966. 

Klebs-Loeffler  bacillus  (see  Bacillus  of 
Diphtheria),   1020,   1039. 

Knee,  articular  ostitis  of,  916 ;  subluxa- 
tion of,  in  poliomyelitis,  815  ;  swelling 
of,  in  scurvy,  234. 

Knee-jerk,  in  acquired  cerebral"  paralysis, 
785  ;    in    birth    paralysis,    783 ;    lost,    in 


INDEX 


1171 


diphtheritic  paralysis,   834  ;  in   multiple 

neuritis,   831  ;  in  tetany,  677. 
Knock-lcnee  in  rickets,  253. 
Koplik's   sign   in   measles,   978. 
Kumyss,   160. 
Kyphosis,  in  rickets,  251 ;  treatment,  258  ; 

in   spinal   caries,   907. 

Lactalbumin,    138,    183. 

Lactation,    care   of   breasts  during.   169. 

Lactic  acid   milk,   160. 

Lactometer,    author's,    139. 

Larynogospasm,  684  ;  in  rickets,  248 ; 
with   tetany,    681. 

Laryngitis,  acute  catarrhal,  468  ;  catar- 
rhal in  measles,  984 ;  chronic,  472 ; 
with  adenoid  vegetations  of  pharynx, 
472  ;  tuberculous,  472  ;  syphilitic,  473  ; 
with  new  growths  of  larynx,  474  ;  spas-  | 
modic,  465 ;  submucous  (edema  of 
glottis),  471. 

Laryngeal  diphtheria,  1033  ;  antitoxin  in. 
1048 ;  intubation  in,  1053 ;  symptoms 
of,   1033. 

Lar.yngotomy  for  foreign  body  in  larynx, 
475. 

Larynx,  diseases  of,  465 ;  foreign  bodies 
In,  475 ;  new  growths  of,  474 ;  spasm 
of,    684. 

Lavage   (see  Stomach  Washing),  62. 

Leukemia,   849. 

Lichen,  urticatus  (see  Urticaria).  934; 
U-opicus,   922. 

Lip,  ■  eczema  of,  269  ;  perleche,  269  ;  dis- 
eases of,  269 ;  herpes  of,  269  ;  malfor- 
mations   of,    267. 

Lisping,   711. 

Liver,  diseases  of.  436  ;  abscess  of,  439  ; 
acute  yellow  atrophy  of,  438  ;  amyloid 
degeneration  of.  441  :  biliary  calculi, 
443  ;  cirrhosis  of,  440  ;  congestion  of. 
439  ;  interstitial  hepatitis,  78  ;  enlarged 
in  congestion,  439  ;  in  abscess,  439  ;  in 
cirrhosis  (early i.  441;  in  chronic  car- 
diac disease,  593 ;  in  marasmus,  222 ; 
hydatids  of,  443 ;  in  rickets,  255  ; 
in  syphilis.  1107,  1022  ;  in  tuberculosis, 
lOSO ;  lardaceous,  441  ;  malformations 
and  malpositions  of.  437  ;  size  and  posi- 
tion of,  40,  436  ;  tuberculosis  of,  1080  ; 
waxy,   441  ;   weight  of,   in  infancy,   436. 

Lumbar  puncture,  737. 

Lung,  diseases  of,  476  ;  alisccss  of.  551  : 
abscesses  of,  in  acute  bronchopneu- 
monia, 505 ;  acute  congestion  of,  in 
malaria,  1140 ;  calcareous  nodules  in, 
1078 ;  caseous  degeneration  of,  1077  ; 
collapse  of,  from  compression,  553 ; 
from  obstruction.  554 ;  in  acute  bron- 
chopneumonia. 500  ;  congenital  atelec- 
tasis of,  74  ;  emphysema  of,  555  ;  acute, 
in  bronchitis  of  infants,  482 ;  gan- 
grene of,  552 ;  gangrene  of,  in  lobar 
pneumonia,    528 ;    hemorrhages    into,    in 


newly     born,     100 ;     inflation     of,     73 ; 
miliary  tuberculosis  of,  1084  ;  peculiari- 
ties   in    disease,    478 ;    in    infancy    and 
early  childhood,  476  ;  physical  examina-  ' 
tion  of,   477  ;  structure  of,  477. 

Lymph  nodes,  diseases  of,  862  ;  calcareous 
cervical;  869 ;  bronchial,  1095 ;  early 
infection  in  tuberculosis,  1072  ;  enlarged 
in  Hodgkin's  disease,  874 ;  in  malnu- 
trition, 227  ;  frequency  of  disease  of, 
41;  inflammation  of  (see  Adenitis), 
862  ;  in  late  hereditary  syphilis,  1121 ; 
in  measles,  986 ;  in  pseudodiphtheria, 
301  ;  in  scarlet  fever,  964  ;  simple  hyper- 
plasia of,  865 ;  situation  and  drainage 
areas  of  the  groups  of  head  and  neck, 
861  ;  syphilitic  disease  of,  866  ;  tubercu- 
lous bronchial,  1078  ;  lesions,  1078,  1082  ; 
symptoms,  1031  ;  cervical,  tuberculosis 
of,  867  ;  mesenteric.  393,  1081  ;  in 
diphtheria,  1027 ;  in  rickets,  255 ;  in 
tonsillitis,  301  ;  epitrochlear,  in  syphilis, 
1121  ;  in  typhoid  fever,  1060  ;  tubercu- 
losis of,  867  ;  retropharyngeal,  abscess 
of,   290. 

Lymphocytes,    840. 

Malaria,  1139  ;  symptoms,  1140 ;  treat- 
ment, 1146  ;  quinin,  methods  of  admin- 
istration,  1146 ;   spleen   in,   878. 

Malnutrition,   226. 

Maltose,    in  Infant   feeding,   208. 

Malt  soup,  use  of,  with  difficult  feeding 
cases,    185,   208. 

Mania,   acute,    following   typhoid,    1064. 

Marasmus,   221. 

Massage,  66  ;  in  chronic  constipation,  406  ; 
in  malnutrition,  230 ;  of  breasts  to 
increase    milk,    174. 

Mastitis,    in   the    newly    born.    117. 

^lastoid  disease,  cerebral  abscess  follow- 
ing.  899  ;  in  acute  otitis,   898. 

Mastoiditis.  942 ;  symptoms,  898 ;  treat- 
ment, 946 ;  dangers  from  operation, 
946. 

Masturbation.  715. 

Matzoon,    161. 

Measles,  975  ;  bronchopneumonia  compli- 
cating, 517  ;  complications  and  sequeliB, 
983 ;  desquamation.  981  ;  diagnosis, 
987  ;  digestive  system,  985  ;  diphtheria 
in,    987  ;    duration    of    infective    period, 

977  ;  ears  in,  938,  986  ;  eruption,  979 ; 
etiology,  975  ;  eyes  in.  986  ;  German  (see 
Rubella  ),  991;  hemorrhage  in,  986; 
hemorrhagic,  980 ;  heart  in,  986 ;  ileo- 
colitis,  985  ;   incubation,   976  ;   invasion, 

978  ;  kidneys  in,  986  ;  larynx  in,  984  ; 
lesions.  977  ;  lungs,  984  :  lymph  nodes, 
986  ;  mode  of  infection,  977  ;  mortality, 
9SS  ;  nervous  system  in,  986  ;  other  in- 
fectious diseases  in.  987 ;  otitis.  986 ; 
predisposition.  976 ;  prognosis,  988  ■ 
prophylaxis,    989 ;    pseudodiphtheria   in, 


1172 


INDEX 


985  ;  quarantine  in,  989  ;  skin  in,  986  ; 
symptoms,  978  ;  throat,  985  ;  treatment, 
989 ;    tuberculosis    following,    987. 

Meats,    from    third    to    sixth    year,    212. 

Meckel's   diverticulum,    114.    349. 

Meconium,  composition  of,  319. 

Mediastinum,  anterior,  abscess  of,  1097 ; 
tumor  of,  due  to  tuberculous  lymph 
nodes.   1096. 

Mediastinitis,   589. 

Melena,    104. 

Meningeal  hemorrhage,  102,  724,  779. 

Meninges,    diseases    of,    719. 

Meningitis,  acute,  726 ;  cerebrospinal, 
727 ;  complications  and  sequelae,  736 ; 
course,  duration  and  termination,  736 ; 
lesions,  728  ;  lumbar  puncture  in,  737, 
743 ;  symptoms,  730,  736 ;  diagnosis, 
737 ;  prognosis,  736 ;  treatment,  738, 
743. 

Meningitis,  acute,  from  other  causes  than 
the  meningococcus,  743  ;  pneumococcus, 
744 ;  influenza,  745  ;  septic,  746 ;  in 
newly  born,  85 ;  from  otitis,  948 ;  in 
pneumonia,    519,    539. 

Meningitis,  chronic  basilar,  755  ;  spinal, 
802  ;   syphilitic,   1108. 

Meningitis,  tuberculous,  747 ;  symptoms, 
749 ;  diagnosis,  752 ;  lumbar  puncture 
in,   756. 

Meningocele,   of  brain,   720  ;   of  cord,   797. 

Meningo-encephalitis,   780. 

Meningomyelocele,  798. 

Menstruation,  effect  of,  on  breast  milk, 
142. 

Mental  deficiency,  789 ;  diagnosis,  790, 
793  ;   treatment,   796. 

Mercury,  elimination  of,  in  milk,  143 ; 
ulcerative  stomatitis  from,  278 ;  in 
syphilis,    1128. 

Microcephalus,  722. 

Microorganisms  in  cow's  milk,  145. 

Micturition,  difficult  or  painful,  667  ; 
frequency  of,   616. 

Miliaria,  921 ;  papulosa,  922 ;  treatment, 
927  ;   rubra,    922. 

Milk,  cow's,  144  ;  composition  of,  182 ; 
bacteriological  standard  for,  147  ; 
handling  and  transportation  of,  144, 
145  ;  average  percentages  in,  from  dif- 
ferent breeds,  148,  149 ;  examination 
of,  149 ;  cream,  151  ;  contaminated,  as 
cause  of  diarrhea,  <?52  ;  differences  from 
woman's  milk,  150 ;  dried  milk,  159 ; 
essentials  of,  for  infant  feeding,  144  ; 
formulas  from  diluting,  187,  et  seq.; 
formulas  reduced  to  percentages,  191, 
192 ;  frozen,  157 ;  microorganisms  in, 
145  ;  modification  of.  percentage,  187 ; 
at  home,  186,  187,  196  ;  top-milk,  152  ; 
formulas  from  whole  milk,  187  ;  sched- 
ule showing  quantities  and  intervals  of 
feeding,  189  ;  modifications  required  by 
particular   symptoms,    192 ;    in   difficult 


cases,  207 ;  in  summer  diarrhea,  368  ; 
in  chronic  constipation,  405 ;  pasteuri- 
zation of,  153,  154,  155  ;  pnotein  of, 
129;  sterilization  of,  at  212°  F.,  155; 
tubercle  bacilli  in,  1020  ;  condensed  (see 
Condensed  Milk),  158;  fermented, 
159,  207  ;  protein,  161  ;  skimmed,  207  ; 
peptonized,  J-57. 

Milk  laboratories,   197. 

Milk-sugar,  132,  184 ;  solution,  how  to 
prepare,   196. 

Milk,  woman's,  134 ;  physical  characters 
of,  134  ;  colostrum  of,  135  ;  daily  quan- 
tity of,  135 ;  average  quantity  at  one 
nursing,  137  ;  composition  of,  137  ;  pro- 
tein, 137,  138,  140 ;  fat,  138 ;  sugar, 
138  ;  salts,  138  ;  reaction,  139  ;  specific 
gravity,  139,  141  ;  average  percentages 
of,  182 ;  conditions  affecting  composi- 
tion of,  141,  144 ;  menstruation,  142 ; 
diet,  142  ;  drugs,  143  ;  pregnancy,  143  ; 
elimination  of  antitoxin  and  other  pro- 
tective substances,  137  ;  nervous  im- 
pressions, 143  ;  examination  of,  139  ; 
variations  in  quality,  141  ;  how  to  mod- 
ify quantity  and  quality,  174,  175  ; 
indications   of  scanty    supply,    171. 

Modified  milk,  schedule  for  feeding  from 
birth,    189. 

Mongolian  idiocy,   793. 

^Monoplegia,  in  birth  paralysis,  781  ;  in 
cerebral  hemorrhage,  109  ;  in  cerebral 
tumor,    766. 

Morphin,  dosage  of,  56 ;  dosage  in  con- 
vulsions, 676  ;  hypodermically  in  cholera 
infantum,    372. 

Mortality,    at    different    ages,    43,    44. 

Mouth,  diseases  of  (see  also  Stomatitis), 
276,  et  seq. ;  care  of,  at  birth,  1,  3 ; 
hemorrhages  from  scurvy,  236  ;  malfor- 
mations of,  267 ;  mucous  patches,  in 
syphilis,    284 ;    "tapir,"    826. 

Mouth  breathing,  with  hypertrophy  of 
tonsils,  309  ;  with  adenoids,  297  ;  with 
retropharyngeal  abscess,  291. 

!\Iumps,  1015  ;  complications  and  sequelae, 
1018 ;  diagnosis,  1019 ;  pathology  and 
lesions,  .1016;  symptoms,  1017;  treat- 
ment,  1019. 

Murmurs,  cardiac   (see  Heart  Mdemurs). 

Muscles,  atrophy  of,  820 ;  in  multiple 
neuritis,  831 ;  In  myelitis,  803 ;  in 
poliomyelitis,  815  ;  contractures  of, 
hysterical,  706 ;  in  infantile  cerebral 
paralysis,  786  ;  in  birth  paralysis,  782  ; 
development  of,   25. 

Muscular  wasting  diseases,  different  types 
of,  822. 

Muscular    pseudohypertrophy,    825. 

Mustard  bath,  59  ;  paste,  57  ;  pack,  58. 

Myelitis,  802  ;  symptoms,  803  ;  treatment, 
804  ;  from  Pott's  disease,  804  ;  diffuse, 
803  ;   transverse,   803. 

Myocarditis,  605  ;  aneurism  in,  605  ;  toxic. 


INDEX 


1173 


in  diphtheria,  835,  1036 ;  in  scarlet 
fever,    968 ;   in    syphilis,    1108. 

Myatonia,  congenital  (Oppenheim's  dis- 
ease),  827. 

Myotonia,  congenital  (Thomsen's  disease), 
702. 

Nail-biting,    718. 

Nails,  in  syphilis,  1114. 

Neck,  cellulitis  of,  in  scarlatina,  964 ; 
congenital  fistula  of,  311  ;  wry-  (see 
Torticollis),   703. 

Necrosis,    of   bone,    in    syphilis,    1106. 

Nematodes  (see  Worms),  425. 

Nephritis;  acute  diffuse,  629 ;  etiology, 
629  ;  lesions,  629  ;  symptoms,  630,  633  ; 
prognosis,  633  ;  treatment,  633 ;  acute 
parenchymatous  type,  630. 

Nephritis,  chronic,  635  ;  etiology,  635  ;  le- 
sions, 636 ;  symptoms,  636 ;  of  the 
parenchymatous  type,  636 ;  of  the  in- 
terstitial type,  637 ;  diagnosis,  638 ; 
prognosis,  637  ;  treatment,  638  ;  chronic, 
diffuse,  with  hydronephrosis,  625  ; 
chronic  interstitial,  syphilitic,  1109  ;  in 
diphtheria,  1027,  1037  ;  interstitial 
(see  Nephritis,  Chronic),  637;  post- 
scarlatinal, 966. 

Nerves,    peripheral,    diseases   of,    828. 

Nervous  impressions,  effect  of,  on  breast 
milk,   144. 

Nervous  system,  diseases  of,  669  ;  general 
hygiene  of,  5  ;  peculiarities  of,  in  child- 
hood, 669. 

Neuritis,  multiple,  828 ;  after  diphtheria, 
833  ;  optic,  in  acute  meningitis,  734  ;  in 
cerebral  tumor,  767  ;  with  cerebral  ab- 
scess, 761. 

Neuropathic  diathesis,  262 ;  neuropathic 
child,    264. 

Newly  born,  diseases  of,  69 ;  acute  in- 
fectious diseases  of,  82  ;  acute  pyogenic 
diseases  of,  82  ;  atelectasis,  congenital, 
74  ;  asphj'xia  of,  69  ;  blood  in,  peculiari- 
ties of,  839 ;  diseases  or  accidents  at 
birth,  30 ;  facial  paralysis  in,  110 ; 
fatty  degeneration  of,  93  ;  hemorrhages 
In,  96 ;  hemorrhagic  diseases  of,  101 ; 
hyperpyrexia  in,  122 ;  icterus  in,  77  ; 
infection  of,  31  ;  malformations  of,  30  ; 
mastitis  in,  117  ;  ophthalmia  of,  89 ; 
pemphigus  in,  94  ;  peritonitis  in,  444  ; 
sclerema  in,  121  ;  skin  of,  920  ;  ulcer  in 
stomach   in,   342. 

Night-terrors,   713. 

Nipples,  care  of,  during  lactation,  169 ; 
fissure  of,  hematemesis  from,  346  ;  rub- 
ber,   choice   of,    196 ;    care   of,    196. 

Nodes,  lymph   (see  Lymph  Nodes),  861. 

Nodules,  subcutaneous  tendinous,  in  rheu- 
matism,  1152. 

Noma  of  face  (see  Stomatitis,  Ganore- 
nods),   285;  of  vulva.   062. 

Nose,  diseases  of,  457  ;  deformities  of,  in 


hereditary  syphilis,  463 ;  difficulty  in 
blowing,  with  adenoids,  296  ;  diphtheria 
of,  1030  ;  discharge  from,  with  adenoids, 
296 ;  foreign  bodies  in,  460  ;  hemor- 
rhage from,  462  ;  in  newly  born,  1004  ; 
in  scurvy,  238 ;  in  hereditary  syphilis, 
462,  1108;  in  late  syphilis,  1122; 
polypi  in,  461  ;  pseudodiphtheria  of, 
301  ;  sprays  for,  60  ;  syringing,  61. 

Nurse,  requisite  qualities  in,  10  ;  wet  (see 
Wet-Ndrse),    176. 

Nursery,   general   requirements   for,    9. 

Nursing,  during  acute  illness,  215  ;  dur- 
ing first  days  of  life,  169  ;  hours  for, 
in  newly  born,  170  ;  during  illness,  177  ; 
importance  of  good  habits  of,  170  ;  un- 
successful, symptoms  of,  171 ;  maternal, 
contra-indications  for,   168. 

Nursing-bottles,  choice  of,  196 ;  care  of, 
196. 

Nutrition,  derangements  of,  218 ;  acute 
inanition,  218 ;  malnutrition,  226 ;  ma- 
rasmus, 221  ;  faulty,  diseases  due  to, 
231  ;   importance   in   pediatrics,    127. 

Nystagmus,  701  ;  in  cerebral  hemorrhage, 
109 ;  in  hydrocephalus,  775  ;  in  tuber- 
culous meningitis,  750 ;  with  tumor  of 
crura  cerebri,  706. 

Oatmeal  water,   165. 

0"Dwyer's  intubation  set,   1053. 

Oil  enemata,  65  ;  in  chronic  constipation, 
407. 

Omphalitis,  in  newly  born,  83. 

Omphalomesenteric  duct,  115,  349. 

Onychia,    syphilitic,    1111. 

Ophthalmia,  in  newly  born,  89. 

Opisthotonus,  7  ;  hysterical,  707  ;  in  cere- 
brospinal meningitis,  731  ;  in  birth  pa- 
ralysis, 782 ;  meningeal  hemorrhage, 
109 ;  in  chronic  basilar  meningitis, 
756  ;  in  marasmus,  224  ;  in  tuberculous 
meningitis,    752. 

Opium,  elimination  of,  in  milk,  143 ; 
acute  intestinal  indigestion  and  di- 
arrhea, 371,  372;  in  bronchitis,  484; 
preparations   and   dosage   of,   53. 

Oppenheim's  disease,   827. 

Optic  nerve,  atrophy  of,  in  cerebral  tu- 
mor.  764. 

Orchitis,  in  mumps,  1018 ;  in  specific 
urethritis,  653 ;  syphilitic,  1109 ;  tu- 
berculous,  1082. 

Orthopnea,  in  chronic  valvular  disease, 
597  ;  in  functional  disorders  of  the 
heart,   60S. 

Osteogenesis  imperfecta,   895. 

Osteomyelitis,  in  newly  born,  85  ;  tuber- 
culous, 918. 

Osteoperiostitis,    chronic,    syphilitic,    1114. 

Ostitis,  primary,  followed  by  joint  dis- 
ease, 906  ;   simulated  by   scurvy,  238. 

Otitis,  acute,  938;  etiology,  938;  lesions. 
939  ;  symptoms,  940  ;  complications  and 


1174 


INDEX 


sequfla>,  942;  treatment.  944:  cereliral 
abscess  in,  759,  943 ;  thromliosis  of 
lateral  sinus  in,  943 ;  facial  paralysis 
in,  944 ;  labyrinth  in,  944 ;  mastoid 
disease  in,  942 ;  meningitis  in,  943 ; 
clironic,  in  late  syphilis,  1122 ;  in  in- 
fluenza, 1139 ;  in  scarlet  fever,  965  ; 
in  syphilis,    1109. 

Oxyuris  vermicularis  (see  Worms,  Intes- 
tinal), 427. 

Ozena,  syphilitic,   463,   1122. 

Pachymeningitis,  acute,  723 ;  chronic  (in- 
ternal), 724;  syphilitic,  1108;  menin- 
geal hemorrhage  from,  725 ;  hemor- 
rhagic,  724  ;   pseudomembranous,  724. 

Pack,   cold,   52  ;  hot,  59 ;   mu.stard,  58. 

Palate,  cleft,  267 ;  diphtheritic  paralysis 
of,  833 ;  hard,  ulceration  of,  279 :  in 
late  syphilis,  1122  ;  soft,  lesions  of,  in 
hereditary   syphilis,    463. 

Pancreas,  ferments  of,  318 ;  syi^hilis  of, 
1109;  tuberculosis  of,  1081. 

Paracasein,  formed  from  casein  in  stom- 
ach digestion,  150. 

Paralysis,  atrophic  (sec  I'oi.iumyklitis  i, 
806 ;  birth,  106,  780 ;  atrophy  and 
sclerosis  following.  780 :  meningo- 
encephalitis, 780  ;  secondary  degenera- 
tions following,  781  ;  symptoms,  781  ; 
Erb's,  111 ;  facial,  110,  836 ;  in  acute 
otitis,  944  ;  hysterical,  706  ;  in  compres- 
sion-myelitis, 805  ;  multiple  neuritis, 
829  ;  in  myelitis,  803  ;  of  face,  in  newly 
born,  110 ;  of  the  upper  extremity  in 
newly  born,  111;  peripheral,  106;  (see 
also  Neuritis,  Multiple),  828;  post- 
diphtheritic, 1037  ;  pseudohypertrophic, 
824 ;    simulated   by   scurvy,    238. 

Paralysis,  infantile  cerebral,  106,  779 ; 
acute  acquired,  783 ;  birth,  780 ;  of 
intra-uterine  origin,  779 ;  varieties  and 
symptoms,  779,  781,  783 ;  prognosis, 
786  ;  diagnosis,  787  ;  treatment,  787. 

Paralysis,  infantile  spinal  (see  Polio- 
myelitis), 806. 

Paraplegia,  Pott's  (see  Myelitis  Com- 
pression),  779,    804;    spastic.   779. 

Parotitis,   epidemic    (see  Mimps),    1015. 

Pasteurized    milk,    154,    155. 

Pathology,  general  considerations  of,  41. 

Pavor   nocturnus,    713. 

Peliosis   rheumatica,    859. 

Pemphigus,  gangrenosa,  932 ;  in  newly 
born,    94 ;    syphilitic,   1110. 

Pepsin,  In  stomach  secretion,  317. 

Peptonized  milk,  preparation  of,   157. 

Percentages,  in  milk  formulas,  how  to 
calculate  them,  191. 

Pericarditis,  588 ;  acute  in  bronchopneu- 
monia, 519 ;  chronic,  with  adhesions, 
593  ;  diagnosis,  592  ;  dry.  589  :  external. 
589  ;  in  newly  born,  85  ;  in  rheumatism. 
589,  590,  1151  ;  mediastinal,  589  ;  prog- 


nosis, 591 ;  purulent,  589  ;  serofibrin- 
ous, 589 ;  tuberculous,  589 ;  with  effu- 
sion. 589  ;  with  effusion  of  blood,  589  ; 
with  lobar  pneumonia,  529  ;  with  pleu- 
ropneumonia, 545  ;  with  transudation 
of  serum,  588. 
Pericardium,    congenital   absence   of,   582 ; 

tuberculosis  of,  1080. 
Perinephritis,  648  ;  acute  peritonitis  com- 
plicating, 445. 
Peritoneum,  diseases  of,  444  ;  hemorrhage 
into,  in  newly  born,  101  ;  in  tubercu- 
losis, 1081. 
Peritonitis,  acute,  444  ;  etiology,  444  ;  le- 
.sions,  445  ;  symptoms,  446  ;  treatment, 
447  ;  chronic,  non-tuberculous,  448 ; 
with  ascites,  448  ;  fetal,  cause  of  mal- 
formations, 349 ;  in  intussusception, 
417  ;  in  newly  born,  84  ;  in  suppurative 
appendicitis,  419 ;  pelvic  from  gonor- 
rhea, 658  ;  tuberculous,  449  ;  miliary, 
with  general  tuberculosis,  450 ;  with 
ascites,  450 ;  fibrous  form,  451 ;  with 
intestinal  ulcers.  393  ;  with  lobar  pneu- 
monia,  539. 

I'ertussis,  1003 ;  bronchopneumonia  in, 
lOOS  ;  complications,  1008  ;  convulsions, 
1009  ;  diagnosis,  1010  ;  etiology,  1004  ; 
hemorrhages  in,  1008 ;  ileocolitis  in, 
1009 ;  incubation,  1005 ;  infective  pe- 
riod, 1009  ;  lesions,  1005  ;  leukocytosis 
in.  1011  :  paralysis  in,  1009 ;  predispo- 
sition to,  1004 ;  prognc«sis,  1011 ;  pro- 
phylaxis, 1012  ;  symptoms,  1006  ;  treat- 
ment. 1012,   1015  ;   vaccines  in,  1014. 

Peyer"s  patches,  in  typhoid  fever,  1060 ; 
swollen,  in  acute  ileocolitis,  359 ;  tu- 
berculosis of,  393 ;  ulceration  of,  in 
ileocolitis,  379. 

Pharyngitis,  acute.  288;  uvulitis  in,  289; 
chronic  catarrhal,   syphilitic,   1108. 

Pharynx,  diseases  of,  288 ;  adenoid  veg- 
etations of  vault,  296 ;  with  adenitis, 
862  ;  diphtheria  of,  1024 ;  diphtheritic 
paralysis  of,  834  ;  lesions  of,  in  heredi- 
tary syphilis,  463  ;  retropharyngeal  ab- 
scess, 290 ;  syphilitic  ulceration  of, 
1108  ;   syringing  of,    61. 

Phimosis,    650. 

Phlebitis,   of  dural   sinuses.    757. 

Phosphorus,   in  rickets,   259. 

Phthisis,  chronic.   1078,   1095. 

Physical    examination,    of   the    child,    34. 

Pica.    719. 

Pinworms  (see  Worms,  Intestinal), 
427  ;  proctitis  from,  432. 

Pleura,  effusion  into,  in  acute  nephritis, 
632 ;    tuberculosis    of,    1075,    1080. 

Pleurisy,  557  ;  dry,  558 ;  in  acute  bron- 
chopneumonia, 504 ;  purulent  (see 
Eaipvema),  563;  tuberculous,  dry  form, 
558 :  with  lobar  pneumonia,  528 ;  with 
serous  effusion,  560 ;  Grocco's  sign  in, 
561. 


INDEX 


n7:j 


Pleuropneumonia,  544  ;  pericarditis  in, 
588,   590. 

Pneumococcus,  iu  lironchopnounionia, 
495 ;  lobar  pneumonia,  495  ;  peri- 
tonitis, 445  ;  diphtheria,  1023,  1035  ; 
empyema,  563 ;  acute  meniugitis,  744 ; 
malignant  endocarditis,  ()04  ;  pericar- 
ditis, 588. 

Pneumonia.  492  ;  anatomical  varieties  and 
classifications  of,  493 ;  broncho  (see 
Bronchopneumoni.\,  Acute),  497; 
catarrhal  (see  Buonchopnecmonia, 
Acute),  497;  chronic  interstitial  (see 
Bronchopneumonia,  Chronic),  547; 
in  newly  born,  84 ;  in  typhoid  fever, 
1063 ;  sources  of  infection,  490  ;  varie- 
ties, classification  of,  495  ;  hyperacute, 
524;  hypostatic,  547;  lobular  (see 
Bronchopneumonia,  Acute),  497; 
pleuro  (see  Pleuropneumonia),  544; 
syphilitic,  1107  ;  tuberculous,  1086 ; 
course,  duration,  termination,  10S7, 
1088 ;  diagnosis,  1094  ;  physical  signs, 
1092;   chronic,  1093. 

Pneumonia,  lobar,  526  ;  etiology,  526  ;  fre- 
quency of,  495,  526 ;  complicating  in- 
fluenza, 1133 ;  complications.  539 ; 
course,  539 ;  abortive,  530 ;  cerebral, 
531  ;  diagnosis,  540  ;  lesions,  527  ;  lysis, 
frequency  of,  533 ;  pathological  differ- 
entiation from  bronchopneumonia,  540  ; 
physical  signs,  535  ;  prognosis,  542 ; 
symptoms,  529  ;  termination,  539  ;  treat- 
ment,  543. 

Pneumothorax,  in  pulmonary  tuberculosis, 
1080. 

Poisons,    gastritis    from,    336,    338. 

Poisoning,    stomach   washing,   in,   63. 

Poliencephalitis,  acute,  causing  cerebral 
paralysis,   785. 

Poliomyelitis,  acute,  806 ;  etiology,  807 ; 
diagnosis,  816 ;  extent  and  distribu- 
tion of  primary  paralysis,  813 ;  elec- 
trical reactions,  815  ;  lesions,  808  ;  prog- 
nosis, 817  ;  symptoms,  810  ;  treatment, 
818. 

Polydipsia,  in  diabetes  insipidus,  021 ; 
mellitus,   1156. 

Polypi,   nasal,   461 ;   rectal,   435. 

Polyuria,  621  ;  hysterical,  707  ;  in  dia- 
betes insipidus,  621  ;  in  diabetes  melli- 
tus,   1156. 

Poreucephalus,  723. 

Pott's  disease  (se(>  Spine,  Caries  of). 
907. 

Precordia,   bulging  of,  577,   600. 

I'regnancy,  effect  of,  on  woman's  milk, 
143 ;  effect  of,  on  nursing  child, 
178. 

Premature   infants,    management   of,    11. 

Prepuce,  adoerent,   650. 

Prickly  htjfit,   922. 

Proctitis,    432. 

Prognosis,   general   consideration   of,   43. 


Progressive  muscular  wasting  diseases, 
the  Werdiglloffnian  type,  822  ;  peron- 
eal type,  823. 

Prolapsus  ani  (see  also  Rectim,  Pro- 
lapse OF),  430;  from  proctitis,  433; 
in  ileocolitis,  382  ;  in  membranous  ileo- 
colitis,  385. 

Prophylaxis,   general   consideration   of,   50. 

Protein,  determination  of,  in  milk,  140  ; 
function  in  diet,  129 ;  in  the  feces, 
320 ;  of  woman's  milk,  131  ;  of  cow's 
milk,  148 ;  percentages  of,  in  modifi- 
cation   of    cow's    milk,    191. 

Protein    milk,    161. 

Pseudodiphtheria  (see  Membranous  Ton- 
sillitis), 300. 

Pseudohypertropbic  paraly.sis,  824. 

Pseudoparalysis  in  rickets,  257  ;  in  scurvy, 
2.35  ;    in   syphilis,    1114. 

Puberty,  delayed,  in  cretins,  884  ;  in  syph- 
ilis, 1123 ;  effect  of,  on  heart,  in  val- 
vular disease,  597,  601. 

Pulse,  examination  of,  36 ;  in  early  life, 
576. 

Purpura,    854 ;    arthritic,    859 ;    blood    in, 

856  ;  fulminans,  858  ;  gangrenous,  858  ; 
hematemesis     in,      857 ;      hemorrhagica, 

857  ;  Henoch's,  857  ;  primary,  855 ; 
rheumatica,  859  ;  simplex,  854 ;  symp- 
tomatic, 854 ;  cachectic,  854 ;  infec- 
tious, 854  ;  neurotic,  855  ;  mechanical, 
855  ;   toxic,   854. 

Pyemia,  in  newly  born,  82  ;  of  bone  (see 
Arthritis,  Acute),  850. 

Pyelitis,  642. 

Pyelocystitis,   642. 

Pyelonephritis,    620. 

Pylephlebitis,  439  ;  cause  of  hepatic  ab- 
scess,   439. 

Pylorus,  hypertrophic  stenosis  of,  321 ; 
diagnosis,   325  ;   treatment,   326. 

Pyogenic  diseases,  acute,  in  newly  born, 
82  ;  general  symptoms,  87  ;  prophylaxis, 
86  ;    treatment,    88. 

Pyonephrosis,    following    pyelitis,    642. 

Pyopneumothorax,  in  pulmonary  tubercu- 
losis,   1080. 

Pyuria,    020;    in    pyelitis,    642. 

Quinin,  dosage,  1147  ;  methods  of  admin- 
istration, 1147  ;  searlatiniform  rash, 
970. 

Quinsy.    307. 

Rachitis    (see   Rickets),  243. 

Reaction,  of  degeneration,  in  Er1)'s  paral- 
ysis. 113 :  in  facial  paralysis.  111  ;  in 
multiple  neuritis,  831  ;  in  poliomyelitis, 
815,     817. 

Rectal  injections  (see  Enemata),  65;  as- 
tringent,  389  ;   oil,    407  ;   saline,   389. 

Rectal   polypus,   435. 

Rectum,  diseases  of,  430 ;  administration 
of  drugs   by,   06;   atresia   of,   348;   con- 


1176 


INDEX 


genital  obstruction  of,  118  ;   feeding  by, 
66 ;    hemorrhage    from    ulcers    of.    433 
inflammation   of    (see   Proctitis),   432 
malformations     of,     348 ;     prolapse     of, 
430  ;  ulcers  of,  433. 

Regurgitation  of  food,  causes  of,  in 
young  infants,  193 ;  nasal,  in  diph- 
theria,   834,    1031,    1039. 

Remittent    fever,    malarial,    1142. 

Renal   calculi,    646 ;    renal    colic,    647. 

Rennet  ferment  in  digestion,   317. 

Respiration,  artificial,  methods  of,  71, 
72 ;  Cheyne-Stokes,  in  cerebrospinal 
meningitis,  734 ;  in  meningitis,  tuber- 
culous, 750  ;  paralysis  of,  in  diphtheria, 
834 ;  rapidity  and  characteristics  of, 
476. 

Respiratory  system,   diseases  of,   457. 

Rheumatism,  1149  ;  diagnosis,  1153  ;  treat- 
ment, 1154  ;  chorea  in.  694,  1152  ;  en- 
docarditis in,  595,  1151  ;  erythema  in, 
1153 ;  purpura  in,  859,  1153 ;  scar- 
latinal, 967  ;  simulated  by  scurvy, 
238 ;  subcutaneous  tendinous  nodules, 
1152  ;  tonsillitis  in,  306,  1152;  torticol- 
lis  in,    703,    1152. 

Rhinitis,  chronic,  461  ;  hypertrophic, 
cause  of  asthma,  488  ;  simple,  461 ; 
syphilitic,   462. 

Rhinopharyngitis,  acute.  457 ;  in  influ- 
enza,  1131  ;  with  adenoids,  296. 

Rhinopharynx,  diphtheria  of,  1025 ;  sim- 
ple catarrh   of,   in   acute  otitis,   939. 

Ribs,  beading  of,  early  symptoms  in  rick- 
ets, 250  ;  resection  of,  in  empyema,  571. 

Rice  water,  165. 

Rickets,  240  ;  etiology,  241  ;  lesions,  244  ; 
symptoms,  248  ;  calcium  metabolism  in, 
256 ;  course  and  termination,  256 ; 
acute,  256  (see  also  Scorbctcs),  232; 
congenital,  256 ;  convulsions  in,  255  ; 
nervous  symptoms  of,  255 ;  diagnosis, 
256  ;  from  scurvy,  238,  257  ;  prognosis, 
258 ;  treatment,  258 ;  of  deformities, 
252  ;  late,  256  ;  spleen  in,   246,   877. 

Ringworm  of  scalp,   936. 

Rotheln   (see  Rubella),  991. 

Roundworms  (see  Worms,  Inte.stinal), 
425. 

Rubella,  991  ;  eruption,  992 ;  treatment. 
994. 

Rubeola   (see  Measles),  975. 

Rumination,   330. 

Saccharomyces  albicans,   in   thrush,    281. 

Saline  solution,  as  rectal  injection,  389  ; 
subcutaneous  injection  of,  in  cholera  in- 
fantum, 372  ;  in  acute  inanition,  221. 

Saliva,    315. 

Salivation,  in  mumps,  1017  ;  in  ulcerative 
stomatitis,   279. 

Salvarsan,  1129. 

Salts,  inorganic,  in  modification  of  cow's 
milk,     186 ;     mineral,     function     of,     in 


diet,  132 ;  of  cow's  milk,  150 ;  of 
woman's  milk,  138. 

Sarcoma,  of  brain,  762  ;  of  kidney,  641  ; 
of  spinal  cord,   819  ;   of  stomach,   345. 

Scabies,    935. 

Scalp,  pustular  eczema  of,  926 ;  ring- 
worm of,  936  ;  seborrhea  of,  923. 

Scarlatina    (see  Scarlet  Fever),  952. 

Scarlatiniform  erythema,   causes  of,  970. 

Scarlet  fever,  952 ;  albuminuria  in,  966 ; 
angina  in,  963  ;  blood  in,  963  ;  cellulitis 
in,  964 ;  complications  and  sequelae, 
963 ;  desquamation,  957 ;  diagnosis, 
969 ;  diphtheria  in,  963,  969  ;  duration 
of  infective  period,  954  ;  eruption,  956  ; 
etiology,  952 ;  heart  in,  919 ;  incuba- 
tion of,  953 ;  invasion,  955  ;  joints  in, 
967 ;  kidneys  in,  966 ;  lesions,  955 ; 
lymph  nodes  in,  964 ;  mode  of  infec- 
tion, 954 ;  mortality  in,  971  ;  myocar- 
ditis in,  967  ;  nervous  system  in,  969 ; 
other  infectious  diseases  with,  969 ; 
otitis  in,  965  ;  predisposition  to,  953 ; 
prognosis,  971  ;  prophylaxis,  971 ;  quar- 
antine in,  971 ;  relapses,  recurrences 
and  second  attacks,  962  ;  symptoms, 
955,  963  ;  surgical,  962  ;  throat  in,  963  ; 
treatment,   972. 

Sclerema,   121  ;   in  cholera  infantum,  365. 

Scorbutus,  231  ;  etiology,  232 ;  lesions, 
235  ;  symptoms,  234 ;  diagnosis,  238  ; 
treatment,  239 ;  rickets  with,  238 ; 
stomatitis  in,   280. 

Scrofula  (see  Adenitis,  Tuberculous), 
867;   (see  Tuberculosis),  1067. 

Scurvy  (see  Scorbutus),  231. 

Seborrhea,  923. 

Senses,    special,   development   of,   26. 

Sepsis,  in  newly  born,  82. 

Serum-therapy  of  diphtheria,   1047, 

Serum-therapy  of  cerebrospinal  meningi- 
tis,  939. 

Shiga  bacillus  (see  Bacillus  of  Dysen- 
tery), 357,  374. 

Shower   bath,    57. 

Sight,   when  developed,  25. 

Singultus,   702. 

Sinuses  of  dura  mater,  thrombosis  of, 
757  ;    lateral,    in   otitis,    943. 

Skin,  diseases  of,  920 ;  of  newly  born, 
920  ;   care   of,   in   newly  born,    4. 

Skull,  asymmetry  of,  in  birth  paralysis, 
780  ;  in  rickets,  249  ;  sutures,  syphilitic 
nodes  on,  1118. 

Sleep,  disorders  of,  712 ;  disturbed,  7, 
713  ;  with  hypertrophy  of  tonsils,  309  ; 
in  intestinal  indigestion.  397  ;  in  rick- 
ets, 248 ;  with  adenoids,  296 ;  exces- 
sive, 714  ;  inspection  during,  33  ;  proper 
periods   of,   5. 

Sleeplessness,    712. 

Smallpox,  protection  against  (see  Vacci- 
nation),  997. 

Smell,  sense  oi.  when  developed,  27. 


INDEX 


1177 


Snuffles,   syphilitic.   462,    1110. 

Spasm,  carpopedal  (see  Tetany),  677;  of 
larynx,  981  ;  habit,  700 ;  nodding,  of 
the  head,  701  ;  rotary,  of  the  head, 
701. 

Speech,  disorders  of,  710  ;  when  acquired, 
27. 

Spina  bifida,  793  ;  with  congenital  hydro- 
cephalus,  773. 

Spinal  cord    (see  Coed,  Spinal),  796. 

Spine,  angular  curvature  of,  in  caries, 
910  ;  caries  of,  907  ;  physical  examina- 
tion, 909  ;  causing  compression  of  cord, 
S04  ;  curvature  of,  in  hip  disease,  915  ; 
hysterical  afEections.  referable  to,  706 ; 
in  rickets,  2-52  ;  lateral  deviatioQ<  of, 
911 ;  Potfs  disease  of  (see  Spine, 
Caries  of),  907. 

Spirocheta   pallida,   in   syphilis,'  1103. 

Spleen,  diseases  of,  876  ;  Banti"s  disease, 
878  ;  amyloid  degeneration  of,  878  ;  en- 
largement of,  877 ;  in  acute  disease, 
877 ;  in  chronic  cardiac  disease,  593 ; 
in  chronic  disease,  878  ;  in  cirrhosis  of 
liver,  441  ;  in  leukemia,  849 ;  in  ma- 
laria, 1143  ;  in  pseudoleukemic  anemia, 
844 ;  in  rickets,  246,  878 ;  in  second- 
ary anemia,  842 ;  in  typhoid  fever, 
1061 ;  with  amyloid  liver,  441  ;  in  diph- 
theria, 1061  ;  in  hereditary  syphilis, 
1107 ;  in  late  syphilis,  1122  ;  in  tuber- 
culosis, 1091  ;  new  growths  and  tu- 
mors of,  878 ;  position  and  methods 
of  examination,    877 ;   weight,    876. 

Sprue    (.see  Thrush),  282. 

Sputum,  means  of  obtaining,  for  exami- 
nation,  1095. 

Stammering,   711. 

Staphylococcus,  in  furunculosis,  931  ;  in 
acute  bronchopneumonia,  496  ;  in  diph- 
theria,  1023  ;  in  empyema,   563. 

Starch,  objections  to,  as  food  of  young 
infants,    132. 

Status   lymphaticus,    49.    891. 

Stenosis,  laryngeal,  in  acute  catarrhal 
laryngitis,  469 ;  in  syphilitic,  473 ;  of 
pylorus,    321  ;    dilated   stomach   in,    341. 

Sterilization  of  milk,  152 ;  changes  pro- 
duced by,  152;  at  212°  F.,  153;  at  low 
temperature,  153  ;  indications  for,  154  ; 
limitatioiiS  of,  154  ;  methods  of,  155. 

Stiirs   disea.se,   902. 

Stimulants,   54. 

Stomach,  diseases  of,  315  ;  absorption 
from.  318 ;  bacteria  of,  318 ;  conges- 
tion of,  in  acute  intestinal  indigestion 
and  diarrhea,  358;  digestion  in,  315; 
dilatation  of,  304 ;  in  chronic  gastric 
indigestion,  339  ;  in  rickets,  254  ;  hem- 
orrhage from,  345  ;  in  newly  born,  104  ; 
in  scurvy,  238 ;  inflammation  of  (see 
Gastritis),  335;  malformations  and 
malpositions  of,  321  ;  ulcer  of,  in 
chlorosis,    844 ;    tuberculosis    of,    1081  ; 


tumors  of,  345  ;  ulcer  of,  342  ;  in  newly 
born,  .342  ;  from  acute  gastritis,  342 ; 
tuberculous,  337 ;  simple,  perforating, 
343. 

Stomach  washing,  62 ;  indications  for, 
63. 

Stomatitis,  aphthous  (see  Herpetic 
Stomatitis),  277;  catarrhal,  276; 
diphtheritic,  285,  1026 ;  follicular  (.see 
Herpetic  Stomatitis),  277;  gangre- 
nous. 285  ;  gonorrheal,  284 ;  herpetic, 
277  ;  in  newly  born,  84  ;  parasitic  (see 
Thrush  I,  281;  syphilitic.  284;  ulcer- 
ative, 278;  vesicular  (see  Herpetic 
Stomatitis),  277. 

Stone,  in  the  kidney,  646  ;  in  the  bladder, 
647. 

Stools,  blood  in.  from  ulcer  of  stomach, 
344  ;  in  catarrhal  ileocolitis,  382,  384  ; 
in  membraneous  ileocolitis,  385  ;  in  in- 
tussusception. 416 ;  in  purpura,  857  ; 
fat  in,  194,  360  ;  green,  explanation  of, 
360 ;  in  acute  intestinal  indigestion 
and  diarrhea,  360  ;  in  cholera  infan- 
tum, 363  ;  in  acute  ileocolitis,  374.  376. 
381,  382  ;  indication  of  improper  feed- 
ing, 192,  193 ;  mucus  in.  in  malnutri- 
tion,  224. 

Strabismus,  with  tumor  of  crura  cerebri, 
766. 

Streptococcus,  angina  (see  Membranous 
Tonsillitis).  300;  pyogenes,  in  acute 
bronchopneumonia,  495  ;  in  complica- 
tions of  scarlet  fever,  963 :  in  derma- 
titis gangrenosa,  932  ;  in  diphtheria, 
1023,  1027,  1035  ;  in  empyema,  563  ;  in 
measles,  984  ;  in  peritonitis,  acute,  445  ; 
in  pseudodiphtheria,  301  ;  in  scarlet 
fever,    952. 

Stridor,  in  catarrhal  spasm  of  larynx, 
467  ;  in  acute  catarrhal  laryngitis,  469  ; 
congenital,    120. 

Strophulus  (see  Miliaria  Rubra),  922; 
(see   L'rticaria),   934. 

Stuttering,    710. 

Sucking,   315  ;   as   a   bad  habit,    714. 

Sudamina.    921. 

Sudden    death,    chief    causes    of,    48,    49. 

Sugar,  cane,  derivatives  in  digestion. 
318 ;  substitute  for  milk  sugar.  132, 
182.  185  ;  milk,  determination  of.  140  ; 
percentage  of.  in  woman's  milk,  182 ; 
milk,  derivatives  in  digestion,  318 ; 
percentages  of,  in  modification  of  cow's 
milk,  181  ;  solutions,  rules  for  making, 
191,  192 ;  stools  in,  diflicult  digestion 
of.  369 ;  symptoms  of  excess  of,  in 
food.    203,    204,    207. 

Summer    diarrhea.    357. 

Suppositories,  in  chronic  constipation, 
407  ;  proctitis  from  long  use  of  glycerin. 
432. 

Suprarenal  capsules,  in  syphilis,  1109  ;  in 
tuberculosis,    1082. 


1178 


INDEX 


Sutures,  closure  of,  22;  premature  ossi- 
fication  of,   24. 

Swallowing,   of  foreign  bodies,  346. 

Sweating,  in  infants,  920 ;  of  head  in 
rickets,   248  ;  in  tuberculosis,   1090. 

Symptomatology,  general  considerations 
of,   31. 

Synovitis,  acute  purulent  (see  Arthritis, 
Acute),   900;   scarlatinal,  967. 

Syphilis,  1103  ;  acute  osteomyelitis  in, 
1106 ;  bone  lesions  in,  1106 ;  chronic 
osteoperiostitis  in,  1114;  dactylitis  in, 
1115  ;  of  larynx.  473  ;  pseudoparalysis 
in,  1114 ;  spleen  in,  878 ;  acquired, 
1103. 

Syphilis,  hereditary,  1104 ;  adenitis  in, 
866  ;  bones,  1106  ;  Colles'  law,  1105  ; 
communicability  of,  1105  ;  diagnosis, 
1124 ;  etiology,  1104  ;  evidences  of,  in 
fetus,  1106  ;  hemorrhages,  1113 ;  le- 
sions, 1105  ;  prognosis,  1125  ;  prophy- 
laxis, 1127 :  pseudoparalysis,  1114 ; 
rhinitis  of,  462 ;  spleen.  1107  ;  symp- 
toms, 1109  ;  at  birth,  1109  ;  treatment, 
1128  ;  salvarsan,  1129  ;  late  hereditary, 
1125 ;  bones.  1128  ;  skin,  1122 ;  liver, 
1107 ;  nervous  system,  1123 ;  spleen, 
1107 ;  teeth,  1117 ;  tertiary,  chronic 
laryngitis  in,  473  ;  intubation  for,  474. 

Syringe,  nasal,  61. 

Syringing,  nasal,  61 ;  of  mouth  and 
pharynx,   61. 

Syringomyelocele,  799. 


Tachycardia,   608. 

Tenia,  cucumerina  or  elliptica,  423 ;  nana, 
424  ;  saginata  or  mediocarnellata,  423  ; 
solium.  423. 

Tapeworms,   423. 

Taste,  when  developed,  27. 

Teeth,  28  ;  eruption  of  first  set,  28  ;  per- 
manent set,  29 ;  care  of,  3 ;  decayed 
(see  Dental  Caries),  272;  cause  of 
adenitis,  862  ;  delayed,  in  rickets,  254 ; 
Hutchinson's,  in  syphilis,  1118. 

Temperature,  at  birth,  36 ;  in  childhood, 
36  ;  subnormal,  37  ;  raised  by  artificial 
heat,  37  ;  variations  of,  in  health,  36 ; 
of  nursery,  9. 

Tenesmus,  from  proctitis,  433 ;  in  intus- 
susception, 416 ;  in  membranous  ileo- 
colitis,  381  ;  treatment  of,   434. 

Testicle,  retraction  of,  with  renal  calculi. 
647 ;  syphilis  of,  1107 ;  undescended, 
652. 

Tetanus,  in  the  newly  born,  90. 

Tetany,   677. 

Therapeutics,  general  consideration  of,  51. 

Thomsen's   disease.    702. 

Thoraplasty,  573. 

Thorax,  description  of,  476 ;  measure- 
ments of,  20,  24  ;  causes  of  deformity  of, 
24. 


Threadworms  (see  Worms,  Intestinal), 
427. 

Throat,  diseases  of  (see  Pharynx  and 
Tonsils),  288,  300. 

Thrombosis,  612  ;  cachectic,  of  dural 
sinuses,  757  ;  in  diphtheria,  1028, 
1036 ;  in  infectious  diseases,  613 ;  in- 
flammatory, of  dural  sinuses,  757 ;  of 
internal  jugular  vein,  613 ;  of  lateral 
sinus  in  acute  otitis,  943 ;  of  sinuses 
of  dura  mater,  758  ;  of  the  aorta,  613  ; 
of  the  vena  cava,  613  ;  septic,  of  dural 
sinuses,    758. 

Thrush,  281. 

Thymus,  enlargement  of.  causing  convul- 
sions, 49  ;  in  status  lymphaticus,  891 ; 
tuberculosis  of,   1081. 

Thyroid   extract   in   cretinism,   887. 

Thyroid  gland,  congenital  absence  of,  in 
cretinism,   882. 

Tibia,  deformities  of,  in  rickets,  253 ; 
sabre-blade  deformity  in  syphilis,   1121. 

Tinea  tonsurans,  936  ;  treatment,   937. 

Toes,  clubbing  of,  in  congenital  heart  dis- 
ease, 583. 

Tongue,  diseases  of,  269 ;  congenital  hy- 
pertrophy of,  268  ;  epithelial  desquama- 
tion of,  269  ;  geographical,  270  ;  inflam- 
mation of,  270  ;  malformations  of,  267  ; 
ulcer  of  frenum,  271. 

Tongue-sucking,    718. 

Tongue-swallowing,  271. 

Tongue-tie,  268. 

Tonics,  54. 

Tonsils,  diseases  of,  300 ;  anatomy  of, 
300  ;  chronic  hypertrophy  of,  308  ;  diph- 
theria of,  1024,  1029 ;  hypertrophy  of, 
cause  of  asthma,  488 ;  hypertrophy  of. 
in  rickets.  255  ;  removal  advised  in  tu- 
berculous adenitis.  872 ;  with  adenitis, 
865  ;  membrane  upon,  in  scarlet  fever, 
963. 

Tonsillitis,  membranous  (pseudodiph- 
theria  ;  streptococcus  angina  ;  croupous 
tonsillitis),  300;  diagnosis,  303;  prog- 
nosis, 303  ;  treatment.  .304  ;  broncho- 
pneumonia in,  302  ;  follicular,  305  ;  di- 
agnosis, 306 ;  treatment,  306 ;  in  rheu- 
matism, 1152  ;  phlegmonous,  307  ;  ul- 
ceromembranous (Vincent's  angina), 
304. 

Tonsillotomy.  310. 

Top-milk.   152. 

Torticollis.  703 :  congenital.  703 ;  from 
cervical  Pott's  disease.  703.  908  ;  from 
hematoma  of  sternomastoid,  97 ;  hys- 
terical, 707  ;  in  phlegmonous  tonsillitis, 
307  ;  in  retropharyngeal  abscess,  303 ; 
rheumatic,   307 ;    spasmodic,    704. 

Touch,   when   developed,   26. 

Toxemia,  in  intestinal  indigestior, 
chronic,  397  ;  vomiting  in,  329  ;  in  acute 
gastric  indigestion,  329. 

Trachectomy,   for   foreign   body  in  larynx. 


INDEX 


n79 


475  ;  in  laryngeal  diphtheria.  105S  ;  in 
retro-esophageal  abscess,  314. 

Transfusion,   of  blood,   68. 

Trousseau's  sign,   in   Tetany,   682. 

Trypsin,   310. 

Tubercle  bacilli  (see  Bacillus  of  Tu- 
berculosis),  1071. 

Tuberculin  test  in  herds,  14.5 ;  in  diag- 
nosis,  1099. 

Tuberculosis,  1067 ;  age,  1067  ;  bacillus 
of  (see  Bacillus  of  Tuberculosis), 
1067  ;  in  milk,  14.5  ;  bronchial  lymph 
nodes  in.  1095  ;  clinical  forms  of,  1082  ; 
bronchopneumonia,  1075.  1086  ;  chronic 
phthisis,  1095  ;  chronic  pulmonary, 
1084 ;  congenital,  1069 ;  diagnosis  of 
pulmonary,  1094  ;  of  bronchial  glands, 
1078 ;  general,  1082 ;  etiology,  1082 ; 
following  measles,  987 ;  following  per- 
tussis, 1012  ;  frequency,  1067  ;  general, 
in  infants,  1082 ;  in  older  children, 
1082 ;  hemoptysis,  1039 ;  incipient, 
symptoms  in,  1082 ;  intestines,  391, 
1081  ;  intra-uterine  infection,  1069 ; 
kidney,  639,  1081  ;  lesions,  1073  ;  mesen- 
teric, 391  ;  miliary,  of  the  lungs,  1084  ; 
mode  of  infection,  1069 ;  of  larynx, 
472 ;  of  lymph  nodes,  cervical,  867  ;  of 
the  skin,  1100 ;  paths  of  infection, 
1072 ;  pericarditis  in,  588 ;  physical 
signs,  1092  ;  pleura  in,  559,  1080  ;  pre- 
disposing causes.  1069 ;  prognosis, 
1101  ;  prophylaxis,  1101  ;  spleen,  1081  ; 
sputum,  means  of  obtaining,  1095  ; 
treatment,  1102 ;  tuberculin  tests, 
1099. 

Tuberculous  adenitis,  867 ;  bronchial 
glands.  1078.  1095,  1098;  meningitis, 
747  ;  nephritis,  639  ;  ostitis,  905  ;  peri- 
carditis, 589 ;  peritonitis,  449 ;  pleu- 
risy. 559  ;   pneumonia,   1086,  1092. 

Tumor,  abdominal,  in  intussusception, 
415 ;  in  stenosis  of  pylorus.  324  ;  cere- 
brail.  762  ;  pituitary,  767  ;  tuberculous, 
1080.  1081  ;  fatt.T.  in  cretinism.  884 ; 
of  spinal  cord,  819 ;  mediastinal  tu- 
berculous lymph  nodes,  1097  ;  of  spleen, 
878.   1107. 

Tunica   vaginalis,    hydrocele   of,   654. 

Turpentine    stupe,    preparation   of,    58. 

Tympanites  in  acute  peritonitis,  446 ;  in 
intestinal  indigestion.  396 :  in  rickets, 
254 ;    in   typhoid   fever.    1061. 

Typhoid  fever,  1058  ;  bacillus  of.  in  milk, 
14(i ;  complications  and  sequelfe,  1063  ; 
diagnosis.  1064  ;  etiology.  1067  ;  le- 
sions, 1060  ;  prognosis.  1065  ;  scarlatini- 
form  erythema  in.  970  ;  symptoms. 
1060 ;  treatment,  1066 ;  paratyphoid, 
1058  ;  fetal,  1058  ;  infantile,  1058. 

T'horomembranous    tonsillitis.    304. 
I'lcers.    catarrhal,    of   intestine.    377  :    fol- 
licular, of  intestine.   377  :   following   tu- 


berculous adenitis,  870 ;  of  stomach, 
342.  lOSl  ;  tuberculous,  of  bronchial 
lymph  nodes,  1097  ;  tuberculous,  of  in- 
testine. 391  ;  tuberculous,  of  skin,  870  ; 
syphilitic,    1122 ;    typhoid,    1060. 

Umbilical  vessels,  arteritis,  in  newly 
born,  83  ;  phlebitis,  in  newly  born,  82  ; 
fistula,   115. 

Umbilicus,  hemorrhage  from,  in  newly 
born,  103 ;  hernia  of,  116 ;  inflamma- 
tion of  vessels,  in  newly  born,  83  ;  tu- 
mors  of,    115. 

Uremia,  acute,  in  scarlet  fever,  969 ;  in 
acute  nephritis,  631  ;  in  chronic  nephri- 
tis,  637. 

Urethra,  hemorrhage  from,  in  newly  born, 
105. 

Urethritis,  653  ;  gonorrheal,  653. 

Uric  acid,  in  early  infancy,  616  ;  infarc- 
tions, in  kidney,  627 ;  causing  hema- 
turia, 105. 

Urine,  arrest  of  secretion  (see  Anuria). 
621  ;  albumin  in,  617  ;  blood  in  (see 
Hematuria),  619;  composition  of,  616; 
daily  quantity  of,  615  ;  examination  of, 
41  ;  hyperacidity  of,  in  rheumatism. 
1155  ;  incontinence  of,  662 ;  with  ade- 
noids, 291  ;  in  diabetes,  1091  ;  retention 
of,  in  myelitis,  779  ;  in  typhoid,  1013 ; 
in  vesical  calculus,  667  ;  in  infancy  and 
childhood,  615 ;  methods  of  collecting, 
41,  615  ;  microscopical  examination  of, 
616  ;  physical  character  of,  616  ;  pus  in 
(see  Pyuria),  620;  reaction  of,  616; 
specific  gravity  of,  616  ;  sugar  in,  617  ; 
uric    acid   in,    616. 

Urogenital  organs,  tuberculosis  of,   1081. 

Urogenital    system,    diseases    of,    615. 

Urticaria,  933  ;  following  diphtheria  anti- 
toxin, 1050 ;  in  intestinal  indigestion, 
397 ;  papulosa,  934  ;  scarlatiniform 
rash   with,   970. 

Uvula,  bifid,  268;  diphtheria  of,  1024; 
elongation  of,  289 ;  cause  of  asthma, 
488 ;  edema  of,  289 ;  inflammation  of, 
289. 

Vaccination,      997 ;      choice      of      lymph, 

997 ;    methods    of,    999 ;    revaccination, 

997. 
Vaccinia,  997. 
Vaccines,    57. 
Vaginitis,    655  ;    simple,    655 ;    gonococcus, 

657. 
Vapor    bath,    59. 
Varicella,  994  ;   symptoms,  995  ;  diagnosis, 

996  ;    gangrenosa,    932,    995  ;    treatment, 

996. 
Vegetables,    third    to    sixth    year,    212. 
Veins,     internal     jugular,     thrombosis    of, 

<il3  :    umbilical.   575. 
Veins,   abdominal,   dilated,   in   cirrhosis   of 

liver,  441  ;   in  thrombosis  of  vena  cava, 

613. 


11  so 


INDEX 


Ventricles,  cardiac,  relative  thickness  of, 
577. 

Vertigo,  in  cerebral  abscess,  760 ;  in 
cerebral  tumor,  764  ;  in  functional  dis- 
turbances of  the  heart,   608. 

Vesical  calculi,  667. 

Vincent's  angina  (see  Ulcero-Membra- 
Nous  Tonsillitis),  304. 

Viscera,  abdominal,  transposition  of, 
350 ;  frequency  of  inflammations  of, 
42 ;  hemorrhages  of,  in  newly  born, 
101  ;  vitamins,  233. 

Voice,  hoarse  or  husky,  with  adenoids, 
297  ;  nasal,  with  hypertrophy  of  ton- 
sils, 309  ;  with  adenoids,  296  ;  in  diph- 
theritic paralysis,   834. 

Volvulus,  fetal  cause  of  malformations, 
349. 

Vomiting,  329,  331  ;  from  overfilling  the 
stomach,  329  ;  in  acute  gastric  indiges- 
tion, 329 ;  in  hypertrophic  stenosis  of 
pylorus,  322 ;  in  acute  intestinal  ob- 
struction, 329 ;  in  peritonitis,  329 ;  in 
nervous  diseases,  329  ;  at  onset  of  acute 
febrile  disease,  330 ;  from  toxic  sub- 
stances in  the  blood,  330;  reflex,  330; 
from  habit,  330  ;  chronic,  331  ;  of  blood, 
in  ulcer  of  stomach,  343  ;  stercoraceous, 
in  intussusception,  414  ;  cyclic,  331 ; 
treatment,  334. 

von   Pirquet's  test  for  tuberculosis,   1099. 

Vulvitis,   gangrenous,    062. 


Walking,  causes  which  prevent,  25  ;  de- 
layed, in  rickets,  255  ;  when  attempted, 
25. 

Wasting,  in  tuberculosis,  1090 ;  simple 
(see  Marasmds),  221. 

Water,  function  of,  in  diet,  133. 


Weaning,  177 ;  time  for,  177 ;  indica- 
tions for,  178  ;   sudden,   177. 

Weather,  hot,  prophylaxis  against .  diar^ 
rhea  in,  366. 

Weight,  15  ;  at  birth,  16 ;  curve  during 
first  few  weeks,  16  ;  curve  of  first  year, 
17 ;  from  second  to  fifth  year,  18 ;  of 
older  children,'  19 ;  from  birth  to  six- 
teenth year,  20  ;  loss  of,  in  acute  inani- 
tion, 219  ;  stationary,  indications,  195  ; 
symptoms  of  unsuccessful  nursing,  171, 
et  scq. 

Werlhof's  disease    (see  Purpura),  854. 

Wet   dressings    vs.    poultices,    58. 

Wet-nurse,  in  acute  indigestion  and  diar- 
rhea, 369 ;  in  gastro-enteric  intoxica- 
tion, 358 ;  in  acute  inanition,  221 ;  se- 
lection of,  176 ;  dangers  from  syphi- 
litic.  1127. 

Wet-nursing,  176 ;  vs.  artificial  feeding, 
168 ;  indications  for,  169 :  disadvan- 
tages of,  166. 

Wheal,   in   urticaria,    934. 

Whey,   162  ;  wine,   162. 

White-swelling  of  knee,  916. 

Whooping  cough    (see  Pertussis),  1003. 

Widal's  test,  in  typhoid  fever,   1064. 

Worms,  Intestinal,  427 ;  tape-,  424 ; 
round-,  425  ;   thread-,   427. 

Wrist,  enlarged  epiphyses  in  rickets,  253. 

Wry-neck  (see  Torticollis),  703. 

X-ray,  in  empyema,  565  ;  in  gastric  re- 
tention, 324 ;  in  osteogenesis  imper- 
fecta, 896  ;  in  osteoperiostitis.  1120  ;  in 
pneumonia,  537,  565  ;  in  syphilitic  dac- 
tylitis, 1117  ;  in  syphilitic  osteo- 
periostitis,   1115. 

Zoolak,  101. 


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